DELEGATION
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BUILDS TRUST
EMPOWERS OTHERS
TEACHES AN MOTIVATES
TEAMWORK DEVELOPS
ENHANCE COMMUNICATION
RAPID PRODUCTIVITY AND RAISED SKILL
WHICH OF THE FOLLOWING IS NOT TRUE
ABOUT MANAGED CARE?
 In delegation , responsibility is transferred,
accountability is shared
 Responsibility is determined by Nurse practice acts,
standards of care, job description and policy
statement
 In delegating identify variables nevertheless this
would not change authority and responsibility
 Delegate to the lowest person on heirarchy that has
the required skills and abilities who is allowed to do
the task legally and according to the organization
 Example: “ feed client if coherent and awake, if
confused do not feed and notify me asap.
IN PLANNING FOR STAFFING ALWAYS TAKE
INTO CONSIDERATION CAPACITY / ABILITY OF
THE STAFF.
SCOPE
R.N. PLANNING AND HEALTH TEACHING
 LICENSURE REQUIREMENTS
 ASSESSMENT AND EVALUATION
 NEED FOR KNOWLEDGE AND SKILL
LPN/LVN STABLE PATIENTS
 STANDARD UNCHANGING PROCEDURES
 SIMPLE
MONITORING
AND
IMPLEMENTATION
 SEQUENCED/PREDICTABLE OUTCOMES
 STATE PRACTICE ACT INCLUSION
UAP-DIRECT PATIENT CARE ACTIVITY AND
STANDARD
OPERATING
UNCHANGING
PROCEDURES
INCIDENT REPORTS
 SEQUENCE-UNEXPECTED OR UNPLANNED
OCCURENCE
 RISK MANAGER
 SITUATIONS-STATEMENT OF FACTS AND
PATIENT PHYSICAL RESPONSE
 ACTUAL AND POTENTIAL-REPORT WITHIN
24 HOURS-INVESTIGATION OF REFERRING
TEAM MANAGEMENT(RISK MANAGER)
In writing an incident report the nurse manager
should state the following guidelines on charting
except
 Don’t include words such as error or inappropriate



Don’t include judgemental statements
Only actual risks should be reported within 24 hours
to the risk manager
Documentation of clients status should be continuous
RESTRAINTS
 LIABLE FOR FALSE IMPRISONMENT
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LAST RESORT
INFORMED CONSENT(PROXY)
ALTERNATIVE MEASURES FIRST
BENEFITS> RISKS
LENGTH OF TIME AND CIRCUMSTANCES
SPECIFIED
ENSURE
SAFETY
–
CIRCULATION
CHECKS,SKIN CARE, ROM AND REMOVE Q2H
RESTRAINTS IS USED FOR:
 THE PURPOSE OF DISCIPLINE
 COMFORT AND CONVENIENCE OF PROVIDER
 REQUIRED TO TREAT MEDICAL SYMPTOMS
 MEASURE USED TO CONTROL BEHAVIOR
 PREVENT BREACH IN SAFE AND EFFECTIVE
DELIVERY OF MEDICAL THERAPY.
 ENSURE SAFETY OF OTHER PATIENTS
 MEDIUM OF LIMIT SETTING AND PROVISION
OF EXTERNAL CONTROLS
COMPLAINTS
 COMPROMISE
/
COLLABORATIVE
AGREEMENT
 LISTEN ATTENTIVELY
 EXPLAIN SCOPES AND LIMITATIONS
 ASK AND RELAY EXPECTED SOLUTIONS
AND TERMS
 NON-DEFENSIVE
A CLIENT WHO IS ABOUT TO BE BATHED BY A
NURSE STATES;”You are too young to know how to
do this, get me someone who knows what they are
doing”.the nurse best response is:
 We do this procedure daily, I have done this several
times, tell me what are you afraid of?
 I can see you are upset , can we talk about it?
 You’re concerns show you are upset, we will talk
about this after I have demonstrated the procedure.
 Can you be more specific about you’re concerns?
Health teaching
 C-CONSIDER
SUPPORT
SYSTEMS
/
COMPLIANCE
 H- olds MOTIVATION AND INSIGHT
 A- ALLOW FEEDBACK
 N-NEEDS MET AND ASSURED
 G- GOALS AND PRIORITIES SET w/ pnt.
 EEMPATHETIC
AND
ENSURES
COLLABORATION
1
Patient Education
Type of learning:
 Cognitive
 Psychomotor
 Affective


Patients motivation –PRIORITY
FACTORS – DURATION , COMPLEXITY AND SIDE
EFFECTS
Discharge planning
 Begins with first encounter
Functional level considered
preferrences
Compromised plan
referrals
and
WHAT IS THE BEST GAUGE THAT THE CLIENT
UNDERSTANDS DISCHARGE TEACHING?
 PATIENT VERBALIZES INTEREST
 PATIENT ASKS QUESTIONS RELATED TO
ADAPTATION TO NEEDED CHANGE IN
BEHAVIOR
 ACCURATE
DEMONSTRATION
OF
PROCEDURE
 PLANS FOR PRACTICE SESSIONS RELATED
TO HEALTH CARE SUGGESTIONS TAUGHT
BY THE R.N.
SAFETY AND INFECTION CONTROL pg.27-49
UNIVERSAL PRECAUTIONS
 STANDARD PRECAUTIONS – BARRIER
COMMUNICABLE DISEASE CONCEPTS
 CLINICAL
MANIFESTATIONSINITIAL,PATHOGNOMONIC/OUTSTANDING
 DIAGNOSTIC TESTS AND ETIOLOGY
 CARE ESSENTIALS AND IMPLICATIONS
MANAGEMENT
SEQUELAE
Category-Specific Isolation
 Strict- prevents transmission of highly contagious or
virulent infections spread by air or direct
contact(diptheria and chickenpox)
 Contact-prevents
transmission
of
highly
transmissible infections spread by close or direct
contact to skin and mucous membranes that do not
warrant strict precautions
 Respiratory – prevents trans mission of infectious
diseases over short distances through air
droplets(measles, meningitis,mumps, pneumonia and
H. Influenza)
airborne
droplet

Enteric precautions – prevents transmission of
infections by direct or indirect contact with
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feces(oral-fecal)( cholera,infectious diarrhea , hepa A
, infectious AGE)
AFB isolation-prevents spread of pulmonary
tuberculosis( laryngeal TB)
Drainage and Secretion precautions- prevents
transmission by direct or indirect contact with
purulent material or drainage from an infected body
site(abcess, burn infection,and infected wound)
Universal blood and body fluid precautionsprevents contact with pathogens transmitted by
direct/indirect contact with infective blood or body
fluids containing blood( AIDS, HEPA-B,SYPHILIS)
Care of severely Immunocompromised clientsprotects client with lowered immunity and resistance
from acquiring infectious organism( LEUKEMIA,
LYMPHOMA, APLASTIC ANEMIA)
WHICH OF THE FOLLOWING IS AN
INCORRECT STATEMENT MADE BY THE
STUDENT NURSE ABOUT INFECTION
CONTROL
HANDWASHING IS THE SINGLE MOST
EFFECTIVE WAY OF PREVENTING THE
SPREAD OF INFECTION
AUTOCLAVING KILLS ALL PATHOGENIC
MICROORGANISMS INCLUDING SPORES
AUTOCLAVED
ITEMS IS CONSIDERED
STERILE UNTIL 6 MOS. ONLY
THE SKIN CAN NEVER BE STERILE
THE
FOLLOWING
PATIENTS
ARE
INCLUDED
IN
REVERSE
ISOLATION
PRECAUTIONS EXCEPT:
BURN PATIENTS
PATIENTS WITH APLASTIC ANEMIA
PATIENT WHO ARE ON STEROID THERAPY
PATIENTS WHO ARE ON CHEMOTHERAPY
PATIENTS WHO ARE ON RADIATION
THERAPY
PATIENTS WITH LEUKEMIA
PATIENTS WITH LYMPHOMA
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POISONING
CHILD PROOF
REFER - POISON CONTROL CENTER
IDENTIFY AND BRING AGENT
SECURE SAFETY AND ABC’S
INDUCE VOMITING W/ IPECAC
STOP/DELAY
ABSORPTION
WATER/MILK/ACTIVATED CHARCOAL

THE NURSE SHOULD INTERVENE IF A
MOTHER OF A VICTIM OF POISONING
VERBALIZES TO DO THE FOLLOWING:
PLANS TO INDUCE VOMITING FOR PATIENT
WITH ASPIRIN POISONING

W/
2
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PLANS TO INDUCE VOMITING WHEN SHE IS
CERTAIN THAT HER CHILD’S GAG REFLEX
AND LOC ARE INTACT
WILL NOT GIVE IPECAC IF CHILD IS
EXHIBITING NARROWED PULSE PRESSURE
WILL WAIT FOR THE SEIZURE TO END
BEFORE ADMINISTERING IPECAC
CONTRAINDICATIONS
OF
IPECAC
/
INDUCTION OF VOMITING
SEIZURE
SUBNORMAL LOC AND GAG REFLEX
SUBSTANCE
CORROSIVE/PETROLEUM
DISTILATE
SHOCK-SEVERE
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RED-UNSTABLE – IMMEDIATE CARE
YELLOW- STABLE – CAN WAIT 30-60 MIN
GREEN –STABLE- CAN WAIT LONGER
BLACK- UNSTABLE – FATAL, LAST SEEN
DOA – SUPPORTIVE COMFORT MEASURES

DURING FIRE WHICH SET OF PATIENTS
WILL THE NURSE MOBILIZE FIRST
AMBULATORY
BEDRIDDEN
CRITICAL
TERMINAL
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WHICH STEP
COMES LAST?
ALARM
CONTAIN
MOBILIZE
EXTINGUISH
IN
FIRE
THE
MANAGEMENT
PREVENTION AND EARLY DETECTION OF
DISEASE
Medical Asepsis/ Clean Technique
Principles:
Ø
Pathogens move through spaces or air current
Ø
Pathogens are transferred from one surface to
another whenever objects touch.
Ø
Hand washing removes microorganism
Ø
Pathogens are released into the air on droplet
nuclei when person speaks, breaths, and sneeze.
Ø
Pathogens are transferred by virtue of gravity
Ø
Pathogens move slowly on dry surface but very
quickly through moisture.
Surgical Asepsis/ Sterile Technique
Areas of the body considered sterile are:
Blood stream
Spinal Fluid
Peritoneal Cavity
Urinary Tract
Muscles
Bones
Chamber of the Eyes
o
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DISASTER PLANNING
TRIAGE-GREATEST
GOOD
FOR
GREATEST NUMBER OF PEOPLE
PRINCIPLES- ABCD , MASLOWS
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Sterile object remains sterile when
touched by another sterile object
Ø
Sterile objects or fields, which falls out of the
range of vision or below one’s waist, are considered
contaminated.
Ø
Sterile items become contaminated when they
come in contact with microorganism transported
through the air.
Ø
When sterile object/ field come in contact with
another surface, it becomes contaminated.
Ø
Fluids flows in the direction of gravity.
The edges of the sterile field are considered unsterile
Isolation Practices
Ø
Strict Isolation- prevents transmission of
highly communicable disease by contact and airborne
transmission
Ø
Respiratory isolation- prevents transmission
by droplet
Ø
Enteric precaution- prevents transmission
through ingestion
Ø
Wound and skin precaution- prevents crossinfection by direct contact with wounds and
contaminated articles
Ø
Discharge precaution- prevent cross-infection
by secretions-contaminated articles
Ø
Blood precaution- prevent transmission by
contact with blood or items contaminated with blood

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GROWTH AND DEVELOPMENT
DEVELOPMENTAL TASKS---MILESTONES ---DELAYS(FIXATIONS/LAG)

IQ = MA / CA X 100
=JUDGEMENT,COMPREHENSIONAND
LISTENING

DDST – BIRTH TO 6 YEARS
=PERSONAL SOCIAL, FINE , GROSS MOTOR
AND LANGUAGE SKILL AREAS

HEALTH SCREENING
OB – GYNE / REPRODUCTIVE TESTS
 UTZ-5 WKS CONFIRM PREGNANCY AND AOG
 AMNIOCENTESIS
–
16
WKS-DETECT
GENETIC DISORDERS – 30 WEEKS – L/S RATIO
( 2-4 WKS RESULT)(EMPTY Bladder)
3
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OCT – (28 WKS)FHR DECELERATIONS – IV
OXYTOCIN 15-20 MIN----3 CONTRACTIONS
OBTAINED WITHIN 10 MINUTES- REACTIVE
NST – FHR ACCELERATIONS (32-34 WKS) –
2-MORE
FHR
ACCELERATION
OF
15BPM/MORE LASTING 15 SECS -20 MINS.
AND RETURN OF FHR TO NORMAL/BASELINE
– REACTIVE
DOPTONE- 12 WEEKS (18 – 20 WKSAUSCULTATION)
AFPT-FETAL SERUM CHON , -DETECT
NEURAL TUBE DEFECTS – 16-18 WKS
CHORIONIC VILLI SAMPLING –FETAL
ABNORMALITIES- 10-12 WKS
NEWBORN/INFANT HEALTH SCREENING
 PKU – GUTHRINE BLOOD TEST-EAT CHON
FOR 2 DAYS MIN.(PHEONISTICS – DIAPER)
 SICKLE CELL DISEASE –ABNORMALLY
SHAPED Hg ,
 ELISA AND WESTERN BLOT
 CARRIER SCREENING FOR CYSTIC FIBROSIS
AND SWEAT CHLORIDE TEST
SCHOOL AGE
HEARING AND VISION TESTS
 ALLEN PICTURE CARDS
 SNELLEN CHART-20/40 AT TODDLER AND
20/20 AT SCHOOL AGE
 WEBER’S-SENSORINEURAL
AND
CONDUCTIVE
 RINNE’S- CONDUCTIVE
 DENTAL EXAM – STARTS AT 2 YEARS
ADOLESCENT
 PPD – INDURATION – 72 HOURS
 BSE
–
(18-20
YRS.)
POST
MENSTRATION/MONTHLY
 TSE – MONTHLY (18-20 YRS)
 PELVIC EXAM WITH PAP SMEAR – IF
SEXUALLY ACTIVE OR 18 Y.O. ANNUALLY
IN TEACHING AN ADOLESCENT PROPER BSE
TECHNIQUE THE NURSE SHOULD INSTRUCT
THE CLIENT TO PERFORM BSE IN THE
FOLLOWING POSITIONS EXCEPT:
 STANDING WITH ARMS ON THE HIPS FACING
THE MIRROR
 LYING DOWN WITH PILLOW UNDER THE
SHOULDERS ARMS AT THE BACK OF THE
HEAD
 RAISE THE ARM OF THE SIDE TO EXAMINED
ABOVE THE HEAD
 POSITION THE ARMS WITH THE BODY IN
ANATOMICAL POSITION
ADULT/ELDERLY
 HPN , DM, HEARING AND VISION
 PROSTATE –ANNUALLY@40
 Ca CHECK-UPS-Q3Y-20YO ; QY – 40 YO
 SIGMOIDOSCOPY- > 50 Y.O. =Q3-5 YRS
 FECAL OCCULT BLOOD TEST- > 50 =
ANNUALLY
 DIGITAL RECTAL EXAM - > 40 Y.O. =
YEARLY
 PELVIC EXAM – 18-40 Y.O. =PERFORMED Q 1
– 3 YEARS WITH PAP TEST
 MAMMOGRAM –
35-39 = BASELINE
o 40-49 = Q2Y
o 50 AND OLDER
= QYEAR
BP SCREENING(mmHg)
UPON INITIAL ASSESSMENT THE PATIENT HAS
A BLOOD PRESSURE OF 170/90 mmHg. WHAT IS
THE FOLLOW-UP REFERRAL FOR THIS
PATIENT?
 REFER AFTER 1 WEEK
 EVALUATE AND REFER FOR FOLLOW-UP
AFTER 2 WEEKS
 EVALUATE AND REFER FOR FOLLOW-UP IN 2
MONTHS
 EVALUATE AND REFER FOR FOLLOW-UP IN 1
MONTH
IMMUNITY
CONTRAINDICATIONS:
 SEVERE FEBRILE ILLNESS
 LIVE
VIRUSES
C/I
FOR
IMMUNOCOMPROMISED
 ALLERGIES
 RECENTLY
ACQUIRED
PASSIVE
IMMUNITY(BLOOD
TRANSFUSION
AND
IMMUNOGLOBULINS)
if child –no evidence of immunization <7 y.o.
 Give DPT,TOPV,TINE
 4-6 WKS LATER MMR
 1 MONTH AFTER DPT AND TOPV
 REPEATED IN ANOTHER MONTH
 AGAIN IN 10-16 MOS.
CAN GIVE DPT,MMR,TOPV, AND TINE
SIMULTANEOUSLY
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TD- 2 DOSES 4-8 WKS APART;3RD DOSE 6-12
MOS;BOOSTER AT 10 YRS FO LIFE
OPV/IPV – 2 DOSES AT 4-8 WKS APART ; 3RD
DOSE 2 -12 MOS AFTER 2ND(OPV NOT USED IN
US)
MMR-ONE DOSE – 12 MOS
VARICELLA – TWO DOSES 4-8 WEEKS APART
STARTS AT 12 MOS.
4
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HEPA B – 3 DOSES;2ND 1-2 MOS AFTER;3RD 4-6
MS AFTER
PPV- ONE DOSE ;IF 65 AND RECEIVED >
5YEARS – ADMINISTER
INFLUENZA –ANNUALLY EACH FALL
ALLERGY CONTRAINDICATIONS
 EGGS – INFLUENZA , MMR
 NEOMYCIN – VARICELLA,IPV,MMR
 YEAST – HEPA-B
 GELATIN – VARICELLA
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PREGNANCY C/I: MMR AND VARICELLA
IMMUNOSUPPRESSED; VARICELLA
WITH Ig or BT PREVIOUS 3-11 MOS – MMR
AND VARICELLA
CONSIDERATIONS-IMMUNIZATION
DPT - IM – ANTERIOR OR LATERAL THIGH
 FEVER AND SWELLING 24-48 H POTENTIAL
 SERIOUSCONVULSIONS,HYPERPYREXIA,LOC
AND
SCREAMING
MMR – SC – ANTERIOR OR LATERAL THIGH
 RASH, FEVER ARTHRITIS-10DAYS-2 WKS
TRIVALENT OPV – PO
PPD-ID- 4-6/11-16YRS.OLD IN HIGH PREVALENCE
AREAS – EVALUATED 48-72 HOURS
VITAL SIGNS
TEMPERATURE:
 ORAL – 98.6 ‘F / 37 ‘C
 RECTAL – 99.6 ‘F / 37.6’C
 AXILLARY – 97.6’F / 36.5’C
Body Temperature
 Ø
The balance between heat produce by the body
and heat loss from the body
 Ø
Types of body temperature
 ·
Core temperature- deep tissue temperature of
the body
 ·
Surface temperature- temperature of the skin,
subcutaneous tissue, and fats
 Ø
The normal core body temperature is between
36.7°C (98.7°F)- 37°C (98.6°F).
 Ø
The thermoregulation center of the body is the
hypothalamus
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A PATIENT WITH HIV-AIDS IS POSITIVE FOR
PPD WHEN THERE IS:
 PRESENCE OF INDURATION OF 10 MM
 PRESENCE OF INDURATION OF 15 MM
 PRESENCE OF INDURATION OF 5 MM
 WHEAL FORMATION OF 10MM
OR
VESCICULAR PROLIFERATION
 PHYSICAL ASSESSMENT
TEACHING OPPURTUNITY
INSPECTION –VISUALLY
PALPATION-WARM HANDS
 DORSUM OF FINGERS FOR TEMP
PERCUSSION-DIRECT,INDIRECT,BLUNT
 RESONANCE-MODERATE
LOW
PITCHED
CLEAR HOLLOW(LUNG)
 HYPERRESONANCEOVERINFLATED(EMPHYSEMA)
 TYMPANY-HIGH
PITCHED,LOUD
DRUMLIKE(BOWEL)
 DULL-SOFT MUFFLED,DENSE FLUID FILLED
TISSUE(LIVER)
 FLAT – SOFT HIGH PITCHED,VERY DENSE
TISSUE-(MUSCLE/BONE)
AUSCULTATION-DIAPHRAGM HIGH PITCHED(LUNG,BOWEL,HEART); BELL
– SOFT LOW PITCHED(HEART MURMURS)
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Ø
Types of fever:
·
Constant- temperature is constantly high
·
Intermittent- the temperature fluctuates
between periods of fever and periods of normal
temperature
·
Relapsing- increase in temperature alternated
with 1 or 2 days normal temperature
Remittent fever- the temperature fluctuates with in a
wide range over 24 hours period but remains above
normal temperature
Ø
Routes of Temperature –Taking
·
Oral
Most accessible and most convenient
Temperature is taken in 2-3 minutes time
15 minutes before taking the oral temperature, don’t
allow the client to take hot or cold foods and fluids
·
Rectal
Most accurate measurement
Thermometer is inserted 0.5-1.5 inches
Temperature is taken in 2 two minutes time.
Axillary
The most non-invasive and the most safest
Temperature is taken in 5-9 minutes time
Ø
If the body temperature declines suddenly, it is
termed as crisis and this indicates hypothalamic
disturbances; while if there is a gradual decline of
fever, we term that as lysis that indicates normal
functioning of the hypothalamus
Ø
Antipyretic is the drug of choice for patients
with fever
Pulse
Ø
It is the wave of blood created by the
contraction of the left ventricle
5
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Ø
Pulse rate is regulated by the autonomic
nervous system (ANS)
Ø
The normal pulse rate of an adult ranges from
60-100 beats per minute
Ø
Pulse amplitute describes the quality of the
pulse in terms of its fullness
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Number Definition
Respiration
Ø
It is the act of breathing: breathing in
(Inhalation), breathing out (Exhalation)
Ø Types of Respiration:
·
External Respiration- exchanges of gasses
(oxygen and Carbon Dioxide) that happens in the
alveoli of the lungs
Internal Respiration- exchange of gasses that happens
in the cell
Description
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0
absent
pulsation
1
thready
easily felt
2
weak
than
thready
3
normal
felt
4
bounding
stronger
o pulsation
no


not

stronger


easily
Ø
Pulse deficit is the difference between the
apical pulse and radial puls
Ø Pulse rate vary in different age levels:
·
1 year old- 80-180 beats per min (BPM)
·
2 years old- 80-140 BPM
·
6 years old- 75-120 BPM
·
10 years old – 50-90 BPM
·
Adult - 60-100
Ø When palpating for the pulse, use two to three
finger tips. Don’t use the thumb
Ø Pulse sites and reasons for use:
·
Temporal- used when radical pulse is not
accessible
·
Carotid- used for infants, in cases of cardiac
arrest, to determine the circulation of the brain
·
Apical- routinely used for infants and children
up to three years old; to determine discrepancies with
radial pulse; used in conjunction with some
medications.
·
Brachial- used to measure blood pressure;
during cardiac arrests of infants
·
Radial- readily accessible and routinely used
·
Femoral- used in cases of cardiac arrest,
infants children, determine the circulation of the legs
·
Popliteal- to determine circulation of the lower
leg and the site for the measurement of BP in the
lower extremities
·
Posterior Tibial- to assess for the circulation
of the foot
·
Pedal- to assess for the circulation of the foot
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Types of breathing:
·
Costal (thoracic) breathing-involves the
movement of the chest
·
Diaphragmatic (abdominal)- involves the
movement of the abdomen
Ø
The medulla oblongata is the primary
respiratory center of the body
Ø
There are three(3) processes involved in
respiration
·
Ventilation- the movement of gasses in and out
of the lungs
·
Diffusion- exchange of gasses from an area of
greater pressure to an area of lower pressure. It
occurs at the alveolo-capillary membrane.
·
Perfusion- movement of blood for transport of
gasses, nutrients, and metabolic wastes products
Ø Normal adult breathes 16-20 times per minute
Blood Pressure
 Ø It is the pressure exerted by the blood in the
arteries
 Ø Normal adult’s BP is 120/80
 Ø Systolic Pressure is the pressure resulting from
the contraction of the ventricles
 Ø
Diastolic pressure is the pressure when the
ventricles are at rest. (Normal: 60-90 mm Hg)
 Ø Pulse pressure is the difference between the
systolic and diastolic pressure (Normal: 30-40)
 Ø Hypertension – abnormally high blood pressure
over 140/90 mm Hg for at least two consecutive
readings
 Ø Hypotension- abnormally low blood pressure,
systolic pressure below 100mm Hg
 Ø Postural/ orthostatic hypotension is a sudden
drop in blood pressure caused by a sudden changed
in position

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
Ø If the BP cuff is too small for a patient, the BP
reading may result to false high measurement; if the
BP cuff is too big for a patient, the BP reading may
result I false low measurement
Ø Women usually have lower BP than men
Ø The series of sounds that the nurse listens during
BP reading is called Korotkoff sounds
6
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Ø
In assessing the BP, use the bell-shaped
diaphragm of the stetoscope since BP is a low
frequency sound
Always read the lower meniscus of the mercury of
the BP apparatus at eye level to prevent error
NORMAL VITAL SIGNS
 NEWBORN=30 – 50 / MIN; 120 – 140 / MIN;
60/40 – 80/50 mmHg

1 – 4 YEARS=20 – 40 / MIN; 80 – 140 /MIN;
90/60 – 99/65 mmHg

5 – 12 YEARS=15 – 25 / MIN; 70 – 115 / MIN;
100/56 – 110/60 mmHg

ADULT=12 – 20 / MIN;60 – 100 / MIN ; 90 / 60 –
140 / 90 mmHg
BREATHING PATTERNS
 CHEYNE STOKES – PERIODIC BREATHING
CHARACTERIZED BY RHYTMIC WAXING
AND WANING
 DYSPNEA - LABORED PAINFUL BREATHING
 HYPERVENTILATION
–
ABNORMALLY
RAPID DEEP PROLONGED BREATHING
 KUSSMAULS – AIR HUNGER , MARKED
INCREASE IN DEPTH AND RATE
 TACHYPNEA – FAST SHALLOW BREATHING
 PARADOXICAL – FLAIL CHEST , DEFLATES
DURING INHALATION
 BIOT’S – SHALLOW BREATHS INTERRUPTED
BY APNEA
NORMAL FINDINGS
 PULSE PRESSURE – 30-40 mmHg
 Intracranial pressure – 10 mmHg
 PULSE DEFICIT–MINIMAL(3-5 ACCEPTABLE)
IDEAL BODY WEIGHT –
 MALES -106 LBS FOR 1ST 5FT THEN ADD
6LBS/INCH
 FEMALE – 100LBS FOR 1ST 5 FT THEN ADD
5LBS/INCH
 ADD OR SUBTRACT 10% DEPENDING ON
BODY FRAME.
 OBESE AND UNDERWEIGHT IF DEVIATION IS
> 20%
SKIN
SCARS,BRUISES AND LESIONS
CHECK COLOR
EDEMA – GRADING
 0-NO EDEMA
 1-BARELY DETECTABLE
 2-INDENTATION<5MM
 3-INDENTATION 5-10MM
 4-INDENTATION >10MM
PRESSURE SORE –GRADING
 1-NONBLANCHABLE ERYTHEMA
 2-EPIDERMIS,PARTIAL THICKNESS
 3-FULL DERMIS AND SQ
 4- SUPPORTING TISSUES AND BONES
TURGOR-PINCH SKIN TENTED 3
NORMAL(ELDERLY-OVER STERNUM)
SECS
Skin Lesions
 macule
 patches
 papule
 plaque
 nodule
 tumor
 vescicle
 bullae
 pus
HAIR AND NAILS
 HIRSUTISM-EXCESS
 ALOPECIA-THINNING
 SHAPE – NORMALANGLE OF NAIL BED-160’;
CLUBBING ANGLE > 180 DUE TO PROLONGED
DECREASED OXYGENATION
 BLANCHING =< 3 SECS-NORMAL
HEAD
SYMMETRY, SIZE AND SHAPE
CRANIAL NERVE ASSESSMENTS
 OPTIC-SNELLEN
 OCULOMOTOR- PERRLA
 TRIGEMINAL – BITE DOWN AND STROKES
WITH COTTON
 FACIAL – FACIAL MOVEMENT AND TASTE
 ACCOUSTIC
–
HEARING
AND
BALANCE(WATCH TICK TEST,OTOSCOPIC
EXAMS AND POSTURE TESTS)
 GLOSSOPHARYGEAL-GAG AND SWALLOW
 VAGUS- SWALLOWING AND SPEAKING
EYES
 PTOSIS-DROOPING OF THE UPPER EYELID
 ASTIGMATISM – UNEVEN CURVATURE OF
CORNEA LEADING TO REFRACTION ERRORS
 NYSTAGMUS- ABNORMAL, INVOLUNTARY
EYE MOVEMENTS
 STRABISMUS-ASSYMETRICAL
LIGHT
EFLECTION ON EACH CORNEA
 RED REFLEX FROM RETINA-NORMAL
 COVER UNCOVER TEST – DET.EYE
ALIGNMENT
 SNELLEN – FAR DISTANCE VISION/VISUAL
ACUITY
 IOP-TONOMETRY TESTS INDENTATION(6-12)
7
EARS
 PINNA
BACK-UP-ADULT;DOWN-BACKCHILD
 RINNE TEST – COMPARES AIR CONDUCTION
WITH BONE CONDUCTION,VIBRATING FORK
PLACED ON THE MASTOID IF SOUND NO
LONGER HEARD POSITIONED IN FRONT OF
EAR CANNAL. SHOULD HEAR A SOUND= 2:1 ;
AIR
CONDUCTION
>
THAN
BONE
CONDUCTION ;= POSITIVE RINNE
=ASSESS CONDUCTIVE HEARING LOSS
EARS
WEBER – SENSORINEURAL AND CONDUCTIVE
HEARING LOSS
 FORK
PLACED
MIDDLE
OF
FORE
HEAD,SHOULD BE HEARD EQUALLY=WEBER
NEGATIVE
 IF NOT EQUAL=SENSORINEURAL HEARING
LOSS.
 SOUND HEARD BETTER IN THE IMPAIRED
EAR=BONE CONDUCTIVE HEARING LOSS, IF
VICE
VERSA
=
SENSORINEURAL
DISTURBANCE
NECK,MOUTH AND PHARYNX
 TEETH-32
 TONSILS – NO TPC , + GAG REFLEX
 CERVICAL LYMPH NODES=<1CM
 CAROTID – PALPATE THRILL,LISTEN BRUIT
 JUGULAR VEINS – NOT DISTENDED
 TRACHEA-MIDLINE
THORAX AND LUNGS
APL DIAMETER-1:2 – 5:7
=1:1 = BARREL CHEST
TACTILE
FREMITUS
NORMALBRONCHOPHONY,EGOPHONY AND WHISPERED
PECTORILOQUY-CONSOLIDATION OF LUNGS
BREATH SOUNDS
 VESICULAR – SOFT-LOW PITCHED BREEZY
SOUNDS –PERIPHERAL LUNG SURFACES
 BRONCHOVESCICULAR-HARSH
SOUNDSMAINSTREAM BRONCHI
 BRONCHIAL- LOUD COARSE - TRACHEA
ADVENTITIOUS BREATH SOUNDS
 RALES-FINE SHORT,CRACKLING OR HIGH
PITCHED SOUNDS-INSPIRATION
 RHONCHI-CONTINOUS
LOW
PITCHED
COARSEGURGLING HARSH SNORING BEST
HEARD ON EXHALATION
 WHEEZES- SQUEAKY SOUNDS HEARD –
EXHALATION
 STRIDOR – HARSH , MUSICAL SQUEAK
HEARD UPON INHALATION
 FRICTION RUB-GRATING , CREAKING
SOUNDS, FIZZ LIKE VIBRATIONS – BOTH
INHALATION AND EXHALATION
HEART SOUNDS
 AORTIC AND PULMONIC VALVE AREAS2ND ICS, R AND L RESPECTIVEY
 ERBS POINT 3RD ICS
 TRICUSPID AREA-4TH / 5TH ICS
 MITRAL AREA – 5TH ICS , LEFT MCL
 PMI-5TH ICS MCL –(INFANTS-LATERAL TO
LEFT NIPPLE-4TH ICS)
 S1LUBB-CLOSURE OFAV VALVES
 S2DUBB-CLOSURE OF SEMILUNAR VALVES
 MURMURS , GALLOP-ABNORMAL HEART
SOUNDS
PERIPHERAL VASCULAR SYSTEM
 ASSESS
PAIN,PALLOR,PARALYSIS,PARESTHESIASAN
D PULSES.
 ASSESS HOMAN’S SIGN
 PULSE DEFICIT
BREASTS
 START – UPPER OUTER CLOCKWISE
 ASSESS FOR SIZE,SHAPE,SYMMETRY AND
NODES
ABDOMEN
 DORSAL RECUMBENT
 INSPECT,AUSCULTATE,PERCUSS
AND
PALPATE
 BOWEL SOUNDS-HIGH PITCHED GURGLES
HEARD AT 5 – 20 SECOND INTERVALS( 525/MIN NORMAL)
 IF NOT HEARD IN 1 MINUTE STAY FOR 3 -5
MINS. MORE. SEQUENCE IS CLOCKWISE
FROM RLQ
*HYPOACTIVE < 3
*HYPERACTIVE
=CONTINOUS,LOUD,FREQUENT
*TINKLING
SOUND
–
BOWEL
OBSTRUCTION
ABDOMEN
REBOUND TENDERNESS- INFLAMMATION OF
PERITONEUM

KIDNEYS- DORSAL LUMBAR
COSTOVERTEBRAL ANGLE

KIDNEY PUNCH TEST
AREA
–
MUSCULOSKELETAL SYSTEM
MUSCLE TONE AND STRENGTH
 0=COMPLETE PARALYSIS
 1=10%-NO MOVEMENT CONTRACTION OF
MUSCLE PALPABLE/VISIBLE
 2=25% - FULL MOVEMENT AGAINST
GRAVITY WITH SUPPORT
 3=50% - NORMAL MOVEMENT AGAINST
GRAVITY
8


4= 75%- NORMAL MOVEMENT AGAINST
GRAVITY WITH MINIMAL RESISTANCE
5=100%-NORMAL FULL MOVEMENT WITH
FULL RESISTANCE
JOINT
MOVEMENTS-CREPITUS=GRATING
SOUNDS ARE ABNORMAL
FASCICULATION ABNORMAL CONTRACTIONS
AND SHORTENING OF MUSCLE FIBERS
TREMOR-INVOLUNTARY TREMBLING
TEST
FOR
ROM
AND
ASSESS
FOR
ATROPHY/HYPERTROPHY/CONTRACTURES
 NEUROLOGIC TESTS
MENTAL STATUS LANGUAGE-CEREBRAL CORTEX-APHASIA
 ORIENTATION(TIME,PLACE,PERSON)(CONF
USION)
 MEMORY- IMMEDIATE RECALL, RECENT
MEMORY AND REMOTE MEMORY
 ATTENTION SPAN AND CALCULATION
 JUDGEMENT – EXPLAIN/INTERPRET /
PERSONAL VIEWS
 PERCEPTION – SENSORY ANALYSIS AND
INTEGRATION
CEREBELLAR FUNCTION- COORDINATION ,
POINT TO POINT TOUCHING,ALTERNATING
MOVEMENTS,GAIT
CRANIAL NERVE FUNCTIONS
SENSORY FUNCTION(e.g. PROPRIOCEPTIONPOSITION SENSE- RHOMBERG’S TEST)




DISORIENTED,CONVERSES=4
USES INAPPROPRIATE WORDS=3
USES INCOMPREHENSIBLE SOUNDS=2
NO RESPONSE=1
ASSESSING MOTOR FUNCTION
WALKING GAITS
ROMBERGS TEST- STAND FEET TOGETHER
ARMS RESTING AT THE SIDES,EYES OPEN THEN
CLOSED. NEG. ROMBERG – MAY SWAY BUT
KEEPS BALANCE.
 SENSORY ATAXIA-CANNOT BALANCE EYES
SHUT
 CEREBELLAR ATAXIA-CANNOT BALANCE
EYES SHUT OR EPON
HEEL-TOE WALKING AND VICE VERSA
FINGER TO NOSE TEST AND OTHER SENSORY
FUNCTION TEST (ONE AND TWO POINT
DISCRIMINATION)
EXTINCTION
PHENOMENON-SYMMETRICAL
AREAS ARE TOUCHED BUT SENSATION ON ONE
SIDE CANNOT BE FELT INDICATES LESIONS OF
SENSORY CORTEX
116 next
NEUROLOGIC TESTS
DEEP TENDON REFLEX
 0-NO REFLEX
 +1 – MINIMAL ACTIVITY(HYPOACTIVE)
 +2 – NORMAL RESPONSE
 +3 – MORE ACTIVE THAN NORMAL
 +4 – MAXIMUM ACTIVITY ( HYPERACTIVE)
 PRESENCE
OF
INFANTILE
REFLEXES(BABINSKI)
IN
AN
ADULT
SIGNIFIES CNS PATHOLOGY
LEVEL OF CONSCIOUSNESS
GLASGOW COMA SCALE=15 POINTS, 7 COMA
EYE OPENING
 SPONTANEOUS=4
 TO VERBAL COMMAND=3
 TO PAIN=2
 NO RESPONSE=1
MOTOR RESPONSE
 TO VERBAL COMMAND=6
 TO PAINFUL STIMULI/LOCALIZES PAIN=5
 FLEXES AND WITHDRAWS=4
 DECORTICATE=3
 DECEREBRATE=2
 NO RESPONSE=1
VERBAL RESPONSE
 ORIENTED,CONVERSES=5
9