HEALTH ASSESSMENT NOTES

NURSING PROCESS OVERVIEW (MRS. GABILAN)

A. CHARACTERISTICS OF A PROCESS
Purpose – goal / aim
Organization – the series of steps or components
Creativity – the process is continuously changing in response to client’s needs
B. NURSING PROCESS
Nursing Process
- An organized, systematic, goal-oriented, humanistic method of planning and
providing nursing care.
- A blueprint for care
- An approach that allows nurses to differentiate their practice from that on the
physician and other health professionals
- Dynamic, continuous process as the client’s needs change
- Without this systematic way of approaching client care, omissions and
duplications may occur
GOALS OF THE NURSING PROCESS:
1. To identify a client’s health care status and actual or potential health problems.
2. To establish plans to meet the identified needs.
3. To deliver specific nursing interventions to address those needs.
STEPS OF THE NURSING PROCESS:
I. ASSESSMENT
- First step in the nursing practice
- The systematic collection, verification, organization, interpretation and
documentation of client’s health status.
- Completeness and correctness of the information
PURPOSE: To establish database
DATABASE: - information about the client prior to entering the health care system
- Generally collected upon admission.
Example: Health History, Physical Examination and Physical
and psychosocial aspect.
ACTIVITIES:

1. DATA COLLECTION
- Begins prior to initial contact between the nurse and the client.
- Descriptive, concise and complete.

TYPES OF DATA
A. SUBJECTIVE DATA
- Can only be described by the person experiencing it.
- Information given verbally by the client
- Best recorded as direct quotes
- Expressions, emotions, physical sensations by the client and family
EXAMPLE:
“ Nagsakit akong tiyan”
-as verbalized by the client”

B. OBJECTIVE DATA
- can only be observed and measured by the data collector
- factual data, observable behaviors, characteristics and information perceived
observed by the data collector
- non-verbal expressions by the client, family or friends
- physical assessment data
- chart info : diagnostics and lab results
EXAMPLE:
SUBJECTIVE DATA:
“Nagsakit akong tiyan” – as verbalized by the client
OBJECTIVE DATA:
Scale of 8 out of 10
Lab results and vital signs
SOURCES OF DATA
1. PRIMARY SOURCE : client / patient itself
2. SECONDARY SOURCE :
- Family and significant others
- Health care team
- Medical records
- Results of diagnostics / lab results
- Relevant literature
- Nurse’s Experience
METHODS OF DATA COLLECTION
1. OBSERVATION (Physical Assessment)
- Done through all sensory capacities
- Look at every parts of the body trying to find deviation
2. INTERVIEW
- A therapeutic interaction initiated for a specific purpose and focused on a specific
content data
- Identifies health needs and risk factors
2. DATA VERIFICATION
- Data are verified as being complete and accurate
PURPOSE: - Keep data as free form error, bias and misinterpretation as possible.
- Invalid information may lead to inappropriate nursing care.
3. DATA ORGANIZING / CLUSTERING
- Clustering facts into groups of information
- Organizes the information together to identify areas of strength and weaknesses.
II. NURSING DIAGNOSIS
Diagnosing – a process which results from data analysis and problem identification
To diagnose in nursing – means to analyze assessment information
Nursing Diagnosis
- A statement of client’s potential or actual alteration of health status
- Uses the critical – thinking skills of analysis and synthesis
- Uses this format:
P – Problem E – Etiology
R – Related to factors S – Signs and Symptoms
S – Signs and Symptoms
P – Problem
ACTIVITIES:
Diagnosis: DATA + PROBLEM + FORMULATION ANALYSIS IDENTIFICATION
Nursing Diagnosis: PROBLEM related to ETIOLOGY or CAUSE
Example: Impaired Skin integrity related to Physical Immobilization
Ineffective airway clearance related to increased mucus secretions

1. DATA ANALYSIS
- The nurse does the following:
a. Clarity
b. Completeness of Data
c. Inconsistencies / Ambiguity of Data
d. Comprehensiveness

III. PLANNING AND OUTCOME IDENTIFICATION

A. OUTCOME IDENTIFICATION
- refers to formulating and documenting measurable, realistic and client – focused
goals
- Provides for the basis for evaluating nursing diagnosis
Tips in OUTCOME IDENTIFICATION:
S – Specific
M – Measurable
A – Attainable
R – Realistic
T – Time – bounded

B. PLANNING
- Determining beforehand the strategies or course of actions to be taken before
implementation of nursing care.
- To be effective, involve the client and his family in planning
TYPES OF PLANNING
1. INDEPENDENT – Own nursing intervention that does not rely on basis
2. DEPENDENT – Medication , IV fluid , Oxygenation
3. INTERDEPENDENT – Depends on the etiology together with the dependent nursing
Intervention

NURSING INTERVENTIONS
- are independent, dependent and interdependent activities that nurses carry
out to provide client care
- are actions performed by the nurse that helps the client to achieve the results
specified by the goal and expected outcomes

IV. IMPLEMENTATION
IMPLEMENTATION
- the execution of the nursing plan of care derived during the planning phase of
the nursing process
- Relevant documentation should be done.
- RATIONALE : The reason why one does a specific intervention

V. EVALUATION
EVALUATION
- Assessing the client’s response to nursing interventions and then comparing the
response to predetermined standards or outcome criteria
PURPOSE: - to determine the effectiveness of those activities in helping client achieve expected
outcome
- Determine the quality of health care delivered
- To promote nursing accountability
HEALTH HISTORY GUIDELINES
INTERVIEW – planned communication
PURPOSE: - To obtain nursing health history
- Identify health needs and risk factors
- To determine specific problems
PREPARING THE INTERVIEW ENVIRONMENT:
1. Assure adequate lighting
2. Maintain a comfortable room temperature
3. Select an environment that is free of noise and destructions as possible
4. Maintain client privacy
5. Make sure that the interview is timed appropriately
6. Promote client’s comfort

TYPES OF INTERVIEW TECHNIQUES

1. OPEN – ENDED QUESTIONS
- To obtain a response of more than 1 or 2 words
- This leads to a discussion in which client actively describe their health status
- Good eye contact and listening skills

2. CLOSE – ENDED QUESTIONS

- Limit the client’s answer to 1 or 2 words only
- Require concise answer and are used to clarify previous information or provide
additional information

PHASES OF INTERVIEW
1. ORIENTATION PHASE
- The nurse reviews the purpose, types of data to be obtained, methods most
appropriate for conducting the interview
- Establish trust with the client
- Client respond freely
- Establish eye contact and listen attentively
- Note nonverbal messages
- Time parameter should be set

2. WORKING PHASE
- Longest phase, focuses on the details of data collection

3. TERMINATION PHASE
- Ideally the client should be given a clue that the interview is coming to an end
- The nurse summarize what was covered or accomplished during the interview
HEALTH HISTORY (MRS. DELA CALZADA)

HEALTH HISTORY
- To gather subjective data from the client and/or the patient’s family so that the
health care team and the patient can collaboratively create a plan that will
promote health, address acute health problems and minimize chronic health
problems.
SOURCES:
1. SUBJECTIVE DATA
- Information reported by the patient or information verbalized by the patient
- May include the signs and symptoms described by the patient but not noticeable
by others.
- include the Demographic Data

2. OBJECTIVE DATA
- Information that health care professional gathers during physical examination
- Can be seen, felt, smelled or heard by the health care professionals
(IPPA – Inspection, Percussion, Palpation, Auscultation)

PARTS OF THE HEALTH HISTORY

1. PERSONAL PROFILE
- Biographical Data
- Reasons for Seeking health care
* Chief complaints
* History of Present Health Concern
P – Provoking / Precipitating O – Onset
Q – Quality / Quantity L – Location
R – Relieving Factors D – Duration
S – Severity C – Characteristics
T – Treatment / Time A – Aggravating Factors
R – Relieving Factors
T – Treatments
S – Severity
*Past Health Status: Allergies, reactions, past hospitalizations, serious or
chronic illness, previous surgical procedures
*Family Health History: GENOGRAM (3 Generation System)
Shared risk within the family
*Psychosocial History: Mental health = mental well-being
Mental Illness = Pattern of behavior that is troubling the
Client
Mental Disorder = combined patterns of behavior

FUNCTIONAL ASSESSMENT
I. PHYSICAL ACTIVITIES OF DAILY LIVING (PADL / ADL)
- Basic tasks that should be accomplished by the individual
- Basic self-care
- Learned from childhood
PADL / ADL’S
1. Hygiene – Bathing, grooming, oral care
2. Continence Management – Person’s mental ability to properly use the bathroom
3. Dressing – The ability to select and wear proper clothes.
4. Feeding – Whether the person can feed themselves or needs assistance
5. Ambulating – Ability to change position or walk independently

II. INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)

- Not necessary for fundamental functioning but let the individuals live
independently in the community
- Teenagers need complex thinking skills and organizational skills
IADL’S
1. Managing Finances – Paying bills and budgeting accurately
2. Shopping / Grocery of basic necessities
3. Preparing Meals – Planning, cooking and preparing
4. Laundry and housework – washing and chores
5. Managing medications – taking medications as prescribed
6. Transportation and communication – able to us public utility vehicles and able to use
telephones and modes of communication.
GORDON’S FUNCTIONAL HEALTH PROBLEM
 Marjorie Gordon (1987)
- Proposed functional health pattern as a guide for establishing comprehensive
nursing database.
- Has 11 categories – systematic and standardized approach to data collection
ORGANIZING DATA ACCORDING TO GORDON’S 11 FUNCTIONAL HEALTH
PATTERNS
FUNCTIONAL HEALTH PROBLEM PATTERN DESCRIBES EXAMPLES

Client’s perceived pattern of health Compliance of medication regimen,

Health Perception/ Health
and well-being and how health is use of health promotion activities
Management
managed such as exercise and annual check-ups

Pattern of food and fluid consumption

Condition of skin, teeth, hair, nails,
Nutritional - Metabolic relative to metabolic need and pattern.
mucus membrane, height and weight
Indicators of nutrient supply.

Pattern of excretory functions (bowel, Frequency of bowel movement,

Elimination
bladder and skin). Includes client’s voiding pattern, pain on urination,
perception of normal function appearance of urine and stool

Exercise, hobbies, may include

Patterns of exercise activity, leisure
Activity – Exercise cardiovascular and respiratory status,
and recreation
mobility, activities of daily living

Vision, hearing, taste, touch, smell,

Sensory, perceptual and cognitive pain perception and management,
Cognitive – Perceptual
pattern cognitive functions such as language,
memory and decision - making

Client’s perception of quality of sleep

Sleep – Rest Patterns of sleep, rest and relaxation and energy, sleep aids, routines that
clients uses

Body comfort, body image, feeling

state, attitudes about self, perception
Client’s self-concept patterns and
Self – Perception / Self Concept of abilities, objective data such as the
perceptions of self
body posture, eye contact and voice
tone
Perception of current major roles and
Client’s patter of role engagements responsibilities (eg. Father, husband,
Role – Relationship
and relationships salesman) satisfaction with family,
work and social relationships

Number and history of pregnancy and

Pattern of satisfaction and
childbirth, difficulties of sexual
Sexuality – Reproductive dissatisfaction with sexuality pattern-
functioning, satisfaction with sexual
reproductive pattern
relationships

Client’s usual manner of handling

General coping pattern and effective stress, available support systems,
Coping / Stress Tolerance
of the pattern of stress tolerance perceived ability to control or manage
situations

Religious affiliations, what client

Patterns of values, beliefs (including
perceived as important in life, values
Values – Belief spiritual) and goals that guide client’s
– belief conflict related to health,
choices or decisions
special religious practices

FUNCTIONAL ASSESSMENT TESTS

I. NEW BORN ASSESSMENT
1. ANTHROPOMETRIC MEASUREMENTS
-Newborn = 0 to 28 days
-observe from head to toe or cephalocaudal

Includes:
- Height - Head and Chest circumference
- Weight - Abdominal Girt

A. LENGTH / HEIGHT
- Body length or birth length
- Tape measure in centimeters (cm)
- Head to heel
- 50 cm (average) – European-American / 48 cm (average) – Asians
B. WEIGHT
- 2.7 kg – 3.8 kg or 6 – 8.5 pounds (average) after birth
- 5 to 10% lost after a week due to fluid loss
- 5 months = the usual weight of an infant doubles the birth weight
- 6 months = 150 – 210 grams of weekly gain weight
- Rapid Weight Gain = means obesity
- Breastfeeding = helps in the growth of the infant
C. HEAD AND CHEST CIRCUMFERENCE
- To determine the growth rate of the skull and brain
- Normocephaly – head circumference is related to the chest circumference
- approximately 35 cm (average head circumference) with 1 or 2 cm variation
- chest circumference is less than the head circumference (at birth) of about less
than 2.5 cm or 1 inch
- As the infant grow around 9 – 10 months, the HC and CC are about equal size
- After 1 year, the CC is larger than that of CC
- Abdominal Girth = the baseline for the stomach

2. APGAR SCORING
- Developed by Virginia Apgar , 1952
An anesthesiologist and wants to quantify the effects of anesthesia to babies
APGAR SCORE
- A method to quickly summarize the health of the new born against infant
mortality
- Has 5 criteria and scoring is from 0 to 2
- Scoring is from 1 minute of birth and 5 minutes after birth
CRITERIA 0 1 2
ACTIVITY(Muscle Limp / Floppy Limbs Flexes Active Movement
Tone)
PULSE (100 – 160 bpm) Absent < 100 beats / min. >100 beats / min
GRIMMACE Cough, Sneeze or
Absent Grimace w/ Stimulation
(Reflexes) cry with stimulation
APPEARANCE (Color) Blue, Bluish – Gray, Body pink but blue
Pink all over
Pale extremities
RESPIRATION
Absent Irregular/ Weak Cry Good / Strong Cry
(Breathing Effort)

II. PEDIATRIC ASSESSMENT

- Less than 18 years old
- Includes:
*Height
*Weight
*Immunization

1. TODDLER
- 1 to 3 years old
A. HEIGHT
- Heels should be placed against the wall and measure with ruler
- Between 1 to 2 years old = 10 to 12 cm (average growth height)
- 2 to 3 years old – the height slows down to 6 to 8 cm

B. WEIGHT
- 2 years old = 4x (times) the birth weight
- 2 – 3 years old – 1 to 2 kg average weight gain
- 3 years old – average of 13.6 kg

C. HEAD CIRCUMFERENCE
- 2.5 cm growth in one year
- 24 months = 80% of the adult’s size
- 70% of the brain is adult size
- 37.5 cm after a year
- Ends at 2 years old

2. PRE – SCHOOL
- 4 – 5 years old

A. HEIGHT
- Growth is 5 cm to 6 cm each year
- 4 years old = doubles the birth length

B. WEIGHT
- 5 years old = should have added 3 – 5 kg to their 3 year old weight
- Approximately 18 to 20 kg

3. SCHOOL AGE
- 6 to 12 years old

A. HEIGHT
- 6 years old = both male and female = 115 cm
- 12 years old = approximately 150 cm height
*girls = between 10 – 12 years old experience growth spurt
*boys = between 12 – 14 years old experience growth spurt

B. WEIGHT
- Boys = 20 – 21 kg more than the girls
- Girls = 40 – 42 kg approximate
IMMUNIZATION
1. BCG or BACILLE CALMETTE GUERIN
- 0.05 ml dose
- Preferably given the first 2 months of life
- Given Intradermal (ID)
- Prevents Tuberculosis

2. HEPATITIS B VACCINE
- 0.5 ml dose
- Given Intramuscular (IM)
- 3 doses
*1st dose = within 24 hours of life
*2nd dose = after 1 to 2 months
*3rd dose = not early than 24 weeks of age

3. DPT or DIPTHERIA, PERTUSIS, TETANUS TOXOID

- 5 doses
- Minimum age given is 6 weeks with an interval of 4 weeks
- Given Intramuscular (IM)
- Diphtheria – caused by corynebacterium diptheriae : causes the thickening of
the wall on the throat, difficulty in breathing
- Pertussis – caused by Bordetella Pertusis : causes difficulty in breathing
- Tetanus Toxoid – caused by Clostridium Tetani : affects the brain and the
Nervous System = Spasm of the muscles
i. TT – Tetanus Toxoid = slow acting
ii. TIg – Tetanus Immunoglobulin = fast acting

4. INNACTIVATED POLIO-VIRUS VACCINE

- 3 doses
- Minimum age given is 6 weeks with an interval of 4 weeks
- Given in combination of DPT and HIB
- Given Intramuscular (IM)
- BOOSTER: Given after 4th birthday or at least 6 months from the previous
dose
HIB VACCINE
- 3 doses
- Given Intramuscular (IM)
- Given in 6 weeks with an interval of 4 weeks
5. ROTA VIRUS VACCINE
- Given Per Orem
- Given 6 weeks with an interval of 4 weeks
- Prevent enteritis – inflammation of the Small Intestines

6. PCV or PNEUMONOCOCCAL CONJUGATE VACCINE

- Given Intramuscular (IM)
- Given 6 weeks with an interval of 4 weeks
- 3 doses
- BOOSTER: 6 months after the 3rd dose

7. INFLUENZA VACCINE
*Trivalent – given to Senior Citizens
*Quadrivalent – standard vaccine
- Minimum age of 6 months
- Given Intramuscular (IM)
- Given annually
*6 mos – 35 mos = 0.25 ml
*36 mos – 18 years old = 0.5 ml
*Between 6 to 8 years old = 2 dose with an interval of 4 weeks

8. MEASLES VACCINE
- Given Subcutaneous (SC)
- Given at 9 months

9. MMR or MEASLES, MUMPS, RUBELLA (German Measles)

- Given Subcutaneous (SC)
- Given at a minimum of 12 months
- 2 doses with a minimum of 4 weeks or 1 month

10. MMVR or MEASLES, MUMPS, VARICELLA (Chicken Pox), RUBELLA

- Given at a minimum of 12 months
- 2 doses

11. HEP A Vaccine

- Given Intramuscular (IM)
- Given at a minimum of 12 months
- 2 doses with an interval of 6 months
12. JE or JAPANESE ENCEPHALITIS
- Given Subcutaneous (SC)
- Given from 9 mos – 17 years old
- BOOSTER : 24 mos from the first dose

13. HPV VACCINE or HUMAN PAPILLOMA VIRUS VACCINE

- Given Intramuscular (IM)
- Has:
*2 doses = vaccinated 9 – 12 years old
*3 doses = vaccinated 15 years old
(Interval of 1 month)

METRO MANILA DEVELOPMENT SCREENING TEST

- To determine normalcy of child’s development
- Determining delays of child’s development and growth less than 6 ½ years
old.
PURPOSE: Measure developmental delays
i. PERSONAL SOCIAL
ii. FINE MOTOR ADAPTIVE
iii. LANGUAGE
iv. GROSS – MOTOR

1. PERSONAL SOCIAL
- The ability of the child to get along with other people as taking care of himself

2. FINE MOTOR
- The child’s ability to see and use his hand

3. LANGUAGE
- Child’s ability to hear, speak and follow directions

4. GROSS MOTOR
- The child’s ability to sit, walk and jump

SCORING
P – Passed, F – Failure, R – Refused, NO – No Opportunity
III. ADULT ASSESSMENT

- Katz Index of Independence of ADL

- Barthel Index

1. KATZ INDEX OF INDEPENDENCE OF ADL

- The test to the ability of an individual to do daily living exercises
SCORING:
0 – Needs Assistance
1 – Complete Independence

2. BARTHEL INDEX
- Used to measure ADL and score may differ

BARTHEL INDEX
1. FEEDING
0 – unable
5 – needs help cutting, spreading butter or etc. or requires modified diet
10 – independent

2. BATHING
0 – Dependent
5 – independent
3. GROOMING
0 – need help with personal care
5 – independent face / teeth / hair / shaving (implements provided)

4. DRESSING
0 – Dependent
5 – needs help but can do about half unaided
10 – independent (including buttons, zip, laces, etc.)

5. BOWEL
0 – incontinent (needs to be given enemas)
5 – occasional accident
10 – Continent
6. TOILET USE
0 – Dependent
5 – need some help
10 – independent

7. TRASFERS
0 – unable, no sitting balance
5 – Major help (one or two people, physical) can sit
10 – Minor help (verbal or physical)
15 – Independent

8. MOBILITY
0 – Immobile on < 50 yards
5 – wheelchair, independent including corners >50 yards
10 – walks with help of one person (verbal or physical) >50 yards
15 – independent (but may use any aid such as stick) >50 yards

9. STAIRS
0 – unable
5 – needs help
10 – independent

IV. ASSESSMENT IN PREGNANCY

 LMP
 EDL / EDD
 AOG
 Fundal Height and Fetal Heart Tones

1. LMP or LAST MENSTRUAL PERIOD

- Determines when was the last day a pregnant woman experienced
Menstruation
2. EDC / EDD or ESTIMATED DATE OF CONFINEMENT OR ESTIMATED DATE OF
DELIVERY
- Naegel’s Rule by Franz Karl Naegele
*The standard way of calculating the due date of pregnancy
*Subtract 3 months, add 7 days , add a year
Example:
12 5 18
-3 +7 +1
9 12 19
September 12, 2019

3. AOG or AGE OF GESTATION

- Determines how many weeks of pregnancy
Example:
LMP: June 30, 2018
JUNE 30 – 1
JULY - 31
AUG - 31
SEPT - 31
OCT - 31
NOV - 31
DEC - 31
JAN - 31
= 216
216 / 7 = 30 WEEKS

4. FUNDAL HEIGHT AND FUNDAL HEART TONE

 Fundal Height – Measurement of the tummy and helps in determining the AOG
 Fundal Heart tone – Heartbeat or heart tone of the baby
FUNDAL HEIGHT ASSESSMENT
GESTATIONAL AGE FUNDAL HEIGHT LANDMARK
12 – 14 weeks Symphysis Pubis
Halfway between Symphysis Pubis and
16 weeks
Umbilicus
20 – 22 weeks Umbilicus Level
36 – 40 weeks Xiphoid Process of Sternum
37 – 40 weeks Regression of Fundal Height between 36 – 32
cm

- BARTHOLOMEIOUS RULE – using the landmarks / fundal height landamark

- McDonald’s Rule - determines how many weeks pregnant
Example:
AOG (mos) = Fundal Height x 2
7
AOG (week) = Fundal Height x 8
7
 LGA or Large for Gestational Age
FACTORS AFFECTING:
- Multiple Pregnancy
- Miscalculation due to wrong LMP provided
 SGA or Small Gestational Age
FACTORS AFFECTING:
- IUGR – Intra-uterine growth restriction
FUNDAL HEART TONE ASSESSMENT
 Leopard’s Maneuver
- A systematic procedure to determine fetal position and presentation
- FETAL BACK : where we can hear the feral heart tone
GUIDE QUESTIONS:
#1. What Lies in the fundus?
#2. Where is the Fetal Back?
#3. Confirmation of question #1: Determines if the presenting part is engage
#4. Determines the degree of flexion or extension of the fetal head: Can be
Missed if the presenting part is buttocks
*Soft and Round – Back part
*Hard and Round – Head Part
V. GERIATRIC HEALTH HISTORY

1. IMMUNIZATION
- Pneumococcal and Flu Vaccine
2. CURRENT MEDICATION
- Maintenance
3. OVER THE COUNTER MEDICATIONS
4. ACTIVITIES OF DAILY LIVING
5. SOCIAL SUPPORT
PHYSICAL EXAMINATION (MS. VILLARIN)
PREPARATION GUIDELINES:
Instrumentation
- Thermometer - Specimen container, slides, wooden
- Sphygmomanometer or plastic spatula
- Stethoscope - Sterile Swabs
- Wristwatch with second hand - Tissues
- Pulse oximeter - Tongue Depressors
- Scale with height measurement - Tuning Fork
- Cotton applicator - Vaginal Speculum
- Flashlight and spotlight - Water - soluble lubricant
- Gloves (sterile and clean) - Eye Chart (Snellen’s Chart)
- Percussion hammer - Forms (Physical or Laboratory)
- Ruler - Gown for the client
- Tape measure - Ophthalmoscope
- Disposable pad

I. BODY TEMPERATURE
- The difference between the amount of heat production and the amount of heat
lost to the environment

TYPES OF TEMPERATURE
 CORE TEMPERATURE
- Temperature of the deep tissues in the body
- Relatively constant

 SURFACE TEMPERATURE
- Varies depending on the blood flow to the skin and the amount of heat lost to
the external environment
- Because of these changes, the acceptable temperature of a person ranges from 36
Centigrade (Celsius) to 38 Centigrade (Celsius)
CORE AND SURFACE TEMPERATURE MEASUREMENT SITE
CORE TEMPERATURE SURFACE TEMPERATURE
Rectum Skin
Tympanic membrane Oral
Temporal artery Axillae (axilla)
Esophagus
Pulmonary artery
Urinary bladder

A. THERMOMETERS
TYPES OF THERMOMETER
- Electronic Thermometer
- Chemical-dot Thermometer
- Mercury – in – glass
- Digital Thermometer

1. ELECTRONIC THERMOMETER
- Consists of a rechargeable battery – powered display unit, thin wire cord, and a
temperature processing probe covered by a disposable probe cover
- Separate unbreakable probes are available for oral and rectal use
- Has 2 modes of operation : 4 second predictive temperature
3 minutes standard temperature

 TYMPANIC MEMBRANE TEMPERATURE

- Used exclusively for tympanic temperature
- An otoscope-like speculum with an infrared sensor tip that detects heat radiated
- Placed in the auditory canal and with-in seconds, a sound signals and a reading
appears on the display unit
 SUPERFICIAL TEMPORAL ARTERY TEMPERATURE
- A handled scanner with an infrared sensor tip detects the temperature of
cutaneous blood flow by sweeping the sensor across the forehead and just behind
the ear
- After scanning is complete, a reading appears on the display unit
- A reliable noninvasive measure of core temperature.
ADVANTAGES:
Easy to read, plastic sheath is durable and suitable for children
DISADVANTAGES:
Expensive
2. CHEMICAL DOT TEMPERATURE
- One thin strip of plastic with a temperature sensor at one end
- Sensor is consist of a matrix of chemically impregnated dots that change color at
different temperature
- Centigrade Version – there are 50 dots, each represents a temperature increment
of 0.1 degrees Celsius over a range of 35.5 degrees Celsius – 40.4 degrees
Celsius
- Fahrenheit Version – there are 45 dots increments of 0.2 degrees Fahrenheit and
range of 96 degrees Fahrenheit to 104.8 degrees Fahrenheit
- Chemical dots on the thermometer change color to reflect temperature reading
usually within 60 seconds
- Single use
- For Oral Temperature

3. MERCURY – IN – GLASS THERMOMETER

- A Glass tube sealed at one end with a mercury bulb at the other end.
Exposure of the bulb to heat causes mercury to expand and rise in the enclosed
tube.
- Length of the temperature has either Fahrenheit and Celsius

REQUIRES CAREFUL PREPARATIONS OF THE DEVICE:

1. Wash Hands
2. Hold end (tip) of glass thermometer with fingertips to reduce contamination of the bulb
3. Read the mercury level
4. Place thermometer into oral or axilla or rectum
5. Leave the thermometer in place for 3 minutes
6. Remove the thermometer. Wipe-off secretions with clean tissue moving toward the bulb
7. With thermometer at eye level, read the finding, store thermometer in storage container.
Perform hand washing

4. DIGITAL THERMOMETER
- Mercury free
- Contains a thermistor inside the tip which is used to measure the temperature
- Provide quick and highly accurate results = a minute reading
- Easy to read with a LCD Display
- Mostly probe type
- Measures oral, rectal and axillary temperature
- Remember that cold or hot drinks or chewing gum can change the temperature
- THERMISTOR: A non-toxic alcohol that expands in volume as it goes warmer,
causing the liquid to move up the thin tube inside the glass
ACCEPATABLE RANGES FOR ADULTS
TEMPERATURE RANGES
36 ° C to 38 ° C
Temperature Range
96.8 ° F to 100.4 ° F
Average Oral / Tympanic Temperature 37 ° C or 98.6 ° F
Average Rectal Temperature 37.5 ° C or 99.5 ° F
Average Axillary Temperature 36.5 ° C or 97.7 ° F

CONVERSION OF TEMPERATURE:
° C = (° F – 32 °) * 5/9
° F = (9/5 * ° C) + 32 °

II. BLOOD PRESSURE

- The force exerted on the wall of an artery by the pulsing blood under pressure
from the heart
SYSTOLIC PRESSURE - The peak of maximum pressure when ejection occurs
DIASTOLIC PRESSURE – The minimal exerted force against the arterial walls
- The standard measurement is millimeters in mercury (mmHg)
- Record blood pressure with the systolic reading first before the diastolic
PULSE PRESSURE – the difference between the systolic reading and the diastolic
reading

AVERAGE OPTIMAL BLOOD PRESSURE FOR AGES

AGE BP (mmHG)
Newborn 40
1 month 85 / 54
1 year 95 / 65
6 years 105 / 65
10 – 13 years 110 / 65
14 – 17 years 120 / 75
>18 years > 120 / 80
CLASSIFICATIONS OF BLOOP PRESSURE FOR ADULTS AGES 18 AND OLDER
CATEGORY SYSTOLIC (mmHg) DIASTOLIC (mmHg)
Normal <120 <80
Pre-Hypertension 120 – 139 80 – 89
Stage 1 Hypertension 140 – 159 90 – 99
Stage 2 Hypertension >160 >100

HYPERTENSION
- Most common alteration in blood pressure
- Often asymptomatic
- Prehypertension is diagnosed in adults when an average of 2 or more diastolic
readings or at least 2 subsequent visits is between 120 and 139 mmHg
- Diastolic readings greater than 90 mmHg and systolic reading is greater than
140 mmHg
- An elevated BP does not qualify as a diagnosis of HYPERTENSION
- Associated with the thickening and loss of elasticity in the arterial wall
- Peripheral Vascular Resistance increases within thick and elastic vessels
- The heart continually pumps against greater resistance and as a result, the blood
flow to the heart, brain and kidney decreases
RISK FACTORS:
- Family history of hypertension
- Obesity
- Cigarette Smoking
- Heavy Alcohol Consumption
- High Volume Content
NURSING INTERVENTIONS ABOUT HYPERTENSION:
- Educate them about Blood pressure values
- Long term follow-up care
- Educate about the usual lack of symptoms or may not be felt
- Therapy’s ability to control but not to cure hypertension
- To follow treatment plan that ensures normal lifestyles

HYPOTENSION
- Present when the systolic BP falls to 90 mmHg or below
- Occurs because of the dilation of the arteries in the vascular bed, loss of a
substantial amount of blood volume (hemorrhage), failure of the heart
muscle to pump adequately (heart attack)
ORTHOSTATIC HYPOTENSION
- Also referred to as Postural Hypotension
- Occurs when a normotensive person develops symptoms and low blood
pressure when rising to an upright position
- Record the client’s position in addition to blood pressure
- Signs and symptoms:
*Fainting
*Weakness
*Light-headedness
- At risk:
*Dehydrated Clients
*Anemic
*Prolonged Bed rest
*Recent Blood loss

A. SPHYGMOMANOMETER
- A Pressure manometer
- An occlusive cloth or vinyl cuff that encloses an inflatable rubber bladder
- A pressure value with a release value that inflates the bladder
TYPES OF MANOMETER
1. ANEROID MANOMETER
- Has a glass – enclosed circular gauge containing a needle that registers
millimeters calibrations
ADVANTAGES:
- Safe
- Lightweight
- Portable
- Compact
2. MERCURY MANOMETER
- Contains mercury, a hazardous substance that is prohibited
- Pressure created by the inflation of the compression cuff moves the column of
the mercury upward against force of gravity
- Millimeter calibrations mark the height of the mercury column
- To ensure accurate readings, the mercury column needs to fall freely
- Place the lower edge off the cuff above the antecubital fossa, allowing room for
positioning the stethoscope bell or diaphragm
GUIDELINES FOR PROPER BLOOD PRESSURE CUFF SIZE
- Cuff width is 20% more than upper arm diameter or 40% of circumference and
2/3s of an arm length
BEFORE OBTAINNG THE CLIENT’S BLOOD PRESSURE
- Control factors that will increase blood pressure = pain, anxiety, exertion
- Obtain and record the BP in both arms and record. Normally there is a difference
of 5 to 10 mmHg.
- Get the BP of the arm with higher pressure
- Pressure difference of 10 mmHg indicates Vascular Problem and should be
reported to a doctor
- Ask the client to state his BP or usual BP
- Inform and educate the client about values of knowing BP, risk factors for
developing Hypertension and dangers of Hypertension

KOROTKOFF
- 1905, KOROTKOFF (Russian Surgeon) who first described the sounds heard
over an artery of a Blood Pressure
KOROTKOFF PHASES
1. A clear rhythmical tapping corresponding to the pulse rate that gradually increases in
intensity
2. A blowing or swishing sound occurs as the cuff continues to deflate
3. As the artery distends, there is turbulence in blood flow. A crispier or more intense tapping
will be heard
4. A softer blowing sounds that fades (cuff is further deflated)
5. Disappearance of sound or silence

B. STETHOSCOPE
PARTS OF A STETHOSCOPE
1. EARPIECE – Fit tingly and comfortably in your ears, follow contour of ear canal
pointing towards the face.
2. BINAURALS – should be angled and strong enough so earpiece stays firmly in ears
3. POLYWEIGHT TUBING – Flexible and 30 cm to 40 cm (12 in to 18 in) in length
4. DIAPHRAGM CHESTPIECE – Circular, flat portion of the chest piece with a thin
Plastic disk
- Transmits high – pitched sounds created by the high-
velocity movement of air and blood
- Used to auscultate bowel, lung and heart sounds
5. BELL – bowl-shaped chest piece usually surrounded by a rubber ring (to avoid chilling
with cold metal)
- Transmits low-pitch sounds created by low-velocity movement of blood
- auscultate heart and vascular sounds
- apply the bell lightly, resting on the skin (compressing the bell reduces low
pitched sounds and create a “diaphragm” of skin)
- Remove the earpiece regularly and clean them of cerumen
- clean the bell and diaphragm of dust, lint and body oils

C. PULSE OXIMETRY
- Measures oxygen saturation
- Acceptable SPO2 ranges from 90 % to 100 %
- However, a range of 85 % to 89 % is acceptable for certain chronic diseases
- Below 85 % is abnormal
- Most appropriate site = finger and earlobe
- Finger is free of moisture and must be free of polish and artificial nail

III. HEIGHT AND WEIGHT

- Reflects a person’s general level of health
- Routine during health screening, when admitted in hospital or when seeking
medical consult
- Infant and child = to assess growth and development
- Older adults = Height and weight assessment determines nutritional status
- Weight clients at the same time of the day on the same clothes to have an
effective comparisons of weights
- Infants – Weight in baskets or platform scales
- Measure weight in ounces and grams
- Measure height in inches and centimeters

IV. GLOVES
- Prevents transmission of pathogen by direct and indirect contact
- use clean gloves when touching blood, body fluids, secretions, excretions (except
sweat), moist mucous membranes, contaminated surface or items
- remove gloves promptly after use before touching non-contaminated items

TWO TYPES OF GLOVES : Clean and Sterile

V. REFLEXES
- Effecting reflexes reaction provides data about the integrity of sensory and
motor pathways of the reflex arc and specific spinal cord segments
- each muscle contains muscle spindle

CATEGORIES OF NORMAL REFLEX

- DEEP TENDON REFLEXES – Elicited by mildly stretching a muscle and
tapping a tendon
- CUTANEOUS REFLEXES – elicited by stimulating the skin superficially

GRADE REFLEXES AS FOLLOWS:

0 – No Response
1 – Sluggish or diminished
2 – Active or expected response
3 – More brisk than expected, slightly hyperactive
4 – Brisk and hyperactive with intermittent or transient clones

- Older adults normally have diminished reflexes

- Reflexes are hyperactive in clients when : increase of alcohol intake

VI. POSITIONS

1. SITTING POSITION
- The patient sits at the edge of the examining table without back support.
- The physician examines head, neck, heart, back and arms
2. SUPINE POSITION
- The patient lies flat on the back
- Head, neck, chest, heart, abdomen, arms and legs are being examined
3. DORSAL RECUMBENT POSITION
- The patient lies face up, with his back supporting all his weight. The patient’s
knees are drawn up and the feet are flat
- Head, neck, chest and heart are being examined
4. LITHOTOMY POSITION
- The patient lies on her back with her knees bent and her feet in stir-ups
attached to the end of the examining table.
- Used during examination of the female genital
5. SIMS’ POSITION (LATERAL)
- The patient lies on the left side. His or her left leg is slightly bent and the left
arm is placed behind the back so that the patient to weight is resting primarily
on the chest.
- Used during rectal or anal insertion
6. PRONE POSITION
- The patient lies flat on the table, facedown. The patient’s head is turned to one
side and his arms are placed at the sides or bent at the elbows.

7. LATERAL RECUMBENT POSITION

- The recovery position refers to one of a series of variation on a lateral recumbent
or three quarters prone position of the body in to which unconscious patient uses.
8. KNEE – CHEST POSITION
- The patient is lying on the table, facedown, supporting the body with the knee
and chest. The patient’s thighs are at 90 ° angle to the table and slightly
separated the head turned to one side and arm placed in the side or above the
head.
9. FOWLER’S POSITION
- The patient lies back on an examining table on which the head is elevated.
- The doctor may examine the head, neck and chest area.
- One of the best position for examining clients who experience shortness of
breath or lower back injury

PREPARING THE ENVIRONMENT

1. Examination Room – Privacy
- Adequate Lighting
- Soundproof
- warm enough
2. Use of special examination table – make clients more accessible
- help client assume different positions
- don’t leave a confused, combative or uncooperative
client unsupervised on an Exam table
PREPARING THE CLIENT
1. Physical Preparation
- Comfort and privacy of the client
- Empty bowl and bladder
- Urinalysis – clean catch midstream urine with correct label of each specimen
- Instruct the client to put on a gown for privacy
- Instruct to sit or lie down on the examination table with a drape over the lap or
lower trunk
- Keep the client warm, eliminate drafts, control room temperature and provide
warm blankets
- Routinely ask if the client is comfortable

2. Positioning
- Assume proper positioning – body parts are accessible and the client can be
comfortable
- Explain the positions and assist the client in assuming it
- Adjust the drape so that the area to be examined is accessible and not expose a
body part
- Client’s ability to assume positions will depend on:
*his or her physical strength
*mobility
*ease of breathing
*age and degree of wellness
3. Psychological Preparations
- Provide a thorough explanation of the purpose and steps of each assessment
- Help the client to feel free to ask questions and mention any discomfort
- Give a more detailed explanation as you examine each body systems
- Convey an open and professional approach
- During the examination, watch the client’s emotional response

4. Physical Guidelines

1. GENDER AND RACE

v. Gender – male / female
- Different physical features can cause confusions

vi. Race – certain illnesses affect specific group of people

- Skin cancer is most common in whites
- Prostate cancer is most common in African – American
- Cancer of the Bladder is 4x more common in men than women
2. BODY BUILD, POSTURE, GAIT

3 Different Types of Body Build:

a. ECTOMORPH (Thin)
- lean and long limbs, slim, slender, narrow waist
- can lose weight easily and have lower levels of body fats
- not predisposed to store fat nor build muscles
b. MESOMORPH (Muscular)
- Lucky one have medium bone, solid torso, low fat levels, wide shoulders with a
narrow waist
- Strong athletic body type
c. ENDOMORPH (Curvy)
- A round body shape, short and tapering limits, larger-boned than other body types
- With loss in difficult, often pear-shaped with a high tendency to store body fat
MOST COMMON BODY SHAPES – FEMALE BODY SHAPES
a. APPLE – have broader shoulder and bust and narrower hips
b. BANANA OR STRAIGHT – Rectangular
c. PEAR, SPOON OR BELL – Triangular upward
d. HOURGLASS – Triangular opposing, facing in
- Ideal, hip and bust measurements nearly equal in size with a
narrower waist measurements

 POSTURE
- Normal standing posture is an upright stance with parallel alignment of hips and
shoulders
- Normal sitting posture involves some degrees of rounding the shoulders
- Posture often reflects mood or pain
- OLDIES – Stooped, forward-bent with the hips and knees somewhat fixed and
the arms bent at the
Elbows, raising the level of the arms
OBSERVE:
- Erect
- Slumped
- Beat Posture
 GAIT
- Observe client walking into the room or at the bedside if ambulatory
- Note whether movements are coordinated or uncoordinated
- A person normally walks with the arms swinging freely at the sides, with head
and face leading the body
3. HYGIENE AND GROOMING
- Note the client’s level of cleanliness
- Grooming depends on the activities being performed just before the exam, as well
as the client’s occupation
- Note the amount and type of cosmetics used

OBSERVE:
- Appearance of the hair
- Skin
- Fingernails
- Clothes are clean or not
COGNITIVE PROCESSES
Young and Middle Adult
1. Finding a Job
- Know skills and talents and personality or characteristics
- Educational preparations and occupation
- Lack resources or support systems to finance education or to develop skills
necessary for many positions in the workplace = limited occupational choices
- Adjustment to changes in the home, workplace and personal lives
2. If Sick
- Decide about the prescribed course of therapy
- Adherence to treatment
- Educational level, socioeconomic factors and motivation and desire to learn
- Language Adequacy – languages spoken and understood
- Memory – present and past medical history
3. Self – perception or self – concept pattern
- Describes client’s self – concept pattern and perceptions of self (self – concept /
worth, emotional patterns, body image)
4. Role – Relationship pattern
- Describes the client’s pattern of role engagements and relationships
- If married = two – career families (man and wife are working)
- ADVANTAGES:
* Successful Employment
* Economic Security
* Leads to friendship, social activities, support, respect from co-workers
- LIABILITIES:
* Increase in family finances
* Transfer to a new city / place due to promotion or training
* Increase in physic al, metal or emotional energy
* Child care demands
* household needs

- ASSESS: to avoid stress = equal division of household chores, shopping and

cooking duties

* Limit recreational expenses

* Hire someone to do routine housework
* Hire someone to take care of the child
5. Risk of Illness
- Come from a family with the history of cardiovascular, renal, endocrine or
neoplastic diseases = increased risk for illness
- Lifestyle changes :
* Smoking
* drinking
* Eating food with high sodium content
6. Personal Lifestyle Interest
- Habits
* Diet
* Sleeping
* Exercise
* Sexual Habits
* Use of caffeine, tobacco, alcohol and use of illicit drugs
* Home condition and pets
- Economics :
* Types of health insurance

- Occupational Environment:
* Type of work
* Exposure to hazardous substances
* Physical or mental stress
* Military records – dates and geographical area of assignment
- Lifestyle Choices:
* Wear and tear on body’s adaptive capacities
- Stress – Related Disease:
* Ulcers, emotional disorders, infections

7. Sexuality – Reproductive Pattern

- Describes the client’s patterns of satisfaction and dissatisfaction with sexuality
- Premenopausal and post-menopausal problems

8. Coping – stress tolerance pattern

- Describes the client’s ability to manage stress, sources of support and
effectiveness of the patterns in terms of stress tolerance
9. Awareness
10. Reasoning
11. Judgment
12. Imagination
COGNITIVE CHANGES
OLDER ADULTS
1. Delirium or acute confusional state
- Reversible cognitive impairment due to a physiological cause
- Causes :
* Electrolytic imbalance
* Cerebral anoxia
* Hypoglycemia
* Medications
* Tumors
* Cerebrovascular Infections
* Stroke
* Hemorrhage

- Environmental Factors that causes:

* Sensory Deprivations
* Unfamiliar Surroundings
* Psychosocial Factors – emotional distress or pain
2. Dementia
- Generalized impairment of intellectual functioning that interferes with social
and occupational functioning
- A gradual, progressive, irreversible cerebral dysfunction
AIZHEIMER’S DISEASE STAGES
STAGE I
- Loss of short-term memory
- Decreased judgement (safety concerns)
- Inability to perform mathematical calculations
- Inability to comprehend abstract ideas
STAGE II (Middle stage, moderate dementia)
- Difficult with speech and language
- Labile personality changes
- Changes in usual grooming habits
- Inability to remember purpose of items
- Urinary incontinence
- Wandering
- Seizures
- Psychotic Behaviors = hallucinations, paranoia and depression
STAGE III (Late stage, severe dementia)
- Inability to perform activities of daily living = eating, dressing, bating and
requires total care
- Unable to remember how to walk, toilet, swallow
- Minimal or no communication
- Eventually becomes bedridden and develops complications of immobility
Example:
* Pneumonia
* Pressure Ulcer
* Constipation
- Treatment : Environmental structuring, provide safe stimulating milieu that
provides a comfortable environment

TREATMENT
Stage I – Reality Orientation
Stage II and Stage III – Validation Therapy
- Needs assurance and affirmation of feelings and thoughts
- Needs assistance with activities of daily living
- Rest between daytime activities (not sleeping)
- Monitor neurological functions = mental and emotional status and motor
capabilities for further deterioration
- Assess vital signs and respiratory status for signs and symptoms of pneumonia
and other infections
- Evaluate for gastrointestinal or urinary problems
- Takes patient to the bathroom or bedside commode before and after meals and
every 2 hours in between
- Prevent falls, burns and other injuries
- Communication = speak slowly and allow time for answers
- Appropriate referrals for counseling, support groups as indicated
- Incorporate into the environment, plants, pets, children, objects having different
tactile surfaces, décor similar to childhood surroundings (provide comfort)
- Music Therapy = enhance emotional and physical well0being and the ability to
communicate and social functioning
- Activity Therapy = include patient’s known earlier interests and preference
encourage interaction with others and provide intellectual stimulation
PHYSICAL ASSESSMENT (MS. VILLARIN)
I. INSPECTION
- The use of vision and hearing to distinguish normal from abnormal findings

To inspect the body parts accurately follow these principles

1. Adequate lighting
2. Position and expose body parts – to view all surfaces
3. Inspect each area – size, shape, color, symmetry, position and
abnormalities
4. Compose each area inspected with the same area on the opposite site of the
body
5. Use additional light (eg. Penlight) to inspect body cavities
6. Do not hurry inspection. Use palpation with or after visual inspection

II. PALPATION
- Use of the hands to touch body parts
TYPES OF PALPATION
1. LIGHT PALPATION – place the hand on the part that will be examined and
depress about 1 cm (1/2 inches)
2. DEEP PALPATION – depress the are you are examining approximately 4 cm (2
inches)
TECHNIQUES:
1. Ask the client to relax and be comfortable – muscle tension impair effective
assessment
2. Ask the client to take slow, deep breaths and place the arms along the side of the
body
3. Palpate tender areas last – Point out the more sensitive areas and note any
nonverbal signs of discomfort
4. Warm hands, short fingernails and a gentle approach
PHYSICAL ASSESSMENT (MRS. GABILAN)
PHYSICAL ASSESSMENT
- An inevitable procedure not just for nurses but also for doctors
- Provide an accurate diagnosis
PRINCIPLE:
- A complete or partial Physical Examination is conducted following a careful,
comprehensive or problem-oriented history
- Conducted in a quiet place and well-lit room for client’s comfort and privacy
APPROACH:
- Begin with a sitting position
- Expose only the part to be assessed
- Conduct the examination systematically
- Consider the underlying anatomical structures, their functions and possible
abnormalities
- Body is bilaterally symmetrical = compare findings on one side on the other
- Explain all the procedures while the examination is conducted to avoid alarming
a worrying the client and to encourage his cooperation

GENERAL SURVEY
- Begin observation on the first contact with the client. Continue throughout the
interview – as the first step in the examination of each body part

A. PHYSICAL APPERANCE
- Factors affecting:
* Age
* Sex
* Level of Consciousness
* Skin Color
* No signs of acute distress
B. BODY STRUCTURES
- Factors Affecting:
* Stature
* Nutrition
* Symmetry
* Posture
* Position
* Body build – contour
C. MOBILITY
- Factors Affecting:
* Gait
* Range of Motion
* No involuntary movements

D. BEHAVIOR
- Factors Affecting:
* Facial Expressions
* Mood and affect
* Speech
* Dress
* Personal Hygiene
* Hair

I. SKIN

 INSPECTION
- Inspect for uniformity of color, bleeding, hair patter, rashes, lesions, pallor,
erythema, skin integrity

 PALPATION
- Palpate for the temperature, tenderness, texture and turgor, edema

II. NAILS

 INSPECTION
- For grooming and cleanliness
- Color, shape, length, configuration and symmetry
- Fingernail and toenail texture and bed color
- Do Schamroth method – test for clubbing of fingers
- Nails should be 160 degrees angle

 PALPATION
- Textures
- Do the Blanch test – capillary refill
– Gently squeeze the nail bed with your thumb and the pad of
your finger to test for adherence of the nail to the nail to the
nail bed
III. SKULL, SCALP AND HAIR

 INSPECTION AND PALPATION

A. SKULL
- Inspect the skull for size, shape and configuration
- Normocephally – shape of the skull

B. SCALP AND HAIR

- Inspect the scalp and hair for general color and condition
- Separate the hair from the scalp at 1 inch intervals, inspect for cleanliness,
dryness or oiliness, parasites, dandruff, lesions and lumps
- Inspect amount of distribution of hair in scalp, body, axillae and pubic hair

IV. FACE

 INSPECTION
- Skin condition, pigmentation, scars, symmetry, facial movements
- Ask the client to smile, should be bilateral nasolabial fold, slightly asymmetry
in fold is normal
- Test functioning of the cranial nerve that innervates the facial movements
CRANIAL NERVE V (Trigeminal)
1. Sensory Function – Facial Sensation
2. Motor Function – Facial Movements

 PALPATION
a. Temporal Artery
b. Temporomandibular Joint (TMJ)
c. Sinuses
- Frontal sinus
- Maxillary sinus

V. EXTERNAL EYE STRUCTURE

 INSPECTION AND PALPATION

A. EYEBROWS
- Symmetrical and in line with each other
- Maybe black, brown, blond depending on race (evenly distributed)
- Scaliness. Parasites
B. EYES
- Observe the position and alignment of the eyeball in the eye socket

C. EYELASHES
- Color dependent on race
- Even, scaling or flashing, secretion, position of lashes

* Entropion – inward growing of lashes

* Ectropion – outward growing of lashes

D. EYELIDS
- Inspect and palpate the eyelids:
- Positive and symmetry, evenness distribution and direction, secretions and
redness
- Access the ability to close
* Palpebral Fissure – the distance between eyelids, equal on both sides
* Ptosis – drooping of the eyelids due to congenital disease or paralysis

E. CONJUCTIVA
 INSPECTION

1. Bulbar conjunctiva and sclera

- Have the client keep the head straight while looking from side to side
- Clear, moist and smooth

2. Palpebral Conjunctiva
- Inspect the palpebral conjunctiva of the lower eyelid
- Evert the upper eyelid and ask the client to look down with eyes slightly open

F. LACRIMAL APPARATUS
 INSPECTION
- Assess the areas of the lacrimal duct
- Inquire for any pain or tenderness

 PALPATION
- To assess for blockage of the nasolacrimal duct
- Use one finger to palpate just inside the lower orbital lens
G. CORNEA AND LENS
 INSPECTION
- Shine a light for the side of the eye for an oblique view
- Look through the pupil to inspect the lens
- Perform corneal sensitivity reflect test
1. By touching a wisp of a cotton ball to the cornea
- Perform the corneal light reflex or extra ocular muscle balance test
1. Shine a light at the bridge of the nose 2 to 3 feet from the client

H. IRIS AND PUPIL

 INSPECTION
- Shape and color of Iris and size and shape of the pupil
- Measure pupil against a gauge
- Equally round
- Consensual response

PERRLA (Pupil Equally Round and Reactive to Light, Accommodation)

1. Darken the room
2. Patient – focus on a distant object
3. To test for direct pupil reaction – shine a bright light obliquely into one eye and
assess the pupillary reaction
4. Look for both the direct (same eye) and consensual (different eye) response

TEST ACCOMMODATION FOR PUPILS

Accommodation – occurs when the client moves his or her focus of vision to a
Distant point to a nearer object causing the pupil to constrict

* Visualization of distant objects – papillary dilation

* Visualization of nearer objects – papillary constriction and convergence

CRANIAL NERVE II
- Testing for visual acuity and peripheral vision

A. VISUAL ACUITY
- Tested using a Snellen Chart or E chart
- E – Chart – used for those people who cannot read, handicapped or those who
cannot communicate verbally
1. Test distant visual acuity
- Position the client 20 feet from the Snellen Chart of E – Chart

2. Test near visual acuity

- The room is well lighted
- A person who wears corrected lenses should be tested with or without them to
check for adequacy of correction.
- Give the client a hand held vision chart, Jaeger reading chart or its substitute
(Magazine) and hold 14 inches from the eyes

B. VISUAL FIELD FOR GROSS PERIPHERAL VISION

1. Perform the Confrontation Test
- Position yourself approximately 2 ft. away from the client’s eye level
- Have the client cover the left eye while you cover your right eye
- Look directly to each other with the uncovered eye
- Fully extend your left arm at midline and slowly move one finger (pencil) upward
from below until the client sees your finger (pencil)
- Repeat the test for the opposite eye

C. TESTING EXTRA OCULAR MUSCLE FUNCTION

1. Corneal Light Reflex Test
- Assess parallel alignment of the eyes

2. Position Tests or Extra Ocular Movement (EOM)

- Assess eye muscle strength and cranial nerve function
- Observe the client’s eye movement

3. Cover Test
- Ask the client to stare straight ahead and focus on a distant object
- Cover one of the client’s eyes with an opaque card
- As you cover the eye, observe the previously covered eye for any movement
- Remove the opaque cad and observe the previously covered eye for any
movement
- Repeat the test on the opposite eye

* Tropia – misalignment of the eye

* Esotropia – inward misalignment
* Exotropia – outward misalignment
VI. EARS

 INSPECTION AND PALPATION

1. Inspect the auricles, tragus and lobule

- Size, shape and position
- Observe for lesions, discoloration and discharge

2. Palpation of the auricle and mastoid process

- Firmness of the cartilage of the auricles
- Tenderness, swelling and nodules

3. Inspection of the Auditory Meatus or the Ear canal

- Color, presence of cerumen, discharges
- ADULT – pull the pinna upward and backward to straighten the canal
- CHILDREN – Pull the pinna downward and backward to straighten the canal

AUDITORY SCREENING TEST

A. Gross Hearing Acuity
1. Perform the Whisper test
- The client should be able to repeat words whispered from a distance of 2 feet

B. Tuning Fork Test

1. Weber’s Test (Test for Internalization)
- Help to evaluate the conduction of sound waves through bone to help distinguish
between conductive hearing and sensorineural hearing

* CONDUCTIVE – The client hears through the poor ear

* SENSORINEURAL – The client hears through the good ear

2. Rinne Test (test for air and bone conduction)

3. Rumberg Test (test for the clients’ equilibrium)
- Ask the client to stand with feet together, arms at the sides and eyes open and
after, eyes closed.

VII. NECK
 INSPECTION
- For position, symmetry, lumps or masses
- Check the range of motion
- Movement of the neck structures
- Cervical vertebrae
 PALPATION
a. Trachea

b. Thyroid Gland
- locate the key landmarks with your thumb and index finger
- to palpate, use the posterior approach
POSTERIOR APPROACH
- Stand behind the client and ask the client to lower the chin to the chest and turn
the neck slightly to the right
- Use your left finger to push the trachea to the right
- Use your right finger to feel deeply in front of the sternomastoid muscle
- Ask the client to swallow as you palpate the right side of the gland. Reverse the
technique to palpate the left lobe of the thyroid.

 AUSCULTATION
- Done only if you find an enlarged thyroid gland during inspection and palpation

VIII. LYMPH NODES

 INSPECTION
- Systematically palpate with the pads of your index fingers and middle fingers for
the various types of nodes
a. Post-auricular
b. Pre-auricular
c. Occipital
d. Tonsillar
e. Submandibular
f. Submental
g. Superficial cervical
h. Supraclavicular
i. Posterior cervical nodes
j. Deep cervical chain

IX. NOSE AND PARANASAL SINUSES

A. EXTERNAL NOSE
 INSPECTION AND PALPATION
- Nasal color, shape, consistency and tenderness
- Flaring of the alae nasi
- Discharges
- Positions of the septum
- Check pathway for airflow through the nostrils
- To test the adequacy of function of the olfactory nerve

B. PARANASAL SINUSES
- Examination of the paranasal sinuses are indirect. Frontal and Mandibular
Sinuses are the ones available

 PALPATION
- Both cheeks – tenderness of the maxillary
- Below the eyebrows – tenderness of the frontal sinus

X. MOUTH
A. LIPS
 INSPECTION
- Consistency and color
- Smooth, no lesions and swelling

B. TEETH AND GUMS

 INSPECTION
- Ask the client to open the mouth
- Note for the no. of teeth, color and condition
- Note any repairs such as crowns or any cosmetics
- Alignment of the upper and lower jaws
- Breath should be assessed during this process
- Put on gloves and retract the client’s lips and cheeks to check gums for colors
and consistency

C. BUCCAL MUCOSA
 INSPECTION
- Check the color and consistency
- Note Stenson’s duct (Parotid Duct) located on the buccal mucosa across from the
second upper molars

D. TONGUE
 INSPECTION AND PALPATION
- Ask the client to stick out the tongue and inspect for color, moisture, size and
texture
- Observe for fasciculation and check for middle protrusions
- Palpate any lesions present for induration
E. VENTRAL SURFACE OF THE TONGUE
 INSPECTION
- Check for the ventral surface of the tongue ,frenulum, and area under the tongue

 PALPATION
- Note any induration
- Check for the frenulum that limits the tongue motion

F. WHARTON’S DUCT
 INSPECTION
- Openings from the mandibular

G. SIDE OF THE TONGUE

- Use the tongue square gauge pad to hold the client’s tongue to each side
- Palpate any lesions, ulcers or nodules for induration

H. STRENGTH OF THE TONGUE

- Place your fingers on the external surface of the client’s cheek
- Ask the client to press the tongue’s tip against the inside of the cheek to resist the
pressure form the fingers
- Repeat to the other side of the tongue

I. ANTERIOR TONGUE’S ABILITY TO TASTE

 SENSORY FUNCTION (CN VIII – FACIAL)
1. Place a sweet, salty, sour or bitter substance near the tip of the tongue
(normally the client can identify the taste)
 Bitter – back of the tongue
 Sweet – tip of the tongue
 Salty – side of the tongue
 Sour – center of the tongue

J. HARD (ANTERIOR) AND SOFT (POSTERIOR) PALATES

 INSPECTION
- Ask the client to open the mouth wide while you use a penlight to look at the roof
- Observe color and integrity
- Note any usual and foul odor

K. UVULA
 INSPECTION
- Apply a tongue depressor to the tongue and shine a penlight into the client’s wide
opened mouth
- Note the characteristics and positioning of the uvula

CRANIAL NERVE X (VAGUS NERVE)

- Ask the client to say “aah”
- Watch for the movement of the uvula and soft palate to move

L. TONSILS
 INSPECTION
- Using the tongue depressor to keep the mouth wide open, inspect the tonsils for
color, size and presence of exudate or lesions
- Grade the tonsils
Grading System used to describe the size of the tonsils can be used
* Grade 1 – behind the pillar
* Grade 2 – between the pillar and uvula
* Grade 3 – touching the uvula
* Grade 4 – in the midline

- Inspect the posterior pharyngeal wall by keeping the tongue depressor in place
and shine a penlight at the back of the throat

XI. AXILLARY NODES

 PALPATION
1. Examine while the client is sitting
2. Place the client’s arm at his side and insert the examining fingers to the apex
of the client’s axilla
3. Rotate the examining hand so that the fingers can palpate the fasciae
* Inguinal Node – size, consistency, tenderness
* Epitrochlear Node – above the Olecranon Process

XII. POSTERIOR THORAX

 INSPECTION
- Shape, spine for mobility and configuration
- Symmetry and mobility upon respiration, skin condition, rate, rhythm and effort
in breathing
- Observe use of accessory muscle by watching the client breath and note the use
of muscles
 PALPATION
- For areas of tenderness, warmth, pain, alignment, bulging or retractions of the
chest intercostal spaces.
- Note skin temperature, turgor, moisture, tenderness

RESPIRATORY / DIAPHRAGMATIC EXCURSION

1. Place the hand on the posterior chest wall with the thumbs at the level of T9 or T10
Vertebrae
2. Press together a small skin told
3. As the client takes a deep breath, observe the movement of your thumb.

VOCAL OR TACTILE FREMITUS

- Using heel or the ulnar surface of your hands to detect vibrations
- Ask the client to fold his arms across his chest
- Ask client to say “99” , “blue moon” or “1,2,3”

 PERCUSSION
- Quick sharp but relax wrist motion on the left middle finger (pleximeter) and
right middle finger (plexor) aim at distal interphalangeal joint
- Begin across the top
- Percuss in the intercostal spaces on the lungs

 AUSCULTATION
- The upper aspect of the posterior fields (ie toward the top of the patients back are
examined first)
- Ask the client to take slow deep breath through the mouth with the diaphragm of
stethoscope. Listen as the client breathe slowly and deeply
 Tracheal Sound – heard over the trachea in the neck,
inspiratory and expiratory

ADVITITIOUS (EXTRA) BREATH SOUND

1. CRACKLES (Rales) – similar to the sound of rubbing you hair between fingers
2. WHEEZES – stridor is an inspiratory where associated with upper airway obstruction
(croup)
3. RHONCHI – Any extra sound that is not a crackle or a wheeze is probably a rhonchi
and is lowpitched
XIII. ANTERIOR THORAX
 INSPECTION
- Observe the rate, rhythm, depth and effort of breathing and note whether the
expiration phase is prolonged
- Listen for obvious abnormal sounds with breathing sounds
- Use of accessory muscles (ie sternomastoid, abdominal)
- Asymmetry, deformation or increased anterior – posterior diameter
- Confirm that the trachea is near the midline

 PALPATION
- note skin temperature, turgor, moisture, tenderness
- feel the anterior thorax for areas of tenderness, alignment, bulging or retractions
of the chest intercostal spaces
- apical pulse located aligned with the left nipple

RESPIRATORY / DIAPHRAGMATIC EXCURSIONS

1. find the level of the diaphragmatic dullness on both sides of the spine at the 10 th vertebra
2. rest your hand at the 5th intercostal space
3. ask the patient to inspire deeply

 PERCUSSION
- Begin above the clavicle in the supraclavicular space and percuss downward from
on intercostal space to the next
- Displace female breast, continue downward from the ICS near the sternum

 AUSCULTATION
- Alternating from side to side of the sternum. Listen down the chest until you
reach the lung base
- Listen to one full respiratory cycle at each site
- Compare findings bilaterally:
a. Vesicular breath sounds
b. Bronchovesicular breath sounds
c. Bronchial breath sounds
XIV. HEART
 INSPECTION
- Inspect the pericardium for any bulging, heaving or thrusting
- Observe for the apical pulse (pulsations of the apex of the heart) and any
abnormal pulsation
- The client should be in a supine position and head is elevated

 PALPATION
- Identify any areas of tenderness or deformity by palpating the ribs and the
sternum
- Palpate with one or two finger pads to palpate for pulsations (aortic, pulmonic,
tricuspid and mitral)
* Aortic – 2nd Right ICS
* Pulmonic – 2nd Left ICS
* Tricuspid – 4th Left ICS
* Mitral – 5th Left ICS
 In the tricuspid area, use the palm of the hand to palpate

 PERCUSSION
1. Hyperextend the middle finger of one hand and place the distal phalynx
2. With the end of the opposite middle finger, use a quick flick of the wrist to strike the
wrist to strike first finger
3. Categorize what you hear as resonance, flat , dull or hyper resonance

 AUSCULTATION

ANATOMIC AREAS FOR AUSCULTATION

a. Aortic Valve – Right 2nd ICS – Sternal Line
b. Pulmonic Valve – Left 2nd ICS – Sternal Line
c. Tricuspid Valve – Left 4th ICS – Sternal Line
d. Mitral Valve – Left 5th ICS – Midclavicular Line

1. Auscultate the heart sounds and hear the sound

2. Listen for the S1 and S2
- S1 = best heard over the mitral valve ; systole; closure of the mitral and tricuspid
Valves
- S2 = best heard over the aortic valve ; diastole ; closure of the aortic and pulmonic
Valves
3. Listen for abnormal heart sounds
- S3 ( Kentucky Sound) = APEX, heard when the client is side-lying position at
the left side
= use the bell
= rarely heard when the client reaches to 40

- S4 (Tennessee) = APEX, heard when the client is in a supine position

= post – athletic individuals mostly experience this sound
= adults above 40
- Murmurs – sign for an abnormal heart

4. Count the heart rate at the apical pulse for one full minute

XV. BREAST (FEMALES)

 INSPECTION
- Color and texture, lesions, size and compare it with the other side
- Localized discoloration and note any retractions, dimpling, swelling or edema
- Look for:
* Lumps
* Pulled-in Nipple
- AREOLAS : size, shape, color and texture of both breasts
- NIPPLES : size and direction of the nipples of both breasts
Note any discharges, dryness, lesions or bleeding
4 MAJOR SITTING POSITIONS
1. Arms by her side
2. Arms straight in the air
3. Hands on her hips (with and without pectoral muscle contractions)
4. Arms extended

 PALPATION
- The client should be in a SUPINE POSITION – place a pillow or folded towel
under the client’s back on the side being examined and place the arm above the
head
- Palpate one breast at a time, beginning with the asymptomatic breast if the client
complains
- Masses, tenderness, temperature, consistency and elasticity
- Preferred examination is a week post-menstruation
METHODS
1. VERTICAL STRIPS
- Start at the clavicle, adjacent to the scapula
- Move your hand downward in a vertical motion
- There is a “tail” of breast tissues that extends form the lateral aspect of the
structure toward the axillae

2. PIE, WEDGE, OR RADIAL SPOKE PATTERN

- Start at the nipple, working outward

3. CIRCULAR PATTERN
- Start at the nipple
- Circular fashion in a clockwise movement

XVI. BREAST (MALES)

 INSPECTION
- Should never be omitted
- Observe the nipple and areola for ulceration, nodules, swelling or discharge
- Palpate the areolar for tenderness and nodules

XVII. ABDOMEN
- In the abdominal assessment, be sure that the client has emptied the bladder
- Place the client in a supine position with knees slightly flexed to relax abdominal
muscles
- Inspection, Auscultation, Percussion, Palpation
- Palpation is last because the patient may be in pain
 INSPECTION
- Skin color, vein, striae, scars, lesions and rashes
- UMBILICUS – color, location, contour
- ABDOMINAL CONTOUR – inspect the area between the lower ribs and pubic
bone and symmetry

 AUSCULTATION
- Precedes percussion because bowel motility and bowel sounds may be increased
by palpation or percussion
- Use the diaphragm of the stethoscope and the hands should be warmed
- Light pressure on the stethoscope is sufficient to detect bowel sounds
- Divide the abdomen into 4 quadrants
Right Upper Q. Left Upper Q.
Right Lower Q. Left Lower Q.
- Start at the right lower quadrant where the ileosecal valve is located
- Normal = 5 to 30 bowel movements
- Confirm the bowel sounds of each quadrant :
o Peristaltic sounds are quite irregular. Examine for 5 minutes especially in
the peri-umbilical area, before concluding that no bowel sounds are present
o Peristaltic Sound – movement of air and fluid

FACTORS AFFECTING BOWEL SOUNDS

1. Presence of food in the GI Tract
2. State of digestion
3. Pathologic conditions of the bowel
4. Bowel surgery
5. Constipation or diarrhea

 PERCUSSION
- Abdominal Percussion is aimed at detecting fluid in the peritoneum (ascites),
gaseous distention and in assessing solid particle in the peritoneum
- The direction of the abdominal percussion follows the auscultation site at each
abdominal guardant

o PERCUSSION OF THE LIVER

- The palms of the left hand are placed over the region of the liver = dullness
- 6 – 12 cm approximate liver span
- Liver – located to the left mid-axillary line

o PERCUSSION OF THE SPLEEN

- Posterior to the left mid-axillary line
- Percuss downward, noting the change from the lung resonance to splenic dullness

o PERCUSSION OF THE KIDNEYS

- For tenderness in difficult – to – palpate structure = use the ulnar side of the right
fist to strike the left hand
- Percussion of the kidneys at the costovertebral angles at the 12th rib

 PALPATION
a. Light Palpation
- Gentle exploration
- Indention is approximately 1 cm
- Examiners hand is parallel to the floor
b. Deep Palpation
- Indentation of at least 4 cm – 5 cm
- Pressing the distal half of the palmar region

o LIVER
Standard Method
- Place your fingers just below the right costal margin and press firmly
- Ask the patient to breathe deeply
Alternate Method
- Useful when the patient is obese
- Hook your fingers just below the right costal margin

XVIII. MUSCULOSKELETAL SYSTEM

 INSPECTION
- Observe for the size, contour, bilateral symmetry and involuntary movements
- Look for gross deformity, edema, presence of trauma such as ecchymosis or other
discolorations
- Edema – start at the lower extremities

 PALPATION
- Feel evenness of temperature
- Tonicity of muscles

PERFORM THE RANGE OF MOTION

- Test for muscle strength
- Examine both the active and passive ROM for each major joints
- Start by asking the client to move through an active Range of Motion
- Proceed to passive ROM if active ROM is abnormal

SPECIFIC JOINTS
1. Finger – flexion / extension , abduction / adduction
2. Thumb – flexion / extension , abduction / adduction
3. Wrist – flexion / extension , abduction / adduction
4. Forearm – flexion / extension
5. Elbow –
6. Shoulder – flexion / extension , internal / external rotation , abduction / adduction
7. Hip – flexion , adduction
8. Knee – flexion
9. Ankle – flexion / extension
10. Toes – flexion / extension , adduction / abduction
11. Foot – eversion / inversion
12. Spine – flexion / extension , right / left bend , rotation

ACTIVE ROM
1. Ask the client to relax and allow you to support
2. Start to perform the ROM
3. Note the type and degree of motion and limitation

PASSIVE ROM
1. Ask the patient to move
2. Note any type of degree of limitation

PLANTAR RESPONSE (BABINSKI)

1. Stroke the lateral aspect of the role of each foot with the end of a reflex hammer or key
2. Inverted J movement
3. Extension of the big toe with fanning of the other toes
4. Documentation – both normal and abnormal findings

XIX. CRANIAL NERVES

 CRANIAL NERVE I – OLFACTORY
- Identify a scented object
- Repeat the procedure for the other nostril

 CRANIAL NERVE II – OPTIC

- Test for distance visual acuity
- Test for near visual acuity
- Assess visual field for gross – peripheral vision by confrontation

 CRANIAL NERVE III – OCULUMOTOR

 CRANIAL NERVE IV – TROCHLEAR
 CRANIAL NERVE VI – ABDUCENS
- Inspect the lid margins of each eye
- Assess for extra ocular movement
- Assess for PERRLA
 CRANIAL NERVE V – TRIGEMINAL
- Test for motor function
- Test for sensory function
- Test for corneal reflex

 CRANIEL NERVE VII – FACIAL

- Test for motor function
- Test for sensory function

 CRANIAL NERVE VIII – VESTIBULOCOCHLEAR

- Testing for hearing activity

 CRANIAL NERVE IX – GLOSSOPHARYNGEAL

 CRANIAL NERVE X – VAGUS
- Test for motor functioning
- Test for gag reflex
- Check for the client’s ability to swallow

 CRANIAL NERVE XI – SPINAL ACCESSORY

- Assess for trapezius muscle
- Assess the sternocleidomastoid muscle

 CRANIAL NERVE XII – HYPOGLOSSAL

- Assess the strength and mobility of the tongue
- Assess conditions and movements of all muscles
- Evaluate gait and balance