‫تقييم صحي المرحلة الثانية‬
UNIVERSITY OF MOSUL
COLLEGE OF NURSING
SECOND YEAR-SEMESTER I
Health assessment
Prepared by:
Munther al-fattah
Msc. Nursing Education
Academic Year 2012-2013
Health Assessment
Munther AL-Fattah .MSC.Adult Nursing
Health Assessment
Nursing process in Nursing Health Assessment
Nursing process
Based on the scientific method, the nursing process is a
systematic way of approaching any health problem. To
use the nursing process, you'll follow the following five
steps:
• Assess the patient.
• Formulate nursing diagnoses.
• Plan your care.
• Implement your plan.
• Evaluate the results.
Assessment
The first and most important step of the nursing process,
assessment involves
 collecting all the relevant information needed to solve
a health problem.
 interpretation of data.
Nursing diagnoses
After collecting all the appropriate data about a patient's health
problem, you'll use it to formulate your nursing diagnoses. Unlike
medical diagnoses, which focus on diseases, nursing diagnoses
focus on the patient's response his actual and potential health
problems. These responses may be physical, emotional,
psychological, cultural, and spiritual.
Plan of care
Just as the nursing diagnoses grow from the assessment
findings, the plan of care grows from your nursing
diagnoses. Creating a useful plan takes nursing
experience and awareness of the patient's individuality.
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This individuality, of course, should already be reflected in
your nursing diagnoses.
Implementation
After you've established your plan, you need to put it into
action. This may require:
• interdependent actions, such as coordinating the
contributions of other health care team members
• dependent actions, such as carrying out a doctor's
orders
• independent actions, such as applying nursing
interventions.
Implementation can be the most creatively demanding
step of the nursing process
Evaluation
In this last step of the nursing process, you evaluate the
success of your plan by determining whether goals have
been met. Thus, this step allows you to maintain a
dynamic plan of care over time as the patient moves
through the stages of illness and recovery.
Purpose of Assessment
The information gathered during an assessment is not merely
collected and
recorded. It is used to evaluate health status and to make a
judgment about:
1. Whether a problem or potential problem exists that requires
nursing intervention.
2.Status of a previously identified problem or condition in relation
to projected outcomes.
3. Strengths present in the situation, be it an individual, family, or
community, that can be used to help solve problems.
Data collection.
Types of Data
Data can be objective or subjective.
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1. Objective data( Signs) are detectable by an observer or can be
tested against an accepted standards. They can be seen, heard,
felt, smelled, or measured.
For example, a discoloration of skin, a blood pressure reading, the
act of crying, , swollen joint, or a hand tremor.
• Objective data can be collected by physical examination,
diagnostic and laboratory test results, pertinent nursing and
medical literature
2. Subjective data ( Symptoms) are apparent only to the person
affected and can be described or verified only by that person.
Itching, pain, and feeling worried are examples of subjective data.
• Subjective data can collected from the client, family, significant
others, health care team members, and health records
Sources of Data
1. Primary( direct source) : the patient; is always the best source
of data. the client can usually provide subjective data that no one
else can offer.
2. Secondary( indirect source):
significant others, health personnel, medical records.
The Role of the Nurse in Health Assessment
1. prepare patient, environment, and equipment needed for
assessment.
2. explain the assessment procedure and expected patient's
feeling during examination to patient or family.
3. ensure that all needed format and documentation papers are
included in patient's file.
4. keep privacy for the patient.
5. the nurse obtains the patient's health history and performs a
physical assessment, which can be carried out in a variety of
settings, including:
* the acute care setting, clinic or outpatient office, school, longterm care facility, or the home.
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6. A growing list of nursing diagnoses is used by nurses to
identify and categorize patient problems that nurses have the
knowledge, skills, and responsibility to treat independently .
7. Reporting and documenting the procedure with it's finding.
8. Orient the patient about the result of assessment including
normal and abnormal findings, and the actions that should be
carried out to correct the abnormalities.
Guidelines In conducting health assessment
a. preparing the patient
to ensure an accurate assessment and physical examination. The
patient must be properly prepared physically and psychologically.
To prepare the patient properly, the nurse will:
1.prepare for patient's physical comfort, by allowing the opportunity
to empty the bowel and bladder.
2. keep privacy while the patient changes into a gown and gives
patient time to understand, assisting if necessary.
3.help the patient assume proper positions during examination so
that body parts are accessible and the patient stay comfortable.
4.thoroughly explain what will be done, what the patient should
expect to feel, and how the patient can cooperate.
5.encourage patient to ask questions and mention discomfort felt
during examination.
6. have a witness or third person present in the examination room
during examination of genitalia when patient and nurse are of
opposite genders.
7. pace or time examination process according to the patient's
physical and emotional tolerance.
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b. preparing equipment.
The nurse uses a variety of equipment throughout the assessment
process.
Equipment and supplies needed for performing a physical
examination
Equipment
Incontinent sheet
Drapes
Gloves
Gown for patient
Paper towel
Percussion hammer
Height/ weight scale
Specimen containers
Sphygmomanometer
and cuff
stethoscope
Tape measure
thermometer
Tongue depressor
Wrist watch with
second hands
Cotton applicators
Eye chart ( snellen
chart
Flashlight
Lubricant
Otoscope
ophthalmoscope
Sterile safety pin
Tuning fork
Vaginal speculum
protoscope
spirometer
Health Assessment
Function
Protect bed linen from getting soiled
Ensure privacy for the client.
Prevent cross infection.
For easy access of different body parts.
Dry hands and arms and to wipe equipment.
Test various reflexes of the body.
For measure body weight and height.
Collect specific sample for laboratory
evaluation.
Measure blood pressure.
Auscultator different bogy sounds
Measure body parts. e.g abdominal girth.
Measure body temperature
Facilitate visualizing pharynx and tonsils.
Record time of examination as needed.
Examine superficial sensation of the skin
including corneal reflex.
Test visual acuity
Facilitate visualization for Ear, Nose, and
Throat and to check corneal reflex.
Lubricate instrument used in rectal and vaginal
examination.
Examine outer ear and the tympanic
membrane
Examine fundus of the eye.
Examine deep sensation of the skin.
Test hearing acuity
Facilitate vaginal examination
Facilitate rectal examination
Facilitate breathing examination
Munther AL-Fattah .MSC.Adult Nursing
C: preparing the environment
to promote patient comfort and ensure an efficient examination,
the examination room should have the following features.
1.
2.
3.
4.
5.
6.
7.
privacy for the patient.
curtains or dividers to enclose the patient's bed.
a warm comfortable temperature.
proper examination clothing for the patient.
adequate lighting.
control of outside noises.
precautions to prevent interruptions by visitors or other
health care personnel.
8. a bed or table set at examiner's waist level.
Ethico- legal considerations
Ethical issues
Whenever information is elicited from a person through a health
history or physical examination,
1. the person has the right to know why the information is
sought and how it will be used. For this reason, it is
important:
 to explain what the history and physical examination are,
 how the information will be obtained,
 and how it will be used .
 It is also important that the person be aware that the
decision to participate is voluntary.
 A private setting for the history interview and physical
examination promotes trust and encourages open, honest
communication.
 After the history and examination are completed, the nurse
selectively records the data pertinent to the patient's health
status. This written record of the patient's history and
physical examination findings is then maintained in a secure
place and made available only to those health professionals
directly involved in the care of the patient. This protects
confidentiality and promotes professional conduct.
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Legal Issues
Legal aspects of assessment are based on the idea that breach of
a duty toward the patient can be viewed as negligence.
When negligence results occurred, it can be the basis for legal
action. Be aware of some common pitfalls
■ Failure to assess: A tendency exists to assess only the patterns
that are directly affected by the medical disease.
■ Insufficient monitoring: Some conditions in problem-focused
assessment require frequent monitoring. After an assessment
indicating the need for this, write clear orders. In addition, the
physician may order specific monitoring; make sure the order is
written clearly. Examples of
the need for frequent monitoring are suicide risk, self-injury,
confusion, and risk for falls.
■ Failure to communicate: Communication failures can occur in
a number of ways, but two situations are most often the cause:
■ Lack of documentation: A basic rule to remember is that if a
nursing assessment or action was not documented, history will
show that the assessment was not performed or no action was
taken.
■ No physician notification: It is important to communicate
significant changes in a patient’s physical or mental status to the
physician. Signs and symptoms need to be investigated. It is
dangerous to assume the physician knows.
■ Failure to follow protocols: Hospitals, localities, and states
may have rules for reporting certain behaviors. For example, many
states have laws requiring a nurse to immediately report suspicion
of patient, child, or elder abuse.
Health Assessment
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Nursing health history
Taking a nursing history requires tact and sensitivity. The nurse
must put the patient at ease while making sure he or she receives
all appropriate information.
Therefore, begin history taking in a friendly, professional manner,
and provide smooth transitions across topics. A continual thread
throughout the assessment is interpreting the meaning of verbal
and nonverbal cues.
Methods of Data Collection
1. Observation: is a conscious, deliberate skill that is developed
only through effort and with an organized approach.
To observe is to gather data by using the five senses. Although
nurses observe mainly through sight , all of the senses are
engaged during observation.
Observation has two aspects.
a. noticing the stimuli, and
b. selecting, organizing, and interpreting the data.
For example , a nurse who observes that a client's face is flushed
must relate that observation to, for example, body temperatures,
activity, environment temperature, and blood pressure.
2. Interviewing
The interview is a process in which understanding of a situation is
gained through the collection of information from the individual who
is then helped to make decisions about his health status. the
interview should be conducted skillfully, with an atmosphere of
support in which rapport between nurse and the patient facilitates
self-exploration.
The amount of self-exploration depends on the purpose of the
interview. These types of interviewing illustrate different purposes.
1. Structured Interview: this is conducted to obtain specific
information and it is seen as appropriate in crisis. All questions are
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decided in advance, in accordance with the specific information to
be gained. the nurse controls the space the of interview.
2. Semi-Structured Interview.
In this interview only some questions are decided in advance. this
is used not only to gain specific information but also to explore
feeling or to promote patient's participation.
3. Unstructured Interview.
This can be valuable to explore patient' feeling.
In this type, questions are not determined in advance, but allows to
arise during the interview.
Some possible purposes are to:
•
•
•
•
•
gather data.
give information.
Identify problems of mutual concern.
Provide support, and
To provide counseling or therapy.
Phases of Interview
1. Introductory Phase:
Be a ware about the following:
* Keep the beginning short to decrease your stress and anxious as
well as the person.
* Address the person, using his/her surname, shake hands if that
seems comfortable, introduce yourself, give the reason of
interview.
2. Working Phase:
The working phase is he data gathering phase. Verbal skills for
this phase include your questions to the patient and your response
to what the patient is said.( open-ended and closed-ended
questions).
3. Closing the interview
The interview should end gracefully. An abrupt or awkward closing
can destroy rapport and leave the person with negative impression
of the whole interview. To ease into the closing, ask the person:
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" Is there anything else you would like to mention?"
"Are there any questions you would like to ask?"
"Are there any other areas I should have asked about?"
," Is there any thing else you'd like to say today"? .this allows the
patient to the choice of terminating the interview or not.
The essential steps of interview are:
1. Set the stage: the interview begins by attending to the setting
factors( the furniture, the lighting, and the environment),by putting
the patient at ease and offering openings to begin the
conversation. The nurse facilitates the process by being
empathetic, warm, encouraging and respectful.
2. Build on the work started: Questioning can help the patient to
explore the problem, to decide what the problem is, and to make
decisions about acting on it.
3. Summarize of interview: at the end of interview or at a logical
point on an interview, many effective nurse communicators find it
useful to summarize what the client has said. Summarizing means
verbally capturing the essence of what the client presented
including pertinent facts, feelings, discrepancies, and untouched
areas.
Communicating Techniques
To elicit the information you need, you may use various communication
techniques. For instance, you may ask open-ended questions, closed
questions, and directive questions. You'll also use common language,
silence, facilitation, confirmation, restatement, reflection, clarification,
confrontation, interpretation, summary, and conclusion.
Open-ended questions
Open-ended questions—such as "What brings you to the hospital
today?" or "Can you tell me about your chest pain?"—tend to elicit a
good deal of information. So you should use them as much as possible.
Unlike closed questions, open-ended ones give the patient a chance to
provide descriptive answers at his own pace. As he does, you can
evaluate his alertness and his mental abilities. However, open-ended
questions also allow the patient to digress and avoid discussing
relevant information. So you may need to gently refocus the patient's
attention.
Examples include:
2Y/
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■ “How have you been managing since your husband died?”
■ “What is it like having a teenager in the house?”
■ “Can you tell me more about that?”
■ “That must have been difficult.” (State this in a caring,
questioning manner, and pause for a response.)
Closed questions
If you need information quickly, use closed questions—such as
"Has your chest pain gone away?" because they require only oneor two-word answers. Closed questions may also cause less
anxiety for patients with poor verbal skills. However, when you use
these questions, you may get only a limited amount of information
and may convey to the patient that you aren't interested in his
plight.
Examples include:
■ “What do you have for breakfast?”
■ “When did the pain start?”
■ “Are you sleeping well?”
Directive questions
You can help the patient focus on one subject by asking him
questions, such as "When I press here, does it hurt?" and "How
painful is this?" You'll use such questions when you need specific
information. But you should use them cautiously because they may
make the patient feel rushed, and he may not share in-formation or
fully develop his thoughts.
Common language
To promote clear communication, be sure to use language that the
patient understands. Avoid using jargon and difficult clinical terms
that create a barrier between you. If the patient uses words you
don't understand, ask him to tell you what he means.
Communicating effectively
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Encourage a dialogue
Watch for nonverbal gestures
Be aware of your own body language
Overcome emotional and cultural barriers
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Collecting Subjective Data
Nursing Health History
Content of the Health History
When a patient is seen for the first time by a member of the health
care team, the first requirement is that baseline information be
obtained (except in emergency situations). The sequence and
format of obtaining data about a patient may vary, but the content,
regardless of format, usually addresses the same general topics. A
traditional approach includes the following:
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Biographical data
Chief complaint
Present health concern (or present illness)
Past history
Family history
Review of systems
Patient profile
Biographical Data
Biographical information puts the patient's health history into
context. This information includes the person's name, address,
age, gender, marital status, occupation, and ethnic origins.
Chief Complaint
The chief complaint is the issue that brings a person to the
attention of the health care provider. Questions such as, “Why
have you come to the health center today?” or “Why were you
admitted to the hospital?” usually elicit the chief complaint. In the
home setting, the initial question might be, “What is bothering you
most today?” When a problem is identified, the person's exact
words are usually recorded in quotation marks
Present Health Concern or Illness
The history of the present health concern or illness is the single
most important factor in helping the health care team arrive at a
diagnosis or determine the patient's needs. The physical
examination is helpful but often only validates the information
obtained from the history. A careful history assists in correct
selection of appropriate diagnostic tests. Although diagnostic test
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results can be helpful, they often support rather than establish the
diagnosis.
Past Health History
A detailed summary of a person's past health is an important part
of the health history. After determining the general health status,
the interviewer should inquire about immunization status according
to the recommendations of the adult immunization schedule and
record the dates of immunization (if known).
Dates of illness, or the age of the patient at the time, as well as the
names of the primary health care provider and hospital, the
diagnosis, and the treatment are noted. The interviewer elicits a
history of the following areas:
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Childhood illnesses—,rubella, polio, whooping cough,
mumps, measles, chickenpox, scarlet fever, rheumatic fever,
strep throat
Adult illnesses
Psychiatric illnesses
Injuries—burns, fractures, head injuries
Hospitalizations
Surgical and diagnostic procedures
Current medications—prescription, over-the-counter (OTC),
home remedies, complementary therapies
Use of alcohol and other drugs
Family History
To identify diseases that may be genetic, communicable, or
possibly environmental in origin, the interviewer asks about the
age and health status, or the age and cause of death, of first-order
relatives (parents, siblings, spouse, children) and second-order
relatives (grandparents, cousins). In general, it is necessary to
include the following diseases: cancer, hypertension, heart
disease, diabetes, epilepsy, mental illness, tuberculosis, kidney
disease, arthritis, allergies, asthma, alcoholism, and obesity. One
of the easiest methods of recording such data is by using the
family tree or genogram .
Psychosocial history
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The psychosocial history of the client describes the client's home
and neighborhood conditions, client's financial status, client's
occupational history, how the illness effect work/study, family and
friends of the patient , and who support him.
Activities of Daily Living
ADL
Ask the patient about his diet, sleep patterns, exercise patterns,
and use of alcohol, drugs, and tobacco.
 Feeding
 Grooming
 Bathing
 General mobility
 Toileting
 Cooking
 Bed mobility
 Home maintenance
 Dressing, and
 Shopping
Review of Systems
The review of systems includes an overview of general health as
well as symptoms related to each body system. Questions are
asked about each of the major body systems in terms of past or
present symptoms.
Functional Assessment
Functional assessment includes
 Independency level,
 Requires use of equipment or device.
 Requires assistance or supervision of another person and
equipment o device.
 dependent and does not participate.
Patient Profile
In the patient profile, more biographical information is gathered. A
complete composite, or profile, of the patient is critical to analysis
of the chief complaint and of the person's ability to deal with the
problem.
A general patient profile consists of the following content areas:
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Past life events related to health
Education and occupation
Environment (physical, spiritual, cultural, interpersonal)
Lifestyle (patterns and habits)
Presence of a physical or mental disability
Self-concept
Sexuality
Risk for abuse
Stress and coping response.
Critical Thinking in Health Assessment
Critical thinking is a process synonymous with the diagnostic
reasoning process. Critical thinking in nursing has four
characteristics:
 Entails purposeful, goal-directed thinking.
 Aims to make judgments based on evidence (fact) rather
than conjecture (guess work).
 Is based on principles of science and scientific method.
 Required strategies that maximize human potential and
compensate for problems caused by human nature.
The depth and breadth of expert knowledge, largely gained
enhance critical thinking ability.
Characteristic of Critical Thinker Nurse in Health
Assessment
 Knowledge is highly organized and structured. Making
recall of information easier ,have a large storehouse of
experiential knowledge.
 Are a ware of resources and how to use them.
 Are usually more self-confident.
 More focus ,less anxious.
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 Comfortable with rethinking procedure if patient needs
require modification of the procedure.
 Have a good idea of suspected problem, allowing them to
question more deeply and to collect more relevant and in
depth data.
 Are challenged by novices questions, clarifying their own
thinking when teaching novices.
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Functional Health Patterns
Functional Health Questions always arise about what information
to collect, in what sequence, and how extensive the assessment
should be. Functional health patterns provide:
■ Items to assess.
■ Structure for organizing assessment data.
■ Purpose and direction to health status evaluation and diagnosis.
Gordon's functional health patterns
Gordon's functional health pattern is a method devised by Major
Gordon to be used by nurses in the nursing process to provide a
more comprehensive nursing assessment of the patient.
The 11 functional health patterns for use with individuals, families,
and communities are:
1. Health Perception and Management
The following questions pertain to those asked by the nurse to
provide an overview of the individual's health status and health
practices that are used to reach the current level of health or
wellness.
History (subjective data):
Client’s general health? Any colds in past year? If appropriate: any
absences from work/school? Most important things you do to keep
healthy? Use of cigarettes, alcohol, drugs? Perform self exams,
i.e. Breast/testicular self-examination? Accidents at home, work,
school, driving? In past, has it been easy to find ways to carry out
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doctor’s or nurse’s suggestions? (If appropriate) What do you think
caused current illness? What actions have you taken since
symptoms started? Have your actions helped? (If appropriate)
What things are most important to your health? How can we be
most helpful? done exercise every what?
2. Nutritional metabolic
This pattern describes nutrient intake relative to metabolic need.
History (subjective data):
Typical daily food intake? (Describe) Use of supplements,
vitamins, types of snacks? Typical daily fluid intake? (Describe)
Weight loss/gain? Height loss/gain? Appetite? Breastfeeding?
Infant feeding? Food or eating: Discomfort, swallowing difficulties,
diet restrictions, able to follow? Healing – any problems? Skin
problems: lesions? Dryness? Dental problems?
Examination (examples of objective data):
Skin assessment, oral mucous membranes, teeth, actual
weight/height, temperature. Abdominal assessment.
3. Elimination
Describes the function of the bowel, bladder and skin. Through this
pattern the nurse is able to determine regularity, quality, and
quantity of stool and urine.
History (subjective data):
Bowel elimination pattern (describe) Frequency, character,
discomfort, problem with bowel control, use of laxatives (i.e. type,
frequency), etc.? Urinary elimination pattern (describe) Frequency,
problem with bladder control? Excess perspiration? Odour
problems? Body cavity drainage, suction, etc.?
Examination (examples of objective data):
If indicated, examine excretions or drainage for characteristics,
color, and consistency. Abdominal assessment.
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4. Activity exercise
This pattern centers on activity level, exercise program, and leisure
activities.
History (subjective data):
Sufficient energy for desired and/or required activities? Exercise
pattern? Type? regularity? Spare time (leisure) activities? Childplay activities? Perceived ability for feeding, grooming, bathing,
general mobility, toileting, home maintenance, bed mobility,
dressing and shopping?
Examination (examples of objective data):
Demonstrate ability for above criteria. Gait. Posture. Absent body
part. Range of motion (ROM) joints. Hand grip - can pick up
pencil? Respiration. Blood pressure. General appearance.
Musculoskeletal, cardiac and respiratory assessments.
5. Sleep/ Rest
Assesses sleep and rest patterns.
History (subjective data):
Generally rested and ready for activity after sleep? Sleep onset
problems? Aids? Dreams (nightmares), early awakening? Rest /
relaxation periods?
Examination (examples of objective data):
Observe sleep pattern and rest pattern.
6. Cognitive-perceptual
Assesses the ability of the individual to understand and follow
directions, retain information, make decisions, and solve problems.
Also assesses the five senses.
History (subjective data):
Hearing difficulty? Hearing aid? Vision? Wears glasses? Last
checked? When last changed? Any change in memory?
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Concentration? Important decisions easy/difficult to make? Easiest
way for you to learn things? Any difficulty? Any discomfort? Pain?
If appropriate – PQRST questions PQRST P – Palliative,
Provocative Q - Quality or quantity R – Region or radiation S Severity or scale T - Timing (Morton, 1977) COLDSPA C Character O - Onset L - Location D - Duration S – Severity P Pattern A - Associated factors (Weber, 2003)
Examination (examples of objective data):
Orientation. Hears whispers? Reads newsprint? Grasps ideas and
questions (abstract, concrete)? Language spoken. Vocabulary
level. Attention span.
7. Self perception/self concept
History (subjective data):
How do you describe yourself? Most of the time, feel good (or not
so good) about self? Changes in body or things you can do?
Problems for you? Changes in the way you feel about self or body
(generally or since illness started)? Things frequently make you
angry? Annoyed? Fearful? Anxious? Depressed? Not able to
control things? What helps? Ever feel you lose hope?
Examination (examples of objective data):
Eye contact. Attention span (distraction?). Voice and speech
pattern. Body posture. Client nervous (5) or relaxed (1) (rate scale
1-5) Client assertive (5) or passive (1) (rate scale 1-5)
8. Role relationship
History (subjective data):
Live alone? Family? Family structure? Any family problems you
have difficulty handling (nuclear/extended family)? Family or others
depend on you for things? How well are you managing? If
appropriate – How families/others feel about your illness?
Problems with children? Belong to social groups? Close friends?
Feel lonely? (Frequency) Things generally go well at work /
school? If appropriate – income sufficient for needs? Feel part of
(or isolated in) your neighborhood?
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Examination (examples of objective data):
Interaction with family members or others if present.
9. Sexuality reproductive
History (subjective data):
If appropriate to age and situation – Sexual relationships
satisfying? Changes? Problems? If appropriate – Use of
contraceptives? Problems? Female – when did menstruation
begin? Last menstrual period (LMP)? Any menstrual problems?
(Gravida/Para if appropriate)
Examination (examples of objective data):
None unless a problem is identified or a pelvic examination is
warranted as port of full physical assessment (advanced nursing
skill).
10. Coping-stress tolerance
History (subjective data):
Any big changes in your life in last year or two? Crisis? Who is
most helpful in talking things over? Available to you now? Tense or
relaxed most of the time? When tense, what helps? Use any
medications, drugs, alcohol to relax? When (if) there are big
problems in your life, how do you handle them? Most of the time,
are these ways successful?
Examination (examples of objective data):
None
11. Value-Belief Pattern
History (subjective data):
Generally get things you want from life? Important plans for future?
Religion important to you? If appropriate - Does this help when
difficulties arise? If appropriate – will being here interfere with any
religious practices?
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Examination (examples of objective data):
None
Kats Index of Independency
The Katz Index of Independence in Activities of Daily Living,
commonly referred to as the Katz ADL, is the most appropriate
instrument to assess functional status as a measurement of the
client’s ability to perform activities of daily living independently. The
Index ranks adequacy of performance in the six functions of
bathing, dressing, toileting, transferring, continence, and feeding.
Clients are scored yes/no for independence in each of the six
functions. A score of 6 indicates full function, 4 indicates moderate
impairment, and 2 or less indicates severe functional impairment.
TARGET POPULATION: The instrument is most effectively used
among older adults in a variety of care settings, when baseline
measurements, taken when the client is well, are compared to
periodic or subsequent measures.
The Katz ADL Index is very useful in creating a common language
about patient function for all practitioners involved in overall care
planning and discharge planning.
Kats Index of Independency in Activities of Daily Living
ACTIVITIES
Points (1 or 0)
BATHING
Points:___________
DRESSING
Points:___________
TOILETING
Points:___________
Health Assessment
INDEPENDENCE:
(1 POINT)
NO supervision,
direction or personal
assistance
DEPENDENCE:
(0 POINTS)
WITH supervision, direction,
personal
assistance or total care
(1 POINT) Bathes self
completely or
needs help in bathing only a
single part of
the body such as the back,
genital area or
disabled extremity.
(1 POINT) Gets clothes from
closets and
drawers and puts on clothes
and outer
garments complete with
fasteners. May
have help tying shoes.
(1 POINT) Goes to toilet,
gets on and
(0 POINTS) Needs help with
bathing more
than one part of the body, getting
in or
out of the tub or shower. Requires
total
bathing.
(0 POINTS) Needs help with
dressing self
or needs to be completely dressed.
(0 POINTS) Needs help
transferring to
Munther AL-Fattah .MSC.Adult Nursing
TRANSFERRING
Points:___________
CONTINENCE
Points:___________
FEEDING
Points:___________
off, arranges clothes, cleans
genital area
without help.
(1 POINT) Moves in and out
of bed or
chair unassisted. Mechanical
transferring
aides are acceptable.
(1 POINT) Exercises
complete self control
over urination and
defecation.
(1 POINT) Gets food from
plate into
mouth without help.
Preparation of food
may be done by another
person.
the toilet, cleaning self or uses
bedpan or
commode.
(0 POINTS) Needs help in moving
from bed to chair or requires a
complete
transfer.
(0 POINTS) Is partially or totally
incontinent of bowel or bladder.
(0 POINTS) Needs partial or total
help
with feeding or requires parenteral
feeding.
TOTAL POINTS = ______ 6 = High (patient independent) 0 = Low (patient very dependent)
Barthel Index
The Barthel Index consists of 10 items that measure a person's
daily functioning specifically the activities of daily living and
mobility. The items include feeding, moving from wheelchair to bed
and return, grooming, transferring to and from a toilet, bathing,
walking on level surface, going up and down stairs, dressing,
continence of bowels and bladder.
How is the Barthel Index used?
The assessment can be used to determine a baseline level of
functioning and can be used to monitor improvement in activities of
daily living over time. The person receives a score based on
whether they have received help while doing the task. The scores
for each of the items are summed to create a total score. The
higher the score the more "independent" the person.
Independence means that the person needs no assistance at any
part of the task. If a person does about 50% independently then
the "middle" score would apply.
Example form:
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Patient Name: __________________ Rater: ____________________ Date:
/
/
:
Activity
Score
Feeding
0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent
0
Bathing
0 = dependent
5 = independent (or in shower)
5
0
Grooming
0 = needs to help with personal care
5 = independent face/hair/teeth/shaving (implements provided)
10
5
0
5
Dressing
0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)
0
5
10
Bowels
0 = incontinent (or needs to be given enemas)
5 = occasional accident
10 = continent
0
5
10
Bladder
0 = incontinent, or catheterized and unable to manage alone
5 = occasional accident
10 = continent
0
5
10
Toilet Use
0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)
0
5
10
Transfers (bed to chair and back)
0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
10 = minor help (verbal or physical)
15 = independent
0
5
10
15
Mobility (on level surfaces)
0 = immobile or < 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; for example, stick) > 50 yards
0
5
10
15
Stairs
0 = unable
Health Assessment
0
Munther AL-Fattah .MSC.Adult Nursing
5
10
5 = needs help (verbal, physical, carrying aid)
10 = independent
TOTAL (0 - 100)
________
Physical Examination
Examination Techniques
The nurse depends on his/her own senses and uses them in five
examination techniques that enable nurse to collect a broad range
of physical data about the patients. these are
1.
2.
3.
4.
5.
Inspection (Using Sight)
Palpation ( Using touch)
Percussion (Using hearing and touch).
Auscultation (Using hearing)
Olfaction ( Using Smell).
Inspection
Inspection is the visual examination, i.e. , assessing using the
sense of sight. The nurse inspects with the naked eye and with a
lighted instrument such as an otoscope(used to view ear). Nurses
frequently use this technique to assess Color, rashes, scars, body
shape, facial expressions that may reflect emotions, and body
structures.
Inspection is an active process, not a passive one. The nurse must
know what to look for and where.
take the health history and perform the physical examination. Still,
your inspection needs to be systematic. When you inspect a
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patient you should, for instance, proceed from head to toe,
observing first for general characteristics, then for specific ones.
Palpation
Palpation is the examination of the body using the sense of touch.
The pads of the figures are used because their concentration of
nerve endings makes them highly sensitive to tactile
discrimination. Palpation is used to determine:
-Texture; e.g., of the hair
-Temperature, e.g., of the skin area
-Vibration , e.g.,. of a joint.
-Position, size, consistency ,and mobility of organs or masses.
-Distension, e.g.,. of urinary bladder.
-Presence and rate of peripheral pulses.
-Tenderness of pain.
There are tow main types of palpation:
1. Light (Superficial) palpation: should always precedes deep
palpation. its use to detect tenderness, pain, texture—ect.
2. Deep palpation: is a technique used more commonly by nurse
practitioners and clinical specialists. its use to detect mass,
organomegally.
Percussion
Percussion is an assessment method in which the body surface is
struck to elicit sounds that can be heard or vibrations that can be
felt.
Percussion is used to determine the size and shape of internal
organs by establishing their borders. It indicates whether tissue is
fluid-filled, or solid. Also its used to evaluate the density of
underlying tissue and to elicit tenderness.
Percussion elicits five types of sound. These are:
1.Flatness: A soft, high-pitched sound of short duration normally
heard over muscles and bones.
is an extremely dull sound produced by very dense tissue such as
muscle or bone. pitched sound of medium intensity normally heard
over the liver.
2. Dullness: A moderately soft, high- heard over the lung, it can
indicate increased density, as in pneumonia.
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is a fluid-like sound produced by dense tissue such as the liver,
spleen, or heart.
3.Resonance: A loud, long, low-pitched sound normally heard
over the lung fields. is a hollow sound such as that produced by
lungs filled with air.
4. Hyper-resonance: A loud, low-pitched, and very long souTnd
heard over lungs that are over inflated with air (as in emphysema
is not produced in the normal body. Its described as booming and
can be heard over an emphysematous ( pathological distension of
lung tissues by air).
5. Tympany: A high-pitched, loud sound of medium duration
usually heard over the stomach, indicating the presence of gastric
air bubbles. is a musical or drum-like sound produced from an airfilled stomach.
Characteristics of percussion sounds
Percussion produces sounds that vary according to the tissue
being percussed. This chart lists important percussion sounds
along with their characteristics and typical locations.
Source
Muscle, bone
Liver, full
bladder,
pregnant
uterus
Normal lung
Gastric air
bubble,
intestinal air
Hyperinflated
lung
(as in
emphysema
Quality
Flat
Duration
Short
Pitch
High
Intensity
Soft
Sound
Flatness
Thud like Moderate
High
Soft to
moderate
Dullness
Low
Moderate to
loud
Resonance
Drum like Moderate
High
Loud
Tympany
Booming
Very
low
Very loud
Hyperreson
ance
Hollow
Long
Long
Auscultation
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Auscultation is the process of listening to sounds produces within
the body. Auscultation may be direct or indirect.
--Direct auscultation is the use of the unaided ear,. E,g. to listen
to a respiration wheeze or the grating of a moving joint.
--Indirect auscultation: is the use of stethoscope, which amplifies
the sounds and conveys them to the nurse's ear. A stethoscope is
used primarily to listen to sounds from within the body. E.g., heart,
lungs, and bowel sounds.
OLFACTION
Olfaction is the sense of smell. Certain alterations in the body
function create characteristics body odors. The sense of smell can
detect abnormalities that go unrecognized by any other means.
Example of odors
Odor
alcohol
Ammonia
Halitosis
Sweet fruity, ketones
Site or Source
Oral cavity
Urine
Oral cavity
Oral cavity
Potential Causes
Ingestion of alcohol
UTI
Poor dental and oral
hygiene, gum disease.
Diabetic acidosis
General survey
General survey is a study of the whole person, covering the
general health status and any obvious physical characteristics.
Objective parameters are used to form the general survey, but
these apply to the whole person, not just to one body system
1. General Appearance
General appearance assessment include the following.
Posture and position.
■ Position:
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The person sits comfortably in a chair or on the bed or
examination table, arm relaxed at side, head turned to
examiner.
■ Posture: the person stands comfortably erect as appropriate
for
Note the normal 'Plumb line" through anterior ear, shoulders,
patella, ankle. Expectation are:
Toddler: toddler lordosis.
Aging person: stopped with kypfosis.
■ Body movements: body movements are voluntary, deliberate,
coordinated, and smooth and even.
■ Dress: dress is appropriate for setting, season, age, gender, and
social group. Clothing fits and is put on appropriately.
■ Personal hygiene and Grooming: the person appears clean
and groomed appropriately for his/her age, occupation, and
socioeconomic status. Hair is clean and groomed, brushed,
women's make-up is appropriate for age and culture.
2. Mental status:
A. Appearance:
B. Behavior, which include.
C. Cognitive function, orient to time, person, place. Able to
attend cooperatively with examiner. Resent and remote memory
intact. Can recall four unrelated words at 5-10, and 30 minutes
testing intervals.
D. Thought processes: perception and thought processes are
logical and coherent. No suicide ideation.
3. Mobility of client
■ Gait- Normally, the base is as wide as the shoulder width,
foot placement is accurate , the walk is smooth, even, and wellbalanced, and associated movements, such as symmetric arm
swing are present.
use of assistive devices.
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■ Range of motion( ROM) of joints. Note full mobility for each
joint, and that movement is deliberate, smooth, and
coordinated, curate. No involuntary movement.
4. Behavior Of Client
■ Level of consciousness: the person is alert and oriented to
date, time and place, attends to your questions and responds
appropriately.
■ Facial expression: facial features are symmetric with
movement. the person maintains eye contact (unless cultural
taboo exists).
Expression is appropriate with situation. Note expression both
while the face is at rest and while the person is talking.
■ Mood and affect: the person is comfortable and cooperative
with the examiner and interacts pleasantly.
■ Speech: articulation ( the ability to form words) is clear and
understandable.
- the stream of talking is fluent, with an even pace.
- the person conveys ideas clearly.
- word choice is appropriate to culture and education.
- the person communicates in prevailing language easily by
himself or herself or with interpreter.
Physical Assessment
Skin, Hair, Nails
Skin: check for the following
Color: observe the skin tone. Normally, it is consistent with
genetic
background and varies from pinkish tan to ruddy dark tan or from
light to dark brown and may have yellow or olive overtones.
Temperature: the skin should be warm, and the temperature
should be equal bilaterally. Warms suggests normal circulation
status. Hands and feet may be slightly cooler in a cool
environment.
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Moisture: perspiration appears normally on the face, hands, axilla,
and skin folds in response to activity, a warm environment, or
anxiety.
Texture: normal skin feels smooth and firm, with an even
surface. skin is intact with no obvious lesions.
Thickness: The epidermis is uniformly thin over most of the body,
although thickened callus areas are normal on palms and soles.
Mobility and Turgor
Mobility is the skin's ease of rising, turgor is the ability of skin to
return to place promptly when released.
Hair: check for the following
Color: color may vary from pale blonde to total black.
Graying begins as early as the third decade of life because of
reduce melanin production.
Texture: scalp hair may be fine or thick and may look straight,
curly, or kinky. Should look shiny.
Distribution: distribution conforms to normal male and female
patterns.
Nail : check for the following:
Shape and Contour: The nail surface is normally slightly curved .
The profile sign: Note the index finger at its profile and note the
angle of the nail base, it should be about 160 degrees.
Consistency: the surface is smooth and regular, not brittle or
splitting. Nail thickness is uniform.
Color: all people normally may have white hairline linear markings
from trauma or picking at the cuticle.
Head and Neck
Head
Note the general size and shape ,normocephalic, is the term that
denote a round symmetric skull that is appropriately to body size.
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The cranial bones that normally protruded are the forehead, the
lateral edge of each parietal bone, the occipital bone, and mastoid
process behind each ear.
Note the facial expression and its appropriateness to behavior or
reported mood . Anxiety is c common in hospitalized or ill person
Neck
Head position is centered in the midline, and the accessory neck
muscles should be symmetric. The head should be held erect and
still.
Note any limitation of movement during active motion.
Palpate the lymph nodes.
Check the trachea and thyroid gland.
Thorax and Lungs
Anterior Chest
Palpate symmetric chest expansion, palpate the anterior chest
wall to note any tenderness and to detect any superficial lumps.
Assess tactile(vocal fremitus) by palpation, begins palpating
over the lung apices in supraclavicular areas. Compare
vibrations from one side to other as the person repeats "ninetynine".
Percuss the anterior chest, note the boarder of cardiac dullness
normally found on the anterior chest.
Check for Breath Sounds. Rate and depth of respiration.
Posterior chest
Inspect Thoracic Cage, note the shape and configuration of
the chest wall. The spinous processes should appears in a
straight line. The thorax is symmetric. The scapulae are placed
symmetrically in each hemi thorax.
Palpate symmetric chest expansion.
Assess tactile fremitus.
Percuss for Lung fields
Check for Breath Sounds.
Heart
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Check the apical and radial pulse.
Auscultate heart sound.
1. The first heart sound (SI): occurs with closure of
the AV Valves and thus signals the beginning of
systole.
2. The second heart sound (S2): occurs with closure
of the semi lunar Valves and signals the end of systole.
Characteristics of Sound
1. Frequency (pitch): heart sounds are described as high
pitched or low pitched.
2. Intensity (Loudness): loud or soft.
3. Duration: very short for heart sounds; silent periods are
longer.
4. Timing: Systole or diastole.
Breast
Male breast: is a rudimentary structure consisting of a thin disc of
undeveloped tissue underlying the nipple. The areola is well
developed, the nipple is relatively very small. During adolescence,
it is common for the breast tissue to temporarily enlarge, producing
gynecomastia.
Female breast:
Stages of breast development
1. Preadolescent Stage: Only a small elevated nipple.
2. Breast bud Stage: A small amount of breast and nipple
develops; the areola widen
3. The breast and areola enlarge: The nipple is flush with the
breast surface.
4. The areola and nipple from a secondary mound over the breast.
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5. Mature breast: only the nipple protrudes, the areola is flush with
the breast contour ( the areola may continue as a secondary
mound in some normal women).
Examination of breast
Check for the followings:
Pain, lump or thickening, discharge, rash, swelling, trauma, history
of breast disease, and self –care behaviors(breast-self
examination).
Axillary
Check for tenderness, lump, swelling, rash, and nodes
Abdomen
Check for the followings:
Appetite: any change in appetite, change in weight and it's
causes.
Dysphagia : any difficulty swallowing.
Food intolerance: are there any food you cannot eat?
Do you use antacids? how often.
Abdominal pain: site, intensity, duration. What makes the pain
worse ( food, position, stress, medication, activity ..etc)
Nausea and vomiting: any nausea or vomiting, is there any odor
or color of vomits.
Bowel habit: any diarrhea or constipation, color and consistency
of stool, any recent change in bowel habit, bowel movement.
Past abdominal history: ever had any operation, post operative
complication. Any past history for ulcer, appendicitis, colitis, hernia.
Medications: ask about use of any medications, alcohol, smoking.
Nutritional assessment: ask for like and dislike foods
The anatomic location of the organ by quadrants is:
Right Upper Quadrants( RUQ)
Left Upper Quadrants(LUQ)
Liver
Stomach
Gallbladder
Spleen
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Duodenum
Head of pancreas
Right kidney and adrenal
Hepatic flexure of colon
Part of ascending and
transverse colon
Left lobe of liver
Body of pancreas
Left kidney and adrenal
Splenic flexure of colon
Part of transverse and
descending colon
Right lower Quadrants(RLQ)
Cecum
Appendix
Right ovary and tube
Right ureter
Right spermatic cord
Left lower Quadrants(LLQ)
Part of descending colon
Sigmoid colon
Left ovary and tube
Left ureter
Left spermatic cord
Midline
Aorta
Uterus ( if enlarge)
Bladder (if distended)
Female and Male Genitalia
Female Genitalia: check for the followings:
Menstrual history: check for last menstrual period(LMP)
Menarche( occur between 12 and 14 years indicate normal growth;
Onset between 16 and 17 years suggests an endocrine problem.
Cycle- normally varies every 18 to 45 days.
Amenorrhea- absent menses.
Duration- average 3 to 7 day
Menorrhagia- heavy menses.
Obstetric history: Gravida- number of pregnancies.
Para- number of births.
Abortions- interrupted pregnancies, including
elective abortions and spontaneous miscarriages.
For each pregnancy, describe duration, any complication, labor
and delivery, baby's sex, birth weight, condition.
Self care behaviors: assess self- care behaviors
( last papanicolaou smear? Result?
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Have your mother ever mentioned taking hormones while pregnant
with you?
Urinary symptoms;- Frequency, urgency, Dysuria, Hematuria,
Bile in urine or urinary tract infection.
True incontinence- loss of urine without warning.
Stress incontinence- loss of urine with physical strain due to
muscle weakness.
Vaginal discharge:- normal discharge is small, clear or cloudy,
and always nonirritating. White, yellow green, gray, curd like, foul
smelling discharge suggests vaginal infection.
Past history: check for any other problem in the genital area(
Sores or lesions-now or in the past), any abdominal pain, any
surgery on the uterus, ovaries, or vagina.
Sexual activity: check for sexual relationship, communication with
spouse, interest, beliefs, and the number of partners.
Contraceptive use- currently planning a pregnancy or prevent
pregnancy.
Which method used.
Sexual transmitted disease (STD) contact; check for any sexual
contact with partner having a STDs ( gonorrhea, herpes, AIDS,
chlamydial infection, venereal warts, and syphilis)
STD risk reduction: check if the person take any
precautions to reduce risk of STDs( use condom).
Male Genitalia: check for the followings:
Frequency : average adult voids five to six times/day, varying with
fluid intake, individual habits.
Urgency
Hesitancy and straining. Loss of force, terminal dribbling, sense
of residual urine.
Penis: pain, lesions, or any discharge.
Scrotum, self-care behaviors. Notice any lump, swelling, hernia.
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Sexual activity and contraceptive use. Ask about relationship
involving sexual intercourse now.
STD contact.
Anus, Rectum, and Prostate
Check for the followings
Usual bowel routine: assess usual bowel routine
Dyschezia: pain may be due to a local
condition (hemorrhoid, fissure, or constipation).
Change in bowel habits: diarrhea, constipation.
Rectal bleeding: Melena (black stools may be tarry due to occult
blood (melena).
Steatorrhea: is excessive fat in the stool.
Medications. Laxatives or stool softness
Rectal conditions. Any itching, pain, or burning, hemorrhoids,
fissure.
Family history: polyps or cancer in colon or rectum, inflammatory
bowel disease, prostate cancer.
Prostate gland
Check for:
Size: 25 cm long by 4 cm wide; should not be protrude more than
1 cm into the rectum.
Shape: heart shape, with palpable central groove.
Consistency: elastic, rubbery.
Mobility: slightly movable.
Sensitivity: non-tender or palpation.
Diagnostic procedures
Invasive:
A: Endoscopy
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Endoscopic Examination
1. Gastroscopy
A gastroscopy is the visual examination of the interior of the
stomach.
Gastroscopy is a procedure that uses a lighted, flexible
endoscope to see inside the upper GI tract. The upper GI tract
includes the esophagus, stomach, and duodenum—the first
part of the small intestine.
Gastroscopy can detect :






ulcers
abnormal growths
precancerous conditions
bowel obstruction
inflammation
hiatal hernia
2. Proctoscopy, Sigmoidoscopy, and Colonoscopy
Inspection of the intestinal tract is done by tubular endoscopes
with appropriate illumination. The instrument for examination of the
rectum is called a proctoscope. To examine the sigmoid colon, a
device called a sigmoidoscope is used, which can visualize up to
25 cm from the anal verge. To examine the entire colon from the
rectum to the cecum a device called a fiberoptic colonoscope is
used. The sigmoidoscope or proctoscope can be either rigid or
flexible. If a malignancy is suspected, tissue can be removed
during the examination for histological study.
3. Bronchoscopy
The visual examination of the bronchi of the lungs by the use of
the bronchoscope which may be inserted into the oral or nasal
cavities. The larynx, pharynx, and trachea may be visualized as
the scope is passed to the bronchi.
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4. Laryngoscopy
a. Direct Visualization
A laryngoscopy is the visual examination of the larynx and
hypopharynx using a laryngoscope.
b. Indirect Visualization
Examination of the interior wall of the larynx by observation of the
reflection of it in a laryngeal mirror.
5. Cystoscopy
A cystoscopy is the examination of the interior of the urinary
bladder by means of a cystoscope. It is inserted into the bladder by
way of the urethra and, therefore, can be used to examine the
urethra as well.
B: biopsy
A biopsy is a medical procedure in which a tissue sample or a
group of cells is removed for laboratory examination. There
are several types of biopsies available. Biopsies are typically
conducted alongside other diagnostic processes. This will
yield a more accurate diagnosis.
Biopsy Types
1. Needle Biopsy
Needle biopsies are frequently performed to analyze growths that
can be felt through the skin. Such growths may include lumps in
the breasts or testes. There are four main types of needle biopsy:

Fine-Needle Aspiration (FNA): In this procedure, a long,
fine needle pierces the skin and is inserted into the
suspicious tissue. A syringe is then used to extract cells from
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


the tissue. FNA is relatively painless and can be performed
in minutes.
Core Needle Biopsy: When solid tissue is biopsied, or when
larger amounts of tissue are needed for evaluation, a hollow
core needle is used to perform the procedure. This needle
will extract a column of tissue from the suspect area.
Sometimes, a small incision must be made in order to make
way for this larger needle. When biopsy necessitates an
incision, local anesthesia is used.
Vacuum-Assisted Biopsy: This procedure is similar to a
normal core needle biopsy. However, in a vacuum-assisted
biopsy, a special machine is used to draw even more cells
from the suspect tissue.
Image-Guided Biopsy: When the suspect tissue cannot be
felt through the skin, but is still a candidate for a needle
biopsy, an image-guided biopsy is performed. In this
procedure, the standard needle biopsy is guided with the aid
of various imaging technologies, such as computed
tomography (CT scan) or ultrasound.
2. Skin (Cutaneous) Biopsy
A skin biopsy is performed to remove cells from the skin, or other
tissues on the body’s surface. Most skin cancers are diagnosed
with a skin biopsy. There are several types of skin biopsy
procedures available:
3. Curettage
In this procedure, the suspect tissue is scraped using a round
curette blade. Sometimes this tool is used in a skin biopsy, but it
can also be used to scrape cells from bone and other internal
tissues.
Non-Invasive diagnostic procedures.
A medical procedure is strictly defined as non-invasive when no
break in the skin is created and there is no contact with the
mucosa, or skin break, or internal body cavity beyond a natural or
artificial body orifice. For example deep palpation and percussion
is non-invasive but a rectal examination is invasive. There are
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many non-invasive procedures, ranging from simple observation,
to specialized forms of surgery, such as radio surgery.
Non-invasive techniques commonly used for diagnosis and
therapy include the following:
Diagnostic images






Dermatoscopy
Diffuse optical tomography
Computed Tomography
Magnetic resonance imaging, using external magnetic fields.
Radiography, and computed tomography, using X-rays.
Ultrasonography using ultrasound waves .


Diagnostic signals
Electrocardiographic tracing



Electrocardiography (EKG or ECG): is a test that records the
electrical activity of the heart.
Electroencephalography (EEG): A measurement of the
continuous brain-wave patterns, or electrical activity of the
brain,
Electromyography (EMG): A measurement of the electrical
activity of skeletal muscles
Laboratory Tests
A: Blood
BLOOD TEST REFERENCE RANGE CHART
Test
Normal Range
Blood Volume
8.5 - 9.1% of total body weight9 56 Liters)
Acidity (pH)
7.35 - 7.45
Complete Blood Cell Count (CBC)
Tests include: Hemoglobin, hematocrit
,mean corpuscular hemoglobin, mean
corpuscular hemoglobin
concentration,mean corspular volume,
platelet count, white blood count
Male: 13 - 18 gm/dL
Hemoglobin
Female: 12 - 16 gm/dL
Male: 45 - 62%
Hematocrit
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Munther AL-Fattah .MSC.Adult Nursing
Female: 37 - 48%
Mean Corpuscular Hemoglobin (MCH)
Mean Corpuscular Hemoglobin
Concentration (MCHC)
Mean Corpuscular Volume (MCV)
Platelet Count
White Blood Cell Count (WBC)
Red Blood Cell Count (RBC)
Erythrocyte Sedimentation Rate (ESR)
Iron
Calcium
Cholesterol
Liver Function Tests
Tests
include:Bilirubin(total),phosphotase(alkaline),
,protein(total and albumin),transaminases
(alanine and aspartate),prothrombin(PTT)
Proteins:
Total
 Albumin
 Globulin
 Bilirubin

76 - 100 cu µm
150,000 - 350,000/mL
4,300 - 10,800 cells/µL/cu mm
4.2 - 6.9 million/µL/cu mm
Male: 1 - 13 mm/hr
Female: 1 - 20 mm/hr
60 - 160 µg/dL (normally higher in
males)
8.2 - 10.6 mg/dL (normally slightly
higher in children)
Tested after fasting: 70 - 110
mg/dL
Less than 225 mg/dL (for age 4049 yr; increases with age)
Glucose FBS

32 - 36% hemoglobin/cell
Alanine transaminase( ALT)
Aspartate transaminase (AST)
Prothrombin (PTT)
6.0 - 8.4 gm/dL
3.5 - 5.0 gm/dL
2.3 - 3.5 gm/dL
Direct: up to 0.4 mg/dL
Total: up to 1.0 mg/dL
1 - 21 units/L
7 - 27 units/L
25 - 41 sec
Arterial blood gases (ABG)
Analyze
pH
H+
PaO2
PaCO2
HCO3−
Range
7.35–7.45
35–45 nmol/L (nM)
80–100 mmHg
35–45 mmHg
22–26 mmol/L
Electrolytes
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Munther AL-Fattah .MSC.Adult Nursing
Analyze
Sodium
(N++)
Potassium ( K+)
Chloride ( Cl-)
Mg2+magnesium
Bicarbonate (HCO3-)
Range
135-145milliEquivalents/liter (mEq/L)
3.5 - 5.0 milliEquivalents/liter (mEq/L),
98 - 108 mmol/L.
1.7 to 2.2 mg/dL
22-30 mmol/L.
Renal Function Test RFT
Analyze
Creatinine
Urea Nitrogen (BUN)
Uric acid
Range
0.7-1.4 mg/dl
7-18 mg/dl
Male 2.1-8.5 mg/dl
Female 2-7 mg/dl
B: Urine
TEST
Color
Turbidity
Specific Gravity
pH
Glucose
Ketones
Blood
Protein
Bilirubin
Urobilinogen
Nitrate for Bacteria
Leukocyte Esterase
Casts
Red Blood Cells
Crytals
White Blood Cells
Epithelial Cells
Health Assessment
NORMAL VALUES
Pale yellow to amber
Clear to slightly hazy
1.015-1.025
4.5-8.0
Negative
Negative
Negative
Negative
Negative
0.1-1.0
Negative
Negative
Occasional hyaline casts
Negative or rare
Acid Urine:
Negative or rare
Few
Munther AL-Fattah .MSC.Adult Nursing
C: Stool
Stool Analysis
A stool analysis is a series of tests done on a stool (feces) sample to help diagnose
certain conditions affecting the digestive tract. These conditions can include infection
(such as from parasites, viruses, or bacteria), poor nutrient absorption, or cancer.
Stool analysis
Normal:
The stool appears brown, soft, and well-formed in consistency.
The stool does not contain blood, mucus, pus, undigested meat fibers,
harmful bacteria, viruses, fungi, or parasites.
The stool is shaped like a tube.
The pH of the stool is 7.0–7.5.
The stool contains less than 0.25 grams per deciliter (g/dL) or less than
13.9 millimoles per liter (mmol/L) of sugars called reducing factors.
The stool contains 2–7 grams of fat per 24 hours (g/24h).
Abnormal: The stool is black, red, white, yellow, or green.
The stool is liquid or very hard.
There is too much stool.
The stool contains blood, mucus, pus, undigested meat fibers, harmful
bacteria, viruses, fungi, or parasites.
The stool contains low levels of enzymes, such as trypsin or elastase.
The pH of the stool is less than 7.0 or greater than 7.5.
The stool contains more than 0.5 g/dL or more than 27.8 mmol/L of sugars
called reducing factors; 0.25–0.5 g/dL and 13.9–27.8 mmol/L is
considered borderline.
The stool contains more than 7 g/24h of fat (if your fat intake is about 100
Health Assessment
Munther AL-Fattah .MSC.Adult Nursing
g a day).
D: Sputum
.
Nutrition
Nutrition is the processes by which the body utilizes foods for
energy, maintenance and growth.
Nutrition is what a person eats and how the body uses.
Assessment Items
History
■ Typical daily food intake? (See Food Guide Pyramid below for
food
groups.)
■ Supplements? Vitamins? Type and timing of snacks?
■ Weight stable? Loss or gain, including amount? Height loss,
including
amount?
■ Appetite?
■ Food or eating discomfort? Problems chewing or swallowing?
■ Food coming back?
■ Diet restrictions? Able to follow restrictions?
■ If appropriate: Breastfeeding?
■ Typical daily fluid intake?
■ Heal well or poorly?
■ Skin problems: Lesions, dryness?
■ Dry mouth?
■ Dental problems? Bleeding gums? Frequency of dentist visits?
Examination
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Munther AL-Fattah .MSC.Adult Nursing
■ Body temperature?
■ Bony prominences: Skin intact? (If pressure ulcer present, see
Pressure
Ulcer Staging at the end of this tab.)
■ Lesions? Color?
■ Skin: Normal? Dry? Moist?
■ Bruises?
■ Ankle edema or rings unusually tight?
■ Oral mucous membranes: Color? Moistness? Lesions?
■ Teeth and gums: General appearance? Alignment of teeth?
Dentures?
Cavities? Missing teeth?
■ Actual weight and height?
■ Body mass index? See below.
■ Waist-to-hip ratio? See below.
■ Intravenous or other type of feeding (specify type)?
Assessment Tools
Waist-to-Hip Ratio
The waist-to-hip ratio is used to determine a cardiac risk factor. It
is a measurement
of waist size divided by hip size.
■ Measure the waist at the navel in men and midway between the
bottom
of the ribs and the top of the hip bone in women.
■ Measure hips at the tip of the hip bone in men and at the widest
point
between the hips and buttocks in women.
■ Divide waist size at its smallest by hip size at its largest to obtain
the
waist-to-hip ratio:
■ Healthy ratio for women is 0.8 or lower; for men 1 or lower.
■ A ratio above 0.85 for women and above 0.90 for men indicates
greater
risk. Waist circumference greater than 85 cm (35 in) in women and
102
cm (40 in) in men indicates greater than normal risk.
Body Mass Index
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Munther AL-Fattah .MSC.Adult Nursing
Body Mass Index (BMI) is an indicator of optimal weight for health.
Calculate the IBW by using the following formula
Weight in Kg.
IBW = ---------------------Height in (m)2
Triceps skin-fold thickness (TSF)
Determine the triceps skin-fold thickness by grasping the patient's
skin between the thumb and forefinger about 1 cm above the
midpoint, as shown below. Hold the calipers at the midpoint and
squeeze for about 3 seconds. Record the measurement registered
on the handle gauge to the nearest 0.5 mm. Take two more
readings; then average all three to compensate for any error.
Compare the patient's percentage measurement with the standard.
A measurement less than 90% of the standard indicates caloric
deprivation; a measurement over 90% indicates adequate or more
than adequate energy reserves.
MEASUREMENT
STANDARD
90%
Triceps skin-fold
thickness
Men : 12.5 mm
Men : 11.3mm
Women: 16.5 mm
Women:14.9mm
Men : 29.3 cm
Men : 26.4 cm
Women: 28.5cm
Women: 25.7cm
Men : 25.3 cm
Men : 22.8cm
Women: 23.2cm
Women: 20.9cm
Mid-arm
circumference
Mid-arm muscle
circumference
Mid-arm circumference and mid-arm muscle circumference
(MAC) (MAMC)
At the midpoint, measure the mid-arm circumference, as shown
here. Then calculate mid-arm muscle circumference by multiplying
Health Assessment
Munther AL-Fattah .MSC.Adult Nursing
the triceps skin-fold thickness (in centimeters) by 3.143 and
subtracting the result from the mid-arm circumference.
Record all three measurements as percentages of the standard
measurements by using the following formula:
Actual measurement
---------------------- X100
Standard measurement
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Munther AL-Fattah .MSC.Adult Nursing