NCMA: HEALTH ASSESSMENT
The Nursing Process
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Is a systematic, rational method of planning, and
providing quality and individualized nursing care.
Series of phases describing the practice of
nursing
GOSH approach for efficient and effective
provision of nursing care.
Goal oriented
Organized
Systematic
Humanistic care
Purposes of the Nursing Process
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To identify a client’s health status and
actual/present and potential/possible health
problems or needs.
To establish plans to meet identified needs
Deliver specific nursing interventions to meet
those needs.
Characteristics of the Nursing Process
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History of present health concern
Past health history
Family history
Lifestyle and health practice
Types of Assessment
Initial comprehensive assessment
o First time to see the patient
o Completing data base
Time-lapsed reassessment
o Ongoing process
o Data about specific problem that has been
identified
Focused or problem-oriented assessment
o Life threatening situation
o Rapid identification and intervention of
client’s need
Time lapsed
o After initial assessment
o Compare current status to baseline data
(next to IC assessment)
Steps of assessment
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Collection of data
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Organizing data
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Validation of data
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Documentation of data
According to Kozier
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Cyclic and dynamic
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Client centered
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Universally applicable
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Focus on problem solving
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Interpersonal collaborative
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Used to critical thinking
Sources of data
o Primary
o Secondary
According to Udan
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Goal oriented
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Organized
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Systematic
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Humanistic
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Efficient and effective nursing care
Types of data
Description
5 steps of the Nursing Process
1.
2.
3.
4.
5.
Assessment
Diagnosis
Planning
Intervention
Evaluation
Sources
Methods used
to obtain data
Assessment
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Collection,
organization,
validation
and
documentation of data. The most important step.
Begins during the first meeting of the nurse and
the client
Continuous process carried out during all phases
of the nursing process. Identifies the patient’s
strengths and limitations.
Skills needed
to obtain data
Examples
SUBJECTIVE
OBJECTIVE
Data elicited and
verified by the
client
- Client
- Client record
- Other health
care
professionals
Data directly/indirectly
observed through
measurement
- Observation and physical
assessment
findings of the health
professionals
- Documentation of the
assessment made in the
client record
- Observation made by the
family or significant others
Observation and physical
examination
IPPA (inspection, palpation,
percussion, and auscultation)
Client interview
Interview and
therapeutic
communication
skills
- “I can’t
breathe”
- “I have a
stomach pain”
- “I can’t sleep”
- Heart rate of 110bpm
- UTZ reveals the client is
pregnant for 18weeks
- X-ray film reveals PTB
4 sections of Assessment
Eloisa
BSN 1-Y2-5
1
Diagnosis
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A statement or conclusion regarding the nature of
phenomena
Analyzing subjective and objective data to make
a professional judgement
Provides basis for the selection of nursing
intervention
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Physiological complication that nurses
monitor to detect their onset or changes in
status.
Referral
o Occurs after assessing the client as a whole.
Types of Nursing Diagnosis
Nursing Diagnosis
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DESCRIPTION
Clinical judgement about individuals, family, or
community responses to actual and potential
health problems and life process.
Wellness
Diagnosis
Diagnostic divisions (NANDA)
o
o
o
o
o
o
o
o
o
o
o
o
o
ACTIVITY/REST
® activity intolerance, fatigue, sleep pattern
disturbance
CIRCULATION
® decreased cardiac output, Altered tissue
perfusion
EGO INTEGRITY
impaired adjustment, ineffective individual
coping, rape trauma
syndrome
ELIMINATION
® bowel incontinence, diarrhea, constipation
FOOD/FLUID
® effective breastfeeding, ineffective
breastfeeding, fluid volume deficit
HYGIENE
® self care deficit
NUEROSENSORY
® altered thought process
PAIN/COMFORT
® acute pain, Chronic pain
RESPIRATION
® ineffective airway clearance, impaired gas
exchange
SAFETY
® altered health maintenance, high risk for
infection, high risk for injury
SEXUALITY
® sexual dysfunction, altered sexuality
patterns
SOCIAL INTERACTION
® altered role performance, altered parenting,
Ineffective family coping
TEACHING / LEARNING
® knowledge deficit, altered growth and
development
After Assessing the Subjective and Objective Data
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Eloisa
Nursing Diagnosis
Collaborative problem
BSN 1-Y2-5
Actual Diagnosis
Risk Diagnosis
Possible
Diagnosis
Syndrome
Diagnosis
Describes human
response to level
of
wellness in an
individual, family,
or
community that
have a readiness
for
enhancement
Problem is present
(+) signs and
symptoms
Problem does not
exist, but the
present of risk
factors indicate a
problem is likely to
develop unless
nurses intervene
Health problem is
incomplete or
unclear
Associated with a
cluster of other
diagnosis
EXAMPLE
Readiness for
enhanced spiritual
well-being
Enhanced family
coping
Ineffective
breathing pattern
Anxiety
Risk for infection
Possible social
isolation related to
unknown etiology
Chronis pain
syndrome; Post
trauma syndrome;
Frail elderly
syndrome
Qualifiers
words that have been added to NANDA labels to
give additional meaning
o Deficient
o Impaired
o Decreased
o Ineffective
o Compromised
Component of Nursing Diagnosis
One-part statement
o consist of NANDA label only
® rape trauma syndrome
® readiness for enhanced spiritual well being
Two-part statement
o Problem + Etiology
® Constipation related to prolonged laxative
use
2
® Anxiety related to change in health status
® Ineffective breathing pattern related to
tracheobronchial obstruction
Three-part statement
o Problem + Etiology + Signs and symptoms
® Acute pain related to surgical trauma and
inflammation as evidenced by grimacing and
verbal reports of pain
Related factor (Etiology)
Etiological cause or causative factor for diagnosis
Defining characteristics (Signs and Symptoms)
Observable assessment cues such as patient
behavior, physical signs
NURSING DIAGNOSIS
Is a statement of nursing
judgement that made by
nurse, by their education,
experience and expertise
It describes the human
response to an illness or
health problem
It may change as the client
response to change
Ineffective breath pattern
Activity intolerance
Disturbed body image
Acute pain
¯
Selecting nursing interventions
¯
Individualized nursing care plan
Planning should be:
Specific
Measurable
Attainable
Realistic
Time-bound
Implementation
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MEDICAL DIAGNOSIS
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It is made by the physician
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Refers to the disease
process
Also called “Intervention”
Putting the nursing care plan into action
Purpose: to carry out planned nursing
interventions to help the client attain goals and
achieve optimal health.
Any treatment based on clinical judgement and
knowledge that a nurse performs to enhance
patience outcomes.
The “doing” phase
Implementation process
A client’s medical
diagnosis remains the
same for as long as the
disease is present
Asthma
Cerebrovascular accident
Amputation
Appendicitis
Reassessing
the client
Implementing
nursing
interventions
Determine
nurse’s need of
assistance
Documenting
nursing activities
Supervising
nursing activities
Planning
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Deliberative, systematic phase of nursing process
that involves decision making and problem
solving
Involves setting goals and outcomes
Individualized plan of care for patient once
diagnosis have been prioritized.
Nurse refers
Client assessment
data and diagnostic
statements
Formulating
client’s goal
Nursing care plan
(NCP) the blue print
of nursing process
Designing
interventions
Prevent, reduce or
eliminate the client’s
health problems
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Direct Care
o Direct intervention
o Interventions are treatments performed
through interaction with patient.
® Ex. Medication administration, VS checking,
insertion of IFC
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Indirect care
o Intervention are treatments performed away
from a patient but on behalf of the group of /
patient.
® Ex. Safety and Infection control,
delegating nurse care
Types
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Planning process
Establish client’s goal
¯
Setting priorities
Eloisa
Approach
•
BSN 1-Y2-5
Dependent
o Actions that require an order from a health
care provider
Collaborative
o Interdependent interventions
3
o
Therapies that require the combined
knowledge, skills, and expertise of multiple
health care providers
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Normal Vital Signs
Evaluation
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Assessing client’s response to nursing progress
toward health care and effectiveness of nursing
care plan
Final step of the nursing process
Crucial to determine if the patient’s condition
improved or worsen after application of the first
four steps of nursing process.
Types of evaluation
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Ongoing evaluation – continuous
Initial evaluation – specific intervals
Terminal evaluation – evaluation at discharge
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Temperature
® 36.5 – 37.2 °C
Adult PR
® 60 – 100 bpm
Respiration
® 16 -20
When to assess vital signs
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Types of outcome
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To monitor clients at risk for alteration in health
Upon admission
A change in health status
Pre and Post Op / Procedure
Pre and Post medication administration
Before and after any nursing intervention that
could affect the vital signs
o Activity, talking, chewing a gum and anxiety
affect pulse, respiration, blood pressure.
o Allow 5 minutes rest before taking VS
The goal was completely met
Partially met
Completely met
The nurse must take note:
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The steps of the nursing process are interrelated
forming a continuous circle of thought and action
that is both dynamic and cyclic.
The nurse must be able to apply some basic
abilities on the knowledge of science and theory.
Creativity and adaptability are very important.
Temperature
Methods in taking Vital signs
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Also known as “Cardinal signs”
The “taking of vital signs” refers to measurement
of the client’s body temperature (T), pulse (P)
and respiratory (R) rates, and blood pressure
(BP)
The first step in the physical examination;
common, non-invasive physical assessment
procedure done to clients.
Usually when a vital sign is abnormal, something
is wrong in at least one of the body systems
Clinical measurements that provide data that
reflect the status of several body system
including cardiovascular, peripheral vascular,
neurologic and respiratory systems.
5th vital sign - pain
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Normal temperature is 36.5 - 37.7 °C
Balance between the heat produced by the body
and heat lost from the body
The degree (°) or intensity of internal het of a
person’s body
Two kinds of temperature:
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Surface temperature
o Fluctuates in response to environment
Core temperature
o Temperature of deep tissue of the body.
o Remains relatively constant.
› Temperature is lowest in the morning (4am 6am), highest during the evening. (8pm to
midnight)
Purpose:
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Eloisa
To obtain baseline data
To detect or monitor change in client’s health
status
BSN 1-Y2-5
4
Hypothalamus
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Types of thermometers
Is a small region located at the base of the brain
that plays a vitals role such as releasing of
hormones
Temperature regulatory center found in the brain
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Age
o Infants and older clients are greatly
influenced by environment
Diurnal variations
o Temperature normally changes throughout
the day (fluctuating temperature – a change
in rate or magnitude)
Exercise
o Strenuous activity = high temperature
Hormones
o Women
® progesterone increases
temperature (.3 - .6 °C )
Stress
o Stimulates sympathetic nervous system =
increase metabolic activity
Environment
o Room temperature may affect assessment
Environment
Ovulation
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Eloisa
Febrile or Hyperthermia
o temperature is above normal or the patient
has fever, may be seen in viral or bacterial
infections, malignancies, trauma, blood and
immune disorders.
Afebrile
o Temperature is normal or without fever
Hypothermia
o (lower than 36.5) may be seen in prolonged
exposure
to
cold,
hypoglycemia,
hypothyroidism or starvation
Thyroid hormone
o regulation of metabolism (BMR)
o Increased Thyroxine output increases
metabolism (Chemical Thermogenesis)
o Thyroid hormones affects blood vessels to
determine body temperature
o Affect protein synthesis
o Hyperthyroidism (overactive thyroid) can
cause a person to feel too hot
o Hypothyroidism (underactive thyroid) can
cause a person to feel too cold
BSN 1-Y2-5
Glass thermometers
o No longer an instrument of choice
Electronic / digital thermometer
o Heat sensitive probe, read in seconds
Tympanic thermometer
o Sensor probe shaped like an otoscope in
external opening of ear canal
Alterations in body temperature
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Pyrexia / Hyperthermia / Febrile
o Body temperature above the usual range
Hyperpyrexia
o A response to prolonged exposure to cold or
need for oxygen in the body
Hypothermia
o A response to prolonged exposure to cold or
need for oxygen of the body, hypoglycemia,
hypothyroidism, starvation
Types of Fever
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Terminologies:
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2.
3.
Factors that influence body temperature:
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1.
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Intermittent fever
o Alternates at regular interval where
temperature is elevated for several hours or
periods of fever and followed by an interval of
normal temperature
® Malaria or other infectious disease
Remittent fever
o Wide range of temperature fluctuations all of
which are above normal (pyrexia) throughout
the day over 24-hour period
® May be associated with viral upper respiratory
tract or caused by drugs
Relapsing fever
o Short periods of high fever (40ºC) with
periods of 1 or 2 days of normal temperature
o Recurrent fever
® May be caused by bacterial infections
Constant fever
o Fluctuates minimally but always remain
above normal
o Temperature does not touch the baseline and
remain above normal throughout the day
Signs and symptoms of fever
1.
2.
3.
4.
5.
6.
7.
8.
9.
Sweating
Chills, shivering, or shaking
Hot or flushed skin
Headache
Body aches
Fatigue and weakness
Loss of appetite
Increased heart rate
Dehydration
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Site for temperature measurement
SITE
ADVANTAGE
DISADVANTAGE
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Oral
(36.5-37.5⁰C)
Accessible & convenient
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Rectal
(37-38.1⁰C)
Reliable measurement
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Axillary
(35.8-37⁰C)
Safe
Non-invasive
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Tympanic
(36.8-37.9)
Readily accessible
Reflects core temperature
Very fast
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Temporal
Safe and non-invasive
Very fast
Thermometers break if
bitten
Inaccurate if the client
ingested hot or cold food,
fluid or smoked
Could injured the mouth
following oral surgery
Inconvenient and more
unpleasant for clients
Difficult for client who
cannot turn to the side
Could injure the rectum
following rectal surgery
Presence of stool may
interfere with thermometer
placement.
The thermometer must be
left in place a long time to
obtain an accurate
measurement
Can be uncomfortable
and involves risk of injuring
the measurement if the
probe is inserted too far.
Repeated measurements;
may vary, right and left
measurements may
differ.
Expensive
Requires electronic
equipment that may be
expensive or unavailable
variation in technique
needed if the client has
perspiration on the
forehead.
Nursing interventions during Fever
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Eloisa
Onset / Chill
o set point increases from normal to higher
than normal
o Core temperature needs time to adjust thus
the body will compensate by heat
production response
® ↑ Heart rate
® ↑ RR (respiratory rate)
® Shivering
® Cold, pallid skin
® Cyanotic nail beds
® “Gooseflesh”
® Cessation of sweating
Course / Plateau
o after the core temperature has reach a new
set point, the person neither feels warm nor
cold
® Absence of Chills
® Skin that feels warm
® Photosensitivity
® Glassy eyed appearance
® ↑ PR and RR (pulse & respiratory rate)
® ↑ Thirst
® Dehydration
® Drowsiness, restlessness, delirium
® Loss of appetite
® Malaise
BSN 1-Y2-5
Take your temperature and assess symptoms
Stay in bed and rest
Keep hydrated or increase fluid intake
Stay cool or manage stress
Tepid sponge bath / use of cold compress
Take over the counter medication or take
medication as prescribed
Blood pressure
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Clinical onset of fever
Defervescence
o Occurs when the cause of fever is suddenly
removed, patient’s body temperature returns
to normal
o The hypothalamus attempts to normalize the
temperature resulting in a sudden
vasodilation
o This event is known as crisis, the flush
defervesce stage of pyrexia
® Flushed skin
® Sweating
® Decreased shivering
® Possible dehydration
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Blood pressure is the measure of pressure
exerted as blood flows through the artery.
May vary, position of the body and the arm
BP in a normal person who is standing is usually
higher due to gravity
BP in normal reclining is slightly lower due to
decrease in resistance
It is measured in terms of millimeters of mercury
(mm Hg) and written in fraction form.
o Systolic pressure
® Pressure of blood as result of contraction
of the ventricles
o Diastolic
® Lower pressure as result of ventricular
relaxation
Terminologies:
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Pulse pressure
o The difference between systolic and diastolic
pressure
Stroke volume
o The volume of blood ejected with each
heartbeat
Factors contributing to blood pressure
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Pumping action of the heart
o if the heart is weak = ↓blood pumped into
arteries
Cardiac output
6
The more blood the heart pumps, the
greater the pressure in blood vessels
Circulating blood volume
o An increase in volume will increase BP
o ↓blood = low BP because of ↓ fluid in
arteries
Peripheral vascular resistance
o vasoconstriction = ↑ BP
o vasodilation = ↓BP
Blood viscosity
o measurement of thickness and stickiness of
blood
o proportion of RBC to plasma is high
(hematocrit)
o 60-65% - (RBC increased)
o common to patients with polycythemia
(thickening of blood)
Elasticity of vessel walls
o An increase stiffness such as
atherosclerosis, will increase BP
o
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Hypertension
o Abnormally high blood pressure over
140/90,
o confirmed by a minimum of 2 consecutive
visits.
o Primary Hypertension.
o Secondary Hypertension
Hypotension
o Abnormally low blood pressure below 100
mmHg systolic.
o Between 85-100 mmHg systolic.
Orthostatic hypotension
o Is a sudden drop in blood pressure when
you stand from seated or lying down
position.
•
Arm with cast
Arm with arteriovenous (AV) fistula
Arm on the side of a mastectomy i.e. rt
mastectomy, rt arm
Factors that influence blood pressure
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Age
Exercise
Stress
Race
Obesity
Sex
Medication
Caffeine or nicotine intake
Extreme emotions/pain
Diurnal Variation
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Lower during sleep
Lower with blood loss
Position changes BP
Anything that causing vessels to dilate or constrict
Medication
Classification of blood pressure (mmHg)
CATEGORY
Normal
Prehypertension
Hypertension –
stage 1
Hypertension –
stage 2
SYSTOLIC
< 120
120-139
DIASTOLIC
> 80
80-89
140-159
90-99
> 160
> 100
Common errors
Cuff
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Factors affecting blood pressure
Alterations in blood pressure
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Do not take B/P in:
Inflatable rubber bladder, tube connects to the
manometer, another to the bulb, important to
have correct cuff size (judge by circumference of
the arm not age)
Support arm at heart level, palm turned upward above heart causes false low reading
o Cuff too wide – false low reading
o Cuff too narrow – false high reading
o Cuff too loose – false high reading
Korotkoff sounds
•
Eloisa
Series of sounds created as blood flows through
an artery after it has been occluded with a cuff
then cuff pressure is gradually released.
BSN 1-Y2-5
7
Pulse
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Pulse points
Wave of blood created by contraction of the left
ventricle of the heart.
Regulated by ANS (Autonomic Nervous System)
A normal pulse rate for adults is between 60 and
100 beats per minute, average 80 bpm
an indirect measurement of cardiac output
obtained by counting the number of apical or
peripheral pulse waves over a pulse point.
Assess: rate, rhythm, strength
o can assess by using palpation & auscultation.
Pulse deficit
o the difference between the radial pulse and
the apical pulse – indicates a decrease in
peripheral perfusion from some heart
conditions
Factors affecting pulse rate
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1.
Age
Gender
Exercise and Fever
Medications
Hemorrhage
Stress
Position changes
2.
3.
4.
Two types of pulse
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Central or Apical pulse
o It is located on the apex of the heart on the
left side of the chest that is monitored using
a stethoscope.
o The apex is usually found at the 5th
intercostal space just inside the midclavicular
line
Peripheral
o Pulses that can be felt on the periphery of the
body by palpating an artery over a bony
prominence.
Pulse rate (beats per minute)
5.
6.
7.
8.
Temporal
o Located in front of the ear and lateral to
eyebrow
Carotid
o Located beside the larynx
Brachial
o Located in the medial antecubital fossa
(hollow in front of the elbow)
Radial
o Located on the thumb side of the forearm at
wrist
Femoral
o located halfway between the anterior
superior iliac spine and the symphysis pubis,
below the inguinal ligament.
Popliteal
o Located behind the knee in the popliteal
fossa with the patient’s knee flexed
Dorsalis pedis
o located on the dorsum of the foot with the
foot plantar flexed. Palpate for this pulse
halfway between the middle of the pt.’s ankle
and the space between the great toe and the
second toe.
Posterior tibial
o Located on the inner side of the ankle slightly
below
Rhythm
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Eloisa
BSN 1-Y2-5
Patterns of beats and interval between the beats
(regular / irregular)
Dysrhythmia or arrhythmia
o may be a random, irregular beats or
predictable pattern of irregular beats
o Apical pulse, ECG
8
Pulse volume
Respiration
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Artery wall elasticity
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Absence of bilateral equality will also affect blood
pressure
Each time the heart beats, pressure is created that
pressure may indicates cardiovascular disorder
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Terminologies:
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Rate – N – 60-100, average 8- bpm
o Bradycardia – less than 60 bpm
o Tachycardia – greater than 100 bpm
Rhythm – pattern of the beats (reg / irreg)
Strength or size – or amplitude, the volume of
blood pushed against the wall of an artery during
the ventricular contraction
o Bounding / full – strong pulse, volume higher
than normal
o Thready / weak – diminished strength, lacks
fullness
o Imperceptible – cannot be felt or heard
0----------------- 1+ --------------------2+--------------- 3+ -----------------4+
Absent
Weak
NORMAL.
Full
Bounding
Assessing the pulse rate
1.
2.
3.
Eloisa
The nurse should begin the assessment by
speaking with the client about the normal pulse
rate.
Palpate a peripheral pulse by placing the first two
fingers on the pulse point with moderate pressure.
Count the rate for a full minute, noting the
regularity (rhythm).
BSN 1-Y2-5
Normal breathing is active & passive n
Women breathe thoracically, while men &
young children breathe diaphramatically
***usually
› Asses after taking pulse, while still holding
hand, so patient is unaware you are
counting respirations
Ventilation
o Movement of air in and out of the lungs
Symmetrical
o Sides of the chest normally rise & fall together
Asymmetrical
o Rise & fall are not together
External respiration
o Interchange of O2 and CO2 between the
alveoli and the pulmonary blood
Internal respiration
o Interchange of O2 and CO2 between the
circulating blood (pulmonary blood) and body
tissues
›
An artery is straight, smooth, soft, and pliable/
elastic.
An elastic artery contains collagen and elastin
filaments which gives it the ability to stretch in
response to each pulse.
It reflects expansibility and deformities
Presence / Absence of bilateral equality
The act of breathing or ventilation
Normal breathing is slightly observable, even
effortless, quiet, automatic, and regular. It can be
assessed by observing chest wall expansion and
bilateral symmetrical movement of the thorax
Inspiration / Inhalation
o Intake of air into the lungs (breathing in)
Expiration / Exhalation
o Breathing out of gases into the atmosphere
(breathing out)
› I&E is automatic & controlled by the
medulla oblongata (respiratory center of
brain)
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Two types of breathing
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Costal (thoracic)
o Involves the movement of the chest
o External intercoastal muscles
o Accessory muscles
o Chest upward then outward at midpoint
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Diaphragmatic (abdominal)
o Involves movement of the abdomen.
o Contraction and relaxation of the diaphragm
o Breath-in, diaphragm contracts – lungs
expands, creating a partial vacuum, allows air
to be drawn in (inhalation)
o Breath-out,
diaphragm
RELAXES
–
abdominal muscles contract and expel air
that contains carbon dioxide
o Tidal volume = 500ml of air
o Diaphragmatic breathing is the most efficient
because of the greater expansion and
ventilation
9
Normal breathing is accomplished by
1.
2.
Depths of respiration
The downward and upward movement of the
diaphragm to lengthen or shorten the chest cavity
The elevation and depression of the ribs to
increase and decrease the anteroposterior
diameter of the chest cavity
Sites
1.
2.
3.
1.
2.
3.
Abnormal patterns
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Hyperventilation
o Increased amount of air in the lungs
characterized by prolonged deep breaths.
o It is a condition in which you start to breathe
very fast
Symptoms:
® Dizziness, shortness of breath, bloating, dry
mouth,
weakness,
confusion,
sleep
disturbances, numbness and tingling or your
arms, muscle spasms, chest pain and
palpitations
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Hypoventilation
o Decreased in amount of air in lungs caused
by shallow breaths (hypopnea) or too slow
(bradypnea) or may be caused by diminished
lung function
Symptoms:
® Bluish discoloration of the skin caused by
lacked of oxygen, fatigue, drowsiness,
headaches, swelling of ankles, waking up
many times at night or waking up from sleep
unrested
Chest wall
Thorax
Nose and mouth
Rate
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Describes as breaths per minute.
o Eupnea – normal
o Bradypnea – slow respiration
o Tachypnea – fast / rapid respiration
o Apnea – absence of breathing
Normal
Deep
Shallow
Cycle /minute or breathes/minute
Sounds
Rhythm
•
•
•
•
Cheyne-stokes
o Characterized by a gradual increase in
breathing then decrease followed by apnea
o Very deep, very shallow with apnea
Kussmauls
o A rapid, deep, labored breathing associated
with acidosis particularly diabetes.
Biots
o Is characterized by regular deep inspirations
followed by regular or irregular periods of
apnea.
Effort of respiration
•
•
•
•
Chest movement
Orthopnea
o Refers to a need to sit up/upright position in
order to breath
Dyspnea
o Describes difficult & labored breathing
® Atelectasis – Partial or complete collapse of
alveoli of lungs (insufficient O2)
Eloisa
•
Stridor
o Shrill harsh sound during inspiration –
laryngeal obstruction
Stertor
o Snoring or sonorous respiration – partial
obstruction of upper airway
Wheeze
o High pitched musical squeak on expiration –
narrowed/partially
obstructed
airway
(asthma)
Bubbling
o Gurgling sounds – moist secretions
(productive cough)
BSN 1-Y2-5
•
•
Intercostal Retractions
o Upper airway (trachea) or small airways
(bronchioles) are blocked as a result,
intercostal muscles are sucked inward
between the ribs
o Reduced air pressure inside chest a sign of a
blocked airway
Substernal Retractions
o Beneath the breastbone
10
Indrawing of the abdomen just below the
sternum (breastbone)
o Belly breathing
Suprasternal Retractions
o Above the clavicles
o
•
Secretions
•
•
•
Hemoptysis
o Coughing up of blood / blood-stained mucus
Productive cough
o Wet cough, produces mucus (type of phlegm)
Non-Productive cough
o Dry cough, does not produce sputum
(phlegm)
•
A comprehensive record of the client’s past and
current health.
This is gathered during the initial assessment
interview.
Purpose
•
•
To document the responses of the client and
actual and potential concerns.
To obtain information about the client’s health.
Obtaining a valid nursing health history requires
professional, interpersonal and interviewing skills
Focuses of Interview
•
•
•
1.
2.
3.
Establishing rapport and trusting relationship
Client’s response to the health concern as a whole
person
•
•
•
•
•
•
•
When client is physically comfortable and free
from pain
Minimal interruptions
Place
•
•
•
Closed-ended question
o (when or did)
Open-ended question
o (how or what)
Rephrasing
Inferring
Providing information
Guidelines of an effective interview
Well lighted, well ventilated
Free of distractions
Place where others cannot overhear or see client
•
•
Seating Arrangement
Eloisa
Facial Expression
Appearance
Demeanor
Silence
Attitude
Listening
Verbal communication
Time
•
•
•
Introductory
Working
Summary and closing
Communication during the Interview
•
•
Convert medical terminology into common
English usage
Interpreters / translators if nurse don’t speak the
same language or dialect
Phases of Interview
Planning the Interview and Setting (TP SA DL)
•
Neither too small or too far
2 to 3 feet during interview
Also varies in ethnicity
o 8-12 inches – Arab
o 24 inches – Britain
o 18 inches – US
o 36 inches – Japan
Non-verbal communication
Interviewing
•
•
•
•
Language
Health history
•
Client in bed – 45-degree angle to bed
Initial admission – overbed table between
Standing and looking down at a client can be
intimidating
Distance
Nursing Health History and Interview Process
•
•
•
•
•
BSN 1-Y2-5
Ask only one question at a time. Multiple
questions limit the client to one choice and may
confuse the client.
Acknowledge the client’s right to look at things
the way they appear to him or her and not the way
they appear to the nurse or someone else.
Do not impose your own values on the client.
11
•
•
•
•
Avoid using personal examples, such as saying,
“if I were you…”
Nonverbally convey respect, concern, interest,
and acceptance.
Be aware of the client’s and your own body
language.
Be conscious of the client’s and your own voice
inflection, tone, and affect.
Special considerations
Gerontologic variations
•
•
•
•
Hearing acuity ® speak slowly, face the client,
position on the better acuity
Feel vulnerable and scared
Speak clearly and use straightforward language
Ask questions in simple terms
§
Types of pain
•
•
•
•
•
•
Pain – 5 Vital sign
•
Whatever the experiencing person says it is;
existing whenever he or she says it does.
An unpleasant sensory and emotional experience
associated with actual or potential tissue damage
(Merskey & Bogduk, 1994).
Terminologies
•
•
•
1.
2.
3.
4.
Transduction
Transmission
Perception
Modulation
Transduction
Pain threshold
Pain tolerance
Hyperalgesia
•
Intensity theory – Plato 428 to 347 BC
Cartesian theory – Rene Descartes 1644
Specificity theory – John Paul Nafe 1929
Gate control theory – Patric David Wall and
Ronald Melzack
•
Acute pain
o Lasts only through the expected recovery
period
o Does not last longer than six months
o Eventually resolves with or without treatment
after injured it area heals
o Unrelieved acute pain can progress to
chronic pain
o It increases the vital signs of the client
•
Chronic pain
o Ongoing pain and last longer than 6 months
o People suffer chronic pain even when there
is no past injury or any body damage
§
Non-cancer pain
® Moderate to severe lasting 6 months
or more
BSN 1-Y2-5
Noxious stimuli trigger the release of biochemical
mediators or algogenic substances:
o
o
o
o
o
Bradykinin ® Universal stimulus for pain
Prostaglandin
Serotonin
Histamine
Substance P (SP)
Transmission
•
Duration and Intensity of pain
Eloisa
Nociceptors / pain receptors
o Somatic
o Visceral
Neuropathic
o Deep somatic
o Cutaneous
Phases of nociception
Theories of Pain
•
•
•
•
Radiating pain
Referred pain
Intractable pain
Phantom pain
Sources of pain
th
•
Cancer pain
® It can be dull, achy, sharp, burning.
® It can be constant, intermittent,
mild, moderate, severe
•
Peripheral nerve fibers form synapses with
neurons in the SC
It will ascend to RAS (reticular activating system),
limbic system, thalamus, cerebral cortex
12
Pain stimuli
•
•
•
Factors influencing pain
•
Mechanical
Chemical
Thermal
•
Perception
•
•
Client becomes conscious of pain
Psychological
o Past experience
o Depression anxiety
Physiological
o Age
o Gender
Cultural
Modulation
•
“Descending system”
o Neurons in the brain stem send signals
back down to the dorsal horn of the
spinal cord.
o Descending fibers:
o Endogenous opioids (endorphins or
enkephalins),
serotonin,
and
norepinephrine
•
Endogenous opioids (endorphins or
enkephalins),
serotonin,
and
norepinephrine
Reaction to pain according to age group
•
•
•
•
•
•
Infant
Toddler / preschool
School-age
Adolescent
Adult
Older adult
Assessing pain
•
•
•
Eloisa
Client’s description of pain
Factors that influence the pain of the client
Client’s response to the pain relief strategies
BSN 1-Y2-5
13
Pain assessment scales
-
Eloisa
BSN 1-Y2-5
14
Snellen chart
Physical Assessment
Otoscope
Objectives
1.
2.
3.
4.
Identify and explain the process of Physical
Assessment
Identify the four physical assessment techniques
Understand the different guidelines involve during
physical examination
Enumerate
the
importance
of
physical
assessment technique
Physical Assessment
•
A systematic way of collecting objective data from
a client using the four examination techniques.
Ophthalmoscope
Purpose of Physical Assessment
1.
2.
3.
4.
5.
6.
Penlight
Obtain physical data about the client’s functional
abilities
Supplement, confirm, or refute data obtained in
the client’s health history
Obtain data that will help the nurse data establish
diagnoses and plan the client’s care
Evaluate the physiologic outcomes of health care
and thus the progress of a patient’s health
problem
To make clinical judgments about a client’s health
status
To identify areas for health promotion and disease
prevention
Percussion hammer
Cotton balls
Preparatory phase
1.
2.
3.
4.
5.
6.
7.
Introduce self to the client. Verify his identity.
Explain the purpose why such procedure is
necessary and how he could cooperate (i.e.
positioning).
Help him put on a clean gown and offer a bedpan
or a urinal to empty his bladder.
Ensure privacy by closing the doors or pulling the
curtains around him.
Invite a relative or a significant other to stay with
the client, as necessary
Provide adequate lighting.
Gather the Materials or Equipment.
Ensure the examination table is at a comfortable
working height. Perform hand hygiene
Weight scale with height measurement
Assessment tools
Sterile gloves
Eloisa
Ruler
BSN 1-Y2-5
15
Paper clips
Skin calliper
Pen and paper
Tuning fork
Tongue depressor
Positioning you Patient
Watch with second hand
Standing / Erect
For: assessment of
posture, gait & balance
Vaginal speculum
Contraindications:
Patients who are weak,
disabled, or paralyzed
may need assistance or
may not be able to
assume this position
Nasal speculum
Scoliosis
Kyphosis
Lordosis
Sitting
seated position, back unsupported and
legs hanging freely
Thermometer
Pulse oximeter
For: Head neck posterior and anterior
thorax, Breasts axillae heart vital signs,
upper extremities lower extremities and
reflexes.
CI: Elderly and weak clients may require
support
Dorsal Recumbent
BP Apparatus
Back lying position with knees
flexed and hips externally rotated;
small pillow under the head; soles
of the feet on the surface
Stethoscope
For: Head and neck, axillae,
anterior & thorax, lungs, breasts,
heart,
extremities,
peripheral
pulses, vital signs and vagina
CI: Clients with cardio pulmonary
problems Not used for abdominal
testing because of the increased
tension in abdominal muscles If
patient has abdominal pain, flexing
knees is usually more comfortable
Eloisa
BSN 1-Y2-5
16
Sim’s
Physical Assessment Techniques
The client is lying on the side with the body turned at 45
degrees. The lower leg is extended, with the upper leg
flexed at the hip and knee to a 45 to 90 degree angle.
Inspection
For: Assessment of rectum and vagina
CI: Difficult for elderly and people with limited joint
movement
•
•
•
•
•
•
•
•
•
•
•
Vision
Smell
Hearing
Observe for color
Size
Location
Movement
Textures
Symmetry
Odors
Sounds
Palpation
Prone
The client is lying on the abdomen with head turned to the
side.
•
Light palpation – Assess for texture, tenderness,
temperature, moisture, elasticity, pulsations,
superficial organs, and masses. Depress the skin
½” to ¾” (1.5 to 2 cm) with your finger pads, using
the lightest touch possible.
•
Deep palpation – Depress the skin 1 1/2” to 2” (4
to 5 cm) with firm, deep pressure. Use one hand
on top of the other to exert firmer pressure, if
needed.
•
Bimanual deep palpitation – Deep Palpation is
done with two hands (bimanually) or one hand
For: Posterior thorax, hip joint movement
CI: Often not tolerated by the elderly and people with
cardiovascular and respiratory problem
Lithotomy
The client is lying on the back with the hips and knees
flexed at right angles and feet in stirrups.
For: Assessment of female rectum and vagina. (for a brief
period only)
CI: May be uncomfortable and tiring for elderly people.
Often embarrassing
Knee-chest
Jack Knife
Assessment of rectal area (for a brief period only)
Eloisa
BSN 1-Y2-5
17
•
Percussion
•
•
•
•
•
•
Striking of the body surface with short, sharp
strokes
Palpable vibrations and characteristic sound
Location, size, shape
Density of underlying structures
To detect the presence of air or fluid in a body
space
Elicit tenderness
Use the bell to pick up low-pitched sounds, such
as third (S3) and fourth (S4) heart sounds. Hold
the bell lightly against the patient’s skin, just
enough to form a seal. Holding the bell too firmly
causes the skin to act as a diaphragm, obliterating
low-pitched sounds. Should be at least 1 inch
wide
Characteristics of sound heard during Auscultation
•
•
•
•
Pitch – ranging from high to low
Loudness – ranging from soft to loud
Quality – gurgling or swishing
Duration – short, medium or long
Assessment in Pregnancy
Objectives
•
Types of Percussion
1.
Direct percussion – using sharp rapid
movements from the wrist, strike the body surface
to be percussed with the pads of two, three, or
four fingers or middle finger alone. Primarily used
to assess sinuses in the adult. Using one hand to
strike the surface of the body
•
•
•
•
Terminologies
•
•
•
2.
Indirect percussion – percussion in which two
hands are used and the plexor strikes the finger of
the examiner’s other hand, which is in contact
with the body surface being percussed
(pleximeter-the middle finger of the nondominant
hand) using the finger of the one hand to tap the
finger of the other
•
•
•
•
•
•
Auscultation
•
Eloisa
Use the diaphragm to pick up high-pitched
sounds, such as first (S1) and second (S2) heart
sounds. Hold the diaphragm firmly against the
patient’s skin, enough to leave a slight ring on the
skin afterward. Should be 1.5 inches wide for
adult
BSN 1-Y2-5
Identify anatomical and physiological variations in
body systems
Compute for expected date of confinement
Know how to assess a pregnant woman
Identify signs and symptoms of pregnancy
Perform Leopold’s maneuver
•
•
•
Gravida / Gravidity
o number of times a woman is or has been
pregnant
Para / Parity
o number of pregnancy that reach the age of
viability
Primigravida
o a woman who is pregnant for the 1st time
Multigravida
o woman who is pregnant for at least 2nd time
and up
Grand Multigravida
o woman who delivered 5 or more infants
Multipara
o woman who has had more than one
pregnancy that reach the age of viability
Nulligravida
o a woman who hasn’t given birth to a child
Multiple Pregnancy
o a woman who gets pregnant to twins or
triplets
Term
o if the baby born anytime between 37 – 42
weeks
Preterm
o if the baby born before 37 weeks
Abortion
o if the baby delivered before the age of viability
LMP
o Last menstrual period
18
•
•
Obstetrics
o branch of medicine and surgery concerned in
child birth and care of woman who is giving
birth
AOG
o Age of Gestation
•
•
Early identification of risk factors during
pregnancy
Early management of problems
Decrease both maternal and infant mortality and
morbidity
Schedule of visit: As soon as the mother missed a
menstrual period
Initial visit:
•
•
•
•
•
•
•
Baseline data collection
Obstetric history
Medical and surgical history
Family history
Current problems
Initial and subsequent visit
Baseline vital signs
•
•
•
•
•
•
3rd visit
2x every other week
TRIMESTER
1st Trimester
WEIGHT GAIN
1 pound / mos
3 to 4 lbs / 3 mos
2nd
0.9 to 1 pound / mos
10 to 12 lbs / 3 mos
3rd
0.5 pound / mos
8 to 11 lbs/ 3 mos
TOTAL WEIGHT GAIN
25 to 35 lbs
Expected date of Confinement / Delivery
(EDC / EDD) Computation
Naegele’s Rule
•
calculation of expected date of confinement
(EDC)
•
LMP
Obstetrical history (GPTPALM)
•
2nd visit
Normal weight gain
Pre-Natal check up
•
Week 13 to 28
(2nd Trimester)
Week 29 to 40
(3rd Trimester)
9th month
Gravida
o number of pregnancies
Para
o total no. of deliveries > 20 weeks AOG
Term
o total no of infants born at term / 37 weeks /
more
Preterm
o total no. of infants born before 37 weeks
Abortion
o total number of spontaneous or induced
abortions below 20 weeks gestation
Living
o total number of children currently living
Multiple
o total number of multiple pregnancies
G7P5T4P1A1L6M1
Aisha Vasquez 38 year old, female is 35 weeks pregnant.
Four of them were born at 39 weeks of gestation and twins
was born at 34 weeks gestation. Two years ago she had
miscarriage at 10 weeks gestation.
January to March
+ 9 months + 7 days
April to December
- 3 months + 7 days + 1 year
Jan 2, 2021
June 11, 2020
1 – 2 – 2021
+ 9 +7
10 - 9 - 2021 / Oct 9, 2021
6 – 11 – 2020
-3+7+1
3 - 18 - 2021 /
Mar 18, 2021
Age of Gestation Computation
Mc Donald’s Rule
•
determines AOG in month by measuring from
symphysis pubis (cm) to the fundus
Fundic Height in cm x 8 = AOG in weeks
7
Fundic Height in cm x 2 = AOG in months
7
Frequency of Prenatal Visit according to DOH
WEEKS OF GESTATION
Week 0 to 12
(1st Trimester)
Eloisa
FREQUENCY OF VISIT
1st visit
BSN 1-Y2-5
19
Bartholomew’s Rule
•
Estimate age of gestation by the relative position
of the uterus in the abdominal cavity
Johnson’s Rule
•
For estimation of fetal weight
Formula:
Fundic height in cm – n X 155 = fetal weight in
grams
n = 12 if the fetus is not engaged
n = 11 if the fetus is engaged
example:
•
•
3rd mo. – the fundus is palpable above symphysis pubis
5th mo. – the fundus is palpable at the level of umbilicus
9th mo. – the fundus is below xiphoid process
Fundic Height based on home-based maternal record
by DOH
•
5th month: 20 cm
•
6th month: 21-24 cm
•
7th month: 25-28 cm
•
8th month: 29-30 cm
•
9th month: 30-34 cm
28cm not engaged
o 28cm - 12 = 16
16 x 155 = 2480gms
34cm engaged
o 34cm – 11 = 23
23 x 155 = 3565gms
Signs of Pregnancy
PRESUMPTIVE SIGNS
OCCURENCE
SIGN
3 - 4 wk
Breast
changes
Pre-menstrual
changes;
oral
contraceptives
4 wk
Amenorrhea
Stress, exercise,
malnutrition,
endocrine
problems
4 - 14 wk
N&V
Gastrointestinal
disorder
6 - 12 wk
Urinary
frequency
Infection
12 wk
Fatigue
Stress, illness
16 - 20 wk
Quickening
Gas, peristalsis
Haase’s Rule
•
To determine the length of the fetus in centimeter
Formula:
1st half of pregnancy x square at month
2nd half of pregnancy X at month by 5
1st half of pregnancy
• 3 mos x 3 = 9cm
• 4 mos x 4 = 16cm
• 5 mos x 5 = 25cm
2nd Half of pregnancy
• 6 mos x 5 = 30cm
• 7 mos x 5 = 35cm
• 8 mos x 5 = 40cm
OTHER
POSSIBLE
CAUSE
Manual computation of AOG
• JAN - 31 days
• FEB - 28/29 days
• MAR - 31 days
• APR - 30 days
• MAY - 31 days
• JUN - 30 days
• JUL - 31 days
• AUG - 31 days
• SEPT - 30 days
• OCT - 31 days
• NOV - 30 days
• DEC - 31 days
example: LMP June 11, 2020
6 - 11 - 2020
- 30
19 Jun
31 Jul
31 Aug
30 Sep
31 Oct
30 Nov
31 Dec
31 Jan
23 Feb
257/7 = 37 wks AOG
PRESUME mnemonics
•
•
•
•
•
•
•
Period absent (amenorrhea)
Really tired (fatigue)
Enlarged breast
Sore breast
Urination increased
Movement of fetus (quickening)
Emesis and nausea
LMP Aug 12, 2020 = 195/7 = 27.85 = 28 1/7 wks AOG
Eloisa
BSN 1-Y2-5
20
PROBABLE SIGNS
OCCURENCE
SIGN
Hegar’s sign
OTHER
POSSIBLE
CAUSE
5 wk
Goodell’s
Sign
Pelvic
congestion
6 - 8 wk
Chadwick’s
Sign
Pelvic
congestion
6 - 12 wk
Hegar’s
Sign
Pelvic
congestion
OCCURENCE
4 - 12 wk
+PT (blood)
H-mole,
choriocarcinoma
5 - 6 wk
Fetus in UTZ
6 - 12 wk
+PT (urine)
Pelvic infection
6 wk
FHT detected
in UTZ
16 wk
Braxton
Hicks
Contraction
Myoma
8 - 17 wk
FHT detected
in
doppler
stethoscope
16 – 28 wk
Ballottement
Tumor
17 - 19 wk
FHT detected
in
fetal
stethoscope
19 - 22 wk
Fetal
movements
palpated
Late
pregnancy
Fetal
movements
visible
•
•
•
•
POSITIVE SIGNS
Goodell’s sign
o softening of the cervix ® increased
vascularity,
slight
hypertrophy
and
hyperplasia
Chadwick sign
o violet-bluish color of the vaginal mucosa and
cervix ® increased vascularity
Hegar’s sign
o softening of the lower uterine segment
Braxton Hicks Contraction
o irregular, painless, and occur intermittently
throughout pregnancy facilitate blood flow to
the placenta
PROBABLE mnemonics
•
•
•
•
•
•
•
•
Positive pregnancy test
Returning of the fetus (ballotment)
Outline of fetus can be palpated
Braxton hicks contraction
A softening of the cervix (Goodell)
Bluish color of vulva, cervix, vagina (Chadwick)
Lower uterine segment becomes soft (Hegar)
Enlarged uterus
SIGN
OTHER
POSSIBLE
CAUSE
No other cause
FETUS mnemonics
•
•
•
•
•
Fetal movements
Electronic device detects fetal heart sounds
The delivery of the baby
Ultrasound detects the fetus
See visible movements of the baby
Physiological changes in Pregnancy
•
•
•
•
•
•
•
•
Cardiovascular system
Endocrine system
Respiratory system
Gastrointestinal system
Urinary / renal system
Musculoskeletal system
Reproductive system
Integumentary system
Cardiovascular system
•
•
•
Eloisa
BSN 1-Y2-5
Increased cardiac output (30 – 50%) / (1500cc)
Fatigue
Epistaxis due to hyperemia
21
•
•
•
•
Heart rate increases 10 – 15 beats per minute
Edema
Varicosities
Hgb and Hct Decrease ® “Anemia of Pregnancy”
Integumentary system
Stria gravidarum /
stretchmarks
Protruding umbilicus
Linea nigra
Diaphoresis
Endocrine system
•
•
•
•
Elevated hCG levels
Estrogen and progesterone increase
Thyroid activity is increased
Estriol levels increased
Respiratory system
•
•
•
•
Shortness of breath
Hyperventilation
Nasal congestion
Increase oxygen consumption and product of
carbon dioxide
o Increase uterus size ® diaphragm will be
pushed and displace ® crowding chest
cavity
Chloasma “mask of pregnancy” Increase production of
melanocytes by the pituitary gland (MSH)
Gastrointestinal system
•
•
•
•
•
•
•
•
Morning sickness
Hyperemesis gravidarum
Heartburn
Food cravings
Ptyalism – increase salivation
Flatulence
Constipation
Hemorrhoids
Spider nevi
Renal system
•
•
•
•
•
Palmar erythema
Urinary frequency
Kidneys increase in size
Glycosuria
Nocturia
Proteinuria
Musculoskeletal system
•
•
•
•
Local changes
Lordosis
Softening of all ligaments and joints
Waddling gait
Leg cramps
•
•
Reproductive system
•
•
•
•
•
•
Eloisa
Amenorrhea
Uterus increase in size
Chadwick’s sign – purplish discoloration of the
cervix and vaginal mucosa
Goodell’s sign – softening of the cervix
Hegar’s sign – softening of the lower uterine
segment
Breast changes
BSN 1-Y2-5
•
•
•
Head and Scalp – Hair tends to grow faster
during pregnancy. Oily hair is common, excess
hair dryness indicates poor nutrition
Eyes – Pale conjunctiva indicates anemia, Edema
of the eyes accompanied by visual disturbances
indicates PIH
Nose – Normal nasal congestion occurs due to
Estrogen
Ears – Nasal stiffness results in blockage in
Eustachian tube which may affect a woman’s
hearing
Mouth and Teeth – Cracked corners of the mouth
maybe caused by vitamin deficiency which
pregnant are prone to develop
22
•
Breast
o Enlargement, wider and darker areola,
prominent veins and Montgomery’s tubercle.
Colostrum can be expressed as early as the
first trimester.
o Increase estrogen ® preparation for lactation
a) Nipples erect
areola becomes darker and colostrum is
formed
b) Production of colostrum and estrogen
•
Assess heart rate using doppler
o Uterine soufflé – corresponds with maternal
heart rate
o Funic soufflé – corresponds with fetal heart rate
Leopold’s Maneuver 3
Pawlik’s grip
•
•
Leopold’s Maneuver
•
•
A systemic way to determine the position,
attitude, fetal presentation, presenting part,
estimate fetal size, fetal back, number of fetus
Christian Gerhard Leopold
Using the dominant hand, grasp the symphysis
pubis using thumb and fingers
Assess whether the presenting part is engaged in
the pelvis
o Floating/movable – presenting part is not
engaged
o Immovable – presenting part is engaged
Leopold’s Maneuver 1
Fundal Grip
•
•
While facing the client, palpate the client’s upper
abdomen with both hands. Assess size, shape,
movement, and firmness of the part
Determine presentation
o Cephalic – hard, firm, and round and moves
independently
o Breech – softer, symmetric, has bony
prominences and moves
Leopold’s Maneuver 4
Pelvic grip
•
•
Leopold’s Maneuver 2
The examiner changes the position by facing the
feet. With two hands, assess the descent of the
presenting part by locating the head or brow of
the fetus.
Assess fetal attitude (relationship of the fetus to
one another)
o If the fetal head of the fetus is well flexed, it
should be on the opposite side from the fetal
back
o If the fetal head is extended though the
occiput is instead felt and is located on the
same side as the back
Umbilical grip
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With both hands moving down, identifying the fetal
back and fetal extremities
Fetal back: hard, resistant, convex structure
Fetal extremities: nodular and irregular
Eloisa
BSN 1-Y2-5
23
Fetal heart tone site
Fetal Lie
Pregnancy discomforts
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Fetal Attitude
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Eloisa
BSN 1-Y2-5
Urinary frequency
o Void as necessary
o Decrease fluids before bed
o Avoid caffeine
o Perform Kegel exercises
o Report signs of infection
Fatigue
o Try to get a full night’s sleep
o Schedule a daily rest time
o Maintain good nutrition
Breast tenderness / soreness
o Wear a supportive and well-fitting bra
o Bra may be worn at night
Vaginal discharge
o Wear cotton underwear
o Avoid tight fitting pantyhose
o Bathe daily
Backache
o Emphasize posture
o Avoid standing for long periods
o Apply local heat
o Stoop to lift objects
o Wear good shoes
Round ligament pain
o Slowly rise from sitting position
o Bend forward to relieve pain
o Avoid twisting motions
Constipation
o Increase fiber intake in the diet
o Set a regular time for bowel movements
o Drink more fluids
o Avoid caffeinated drinks
o Rest on the left side with the hips and lower
extremities elevated
Hemorrhoids
o Avoid constipation
o Apply witch hazel pads to the hemorrhoids
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Take sitz baths with warm water as often as
needed
Nausea & vomiting
o Dry crackers on arising
o Eat small frequent meals
Varicosities
o Apply ice packs for reduction of swelling, if
preferred over heat
o Walk regularly
o Rest with the feet elevated daily
o Avoid standing for long periods
o Avoid crossing the legs
o Avoid wearing constrictive knee-high
stockings; wear support stockings instead
Ankle edema
o Avoid standing for long periods
o Rest with the feet elevated
o Avoid wearing garments that constrict the
lower extremities
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Psychological Adaption to Pregnancy
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Accepting the pregnancy
Accepting the baby
Preparation to parenthood
Nutrition
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Eloisa
Weight gain
o Variable, but 25 lb usually appropriate for
average woman with single pregnancy
o Woman should have consistent, with only 2
- 3 lbs in first trimester, then average 12 oz
gain every week in second and third
trimesters
Nutrition
o Increase energy & caloric requirements to
create new tissue and meet increased
metabolic needs (+300 kcal/ day)
o Protein 60g
o Fat-soluble vitamins (Vit. A, D, E)
o Water-soluble vitamins (Vit. C, Folic acid,
Niacin, Riboflavin, Thiamine, Vit. B6, and Vit.
B1)
o Minerals (Calcium (1200mg/day),
Phosphorus, Iodine, Iron, and Zinc)
Nutritional requirement
o Calorie
: 2, 500 kcal
o CHON
: 40 grams
o Vitamin C
: 85 mg
o Folic Acid
: 600 mg
o Calcium
: 1,200 mg
o Phosphorus
: 700 mg
o Iron
: 30mg
BSN 1-Y2-5
25