Nursing Health Assessment
Akram Mohammad AbuSalah
BNS, MSN, Ph. D.
Islamic University of Gaza Strip
1
Chapter (1)
The Interview
Islamic University of Gaza Strip
The first assessment begin in (1992) by American medical
association
 In (1995) health assessment considered as basic human right
 Preventive health care divided in three categories, primary,
secondary and tertiary prevention. Each level of prevention
is based on a thorough assessment of the client's health as
status.
 Periodic health assessment needed to be performed by a
physician, or a nurse
3
Objectives of health assessment
 Surveillance of health status, identification of occult disease,
screening, and follow-up care
 The periodic assessment, at regular intervals
 Increasing client participation in health care
 Accurately define the health and risk care needs for individuals
 Health assessment is shared with the client in a clearly and
understandable manner
 The client must share in decision making for his own care.
4
Types of Assessment
 Comprehensive assessment: is usually the initial
assessment it very thorough and includes detailed health
history and physical examination and examine the client's
overall health status
 Focused assessment : is problem oriented and may be
the initial assessment or an ongoing assessment
5
Frequency of assessment
 The persons under (35) years every (4 – 5) years
 The persons from (35 – 45) every (2 – 3) years.
 Persons from (45-55) years of age undergo a thorough
health assessment every year.
 Persons over (55) years may needs assessment every 6
months or less
6
Importance of nursing health assessment
F
1. Systematic and continuous collection of client data
2. It focus on client responses to health problems
3. The nurse carefully examine the client’s body parts to
determine any abnormalities
4. The nurse relies on data from different sources which can
indicate significant clinical problems
5. Health assessment provides a base line used to plan the
clients care
7
6. Health assessment helps the nurse to diagnose client’s
problem & the intervention
7. Complete health assessment involves a more detailed
review of client’s condition
8. Health assessment influence the choice of therapies &
client's responses
8
Purposes of health assessment
1. Gather data
2. Confirm or refuse data obtained in the health history
3.To identify nursing diagnoses
4. To make clinical judgments about client's changing health
status
5.To evaluate bio-psycho-social and spiritual outcomes of
care
9
Nursing and medical diagnosis
 There is a big Difference between both because:
 Nursing diagnose is independent role of the nurse
 Nursing
diagnoses
depends
on
the
client's
problems/response associated with specific disorder
Any problem in nursing diagnosis must notice from a
holistic view e.g. bio-psycho-social and spiritual
relations
10
Medical diagnoses
 Depends on clinical picture and laboratory findings
 The specialist doctor has a right to diagnose not else
Example:
- DM is medical diagnoses (hypo or hyperglycemia)
- Nursing diagnoses in this case e.g. Impaired skin integrity R/T poor
circulation, Knowledge deficit about the effects of exercise on needs of
insulin.
The difference between medical diagnosis, a collaborative
problem, and nursing diagnosis is explained with the next
table:11
12
Health Assessment
Holistic approach:
1. The interview
2. Psychosocial assessment
3. Nutritional assessment
4. Assessment of sleep-wakefulness patterns
5. The health history.
13
1. Interview
 Definition: communication process focuses on the
client's development of psychological, physiological,
sociocultural, and spiritual responses, that can be
treated with nursing & collaborative interventions
14
Major purpose:
 To obtain health history and to elicit symptoms and the time
course of their development. The interview conducted before
physical examination is done.
Components of nursing interview
1. Introductory phase
2. Working phase
3. Termination phase
15
1. Introductory phase:
 Introduce yourself and explains the purpose of the
interview to the client.
 Before asking questions, Let client to feel Comfort,
Privacy and Confidentiality
16
Working phase:
The nurse must listen and observe cues in addition to using critical
thinking skills to validate information received from the client. The
nurse identify client's problems and goals.
Termination phase:
1.The nurse summarizes information obtained during the working
phase
2.Validates problems and goals with the client.
3.Making plans to resolve the problems (nursing diagnosis and
collaborative problems are identified and discussed with the client)
17
Communications techniques during interview
1. Types of questions :
 Begin with open ended questions to assess client's feelings e.g.
what, how, which“
 Use closed ended question to obtain facts e.g." when,
did…etc
 Use list to obtain specific answers e.g. "is pain sever, dull
sharp
 Explore all data that deviate from normal e.g. “increase or
decrease the problem
18
2. Types of statements to be use:
 Repeat your perception of client's response to clarify
information and encourage verbalization
3. Accept the client silence to recognize thoughts
4. Avoid some communication styles e.g.
 Excessive or not enough eye contact.
 Doing other things during getting history.
 Biased or leading questions e.g. "you don't feel bad"
 Relying on memory to recall information
19
5. Specific age variations : Pediatric clients: validate information from parents.
 Geriatric clients: use simple words and assess hearing acuity
6. Emotional variations:
 Be calm with angry clients and simply with anxious and
express interest with depressed client
 Sensitive issues "e.g. sexuality, dying, spirituality" you must
be aware of your own thought regarding these things.
20
7. Cultural variations:
 Be aware of possible cultural variations in the communication
styles of self and clients
8. Use culture broker:
 Use culture broker as middleman if your client not speak
your language.
 Use pictures for non reading clients.
21
Chapter (2)
Psychosocial assessment
Islamic University of Gaza Strip
Psychosocial assessment
 Psychological assessment involves person's growth and
development throughout his life.
 Discuss crises with the clients to assess relationship
between health & illness. “It depends on multiple G&D
theories e.g. Erickson, Piaget, and Freud …. etc.
23
Stages of Age
 Infancy period: birth to 12 months






Neonatal Stage: birth-28 days
Infancy Stage: 1-12 months
Early childhood Stage: It’s refers to two integrated stages of development
Toddler:
1 - 3years.
Preschool: 3 - 6 years.
Middle childhood
6-12 years
Late childhood:
Pre pubertal: 10 – 13 years.
Adolescence: 13 - 19 years
Young adulthood
20-40 years
Middle adulthood
40-65years
Late adulthood
65 and more
Chapter (3)
Nutritional assessment
Islamic University of Gaza Strip
Nutritional assessment
 Nutrition plays a major role in the way an individual
looks, feels,& behaves.
 The body ability to fight disease greatly depends on
the individual's nutritional status
26
Major goals of nutritional assessment
1. Identification of malnutrition.
2. Identification of over consumption
3. Identification of optimal nutritional status.
Components of Nutritional Assessment
1. Anthropometric measurement.
2. Biochemical measurement.
3. Clinical examination.
4. Dietary analysis
27
1. Anthropometric measurement
 Measurement of size, weight, and proportions of human body.
 Measurement includes: height, weight, skin fold thickness, and
circumference of various body parts, including the head, chest,
and arm.
a direct and continuous
relationship to morbidity and mortality in studies of large
populations. High ratios of waist to hip circumference are associated
 Assess body mass index (BMI) to shows
with higher risk for illness & decreased life span.
BMI
28
=
(Wt. in kilograms) =
(High in meters) 2
60
(1.6)2
=
60
2.56
= 23.4
BMI RANGE
Rang kg/m2
less than 16.0
16.0 - 18.4
18.5- 24.9
25–29.9
30-34.9
≥ 35
Condition
Very thin
Thin
Average
Overweight
Obese
Highly obese
2. Biochemical Measurement
 Useful in indicating malnutrition or the development of diseases
as a result of over consumption of nutrients. Serum and urine
are commonly used for biochemical assessment.
 In assessment of malnutrition, commonly tests include: total
lymphocyte count, albumin, serum transferrin, hemoglobin, and
hematocrit …etc. These values taken with anthropometric
measurements, give a good overall picture of an individual's
skeletal and visceral protein status as well as fat reserves and
immunologic response.
3. Clinical examination
 Involves, close physical evaluation and may reveal signs
suggesting malnutrition or over consumption of
nutrients.
 Although examination alone doesn't permit definitive
diagnosis of nutritional problem, it should not be
overlooked in nutritional assessment
31
Nutritional assessment technique for clinical examination
A. Types of information needed
 Diet: Describe the type: regular or not, special, "e.g.
teeth problem, sensitive mouth.
 Usual mealtimes: How many meals a day: when?
Which are heavy meals?
 Appetite: "Good, fair, poor, too good".
 Weight: stable? How has it changed?
32
 Food preferences: e.g." prefers beef to other meats"
 Food dislike:What & Why? Culture related?
 Usual eating places: Home, snack shops, restaurants.
 Ability to eat: describe inabilities, dental problems: "ill
fitting dentures, difficulties with chewing or swallowing
 Elimination"
urine & stool: nature, frequency
problems
 Exercise & physical activity: how extensive or
33
deficient
 Psycho social - cultural factors: Review any thing which can
affect on proper nutrition
 Taking Medications which affect the eating habits
 Laboratory
determinations
e.g.:
“Hemoglobin,
protein,
albumin, cholesterol, urinalyses"
 Height, weight, body type "small, medium, large"
After obtaining information, summarize your findings and
determine the nutritional diagnosis and nutritional plan of
care.
Imbalanced nutrition: Less than body requirements, related to lack of
knowledge and inadequate food intake
Risk for infection, related to protein-calorie malnutrition
B. Signs & symptoms of malnutrition
 Dry and thin hair
 Yellowish lump around eye, white rings around both
eyes, and pale conjunctiva
 Redness and swelling of lips especially corners of mouth
 Teeth caries & abnormal missing of it
 Dryness of skin (xerosis): sandpaper feels of skin
 Spoon shaped Nails " Koilonychia “ anemia
 Tachycardia, elevated blood pressure due to excessive
sodium intake and excessive cholesterol, fat, or caloric
intake
 Muscle weakness and growth retardation
35
36
4. Dietary analysis
 Food represent cultural and ethnic background and socio-
economic status and
psychological meaning
have
many
emotional
and
 Assessment includes usual foods consumed & habits of food
 The nurse ask the client to recall every thing consumed
within the past 24 hour including all foods, fluid, vitamins,
minerals or other supplements to identify the optimal
meals
 Should not bias the client's response to question based on
the interviewer's personal habits or knowledge of
recommended food consumption
37
Diseases affected by nutritional problems
1- Obesity: excess of body fat.
2- Diabetes mellitus.
3- Hypertension.
4- Coronary heart disease.
5- Cancer.
38
Chapter (4)
Sleep-wakefulness patterns
Islamic University of Gaza Strip
Assessment of sleep-wakefulness patterns
 Normal human has “homeostasis” (ability to maintain a
relative internal constancy)
 Any person may complain of sleep-pattern disturbance as
a primary problem or secondary due to another
condition
 1/4 of clients who seek health care complain of a
difficulty related to sleep
40
Factors affecting length and quality of sleep
1. Anxiety related to the need for meeting a tasks, such as waking
at an early hour for work.
2.The promise of pleasurable activity such as starting a vacation.
3.The conditioned patterns of sleeping.
4. Physiologic wake up.
5. Age differences.
6. Physiologic alteration, such as diseases
41
 Good sleep depends on the number of awakenings and the total
number of sleeping hours
 The nurse can assess sleep pattern by doing interview with
the client or using special charts or by EEG
Disorders related to sleep
1.Sleep disturbances affects family life, employment, and general social
adjustment
2. Feelings of fatigue, irritability and difficulty in concentrating
3. Difficulty in maintaining orientation
42
4. Illusions, hallucination (visual & tactile )
5. Decreased psychomotor ability with decreased incentive to
work
6. Mild Nystagmus
7.Tremor of hands
Increase in gluco-corticoid and adrenergic hormone secretion
9. Increase anxiety with sense of tiredness
10. Insomnia "short end sleeping periods“
11. Sleep apnea "periodic cessation of breathing that occurs
during sleep
12. Hypersomnia: "sleeping for excessive periods” the sleep
period may be extended to 16-18 hours a day
13. Peri-hypersomnia. "Condition that is described as an
increased used for sleep "18-20 hours a day" lasts for only
few days
14. Narcolepsy "excessive day time drowsiness or uncontrolled
onset of sleep.
15. Cataplexy: abrupt weakness or paralysis of voluntary muscles
e.g. arms, legs & face last from half second to 10 minutes,
one or twice a year
16. Hypnagogic hallucinations: " Disturbing or frightening
dream that occur as client is a falling a sleep
44
Assessment of sleep habits
 Let the client record the times of going to sleep and awakening
periods, including naps.
 Allow client to described their sleep habits in their own words
You can ask the following questions:
How have you been sleeping?‖
Can you tell me about your sleeping habits?"
Are you getting enough rest?"
Tell me about your sleep problem"
Good History includes: a general sleep history, psychological
45
history, and a drug history
Chapter (5)
Nursing Health History
Islamic University of Gaza Strip
Definition of Health History
Systematic collection of subjective
data which stated by the client,
and objective data which
observed by the nurse
That using to determine a client
functional health pattern status.
47
Phases of taking health history
Two phases:The
interview
phase
which
elicits
information (primary sources)
The recording phase (secondary sources).
48
the
Guidelines for Taking Nursing History
Private,
comfortable,
environment.
and
quiet
Allow the client to state problems and
expectations for the interview.
Orient the client the structure, purposes,
and expectations of the history.
49
Guidelines for Taking Nursing History cont..
Communicate and negotiate priorities
with the client
Listen more than talk.
Observe non verbal communications e.g.
"body language, voice tone, and
appearance".
50
Guidelines for Taking Nursing History cont..
Review information about past health history
before starting interview.
Balance between allowing a client to talk in an
unstructured manner and the need to structure
requested information.
Clarify
the
descriptors)
51
client's
definitions
(terms
&
Guidelines for Taking Nursing History cont..
Avoid yes or no question (when detailed
information is desired).
Write adequate notes for recording?
Record nursing health history soon after
interview.
52
Types of Nursing Health History
Complete health history: taken on initial visits
to health care facilities.
Interval health history: collect information in
visits following the initial data base is collected.
Problem- focused health history: collect data
about a specific problem
53
Components of Health History
1-Biographical Data: This includes
Full name
Address and telephone numbers (client's permanent
contact of client)
Birth date and birth place.
Sex
Religion and race.
Marital status.
Social security number.
Occupation (usual and present)
Source of referral.
Usual source of healthcare
Source and reliability of information.
Date of interview.
54
2- Chief Complaint: “Reason For Hospitalization
Examples of chief complaints:
Chest pain for 3 days.
Swollen ankles for 2 weeks.
Fever and headache for 24 hours.
Pap smear needed.
Physical examination needed for camp.
55
SYMPTOM ANALYSIS
P
Q R ST
a. Provocative or Palliative
 First occurrence :
 What were you doing when you first experienced or noticed
the symptom?
 What to trigger it ? stress? Position?, activity?
 What seems to cause it or make it worse? For a psychological
symptom .
 What relieves the symptom : change diet? Change position ?
Take medication ? Being active?
 Aggravation: what makes the symptom worse?
SYMPTOM ANALYSIS
P
Q
R ST
b. Quality Or Quantity
 QUALITY:
 How would you describe the symptom- how it feels, looks, or
sounds?
 QUANTITY:
 How much are you experiencing now?
 Is it so much that it prevents you from performing any activity?
SYMPTOM ANALYSIS
P Q R S T
C. Region Or Radiation
 Region :
 Where does the symptom occur?
 Radiation :
 Does it travel down your back or arm, up your neck or
down your legs?
SYMPTOM ANALYSIS
P Q R
S
T
d. Severity scale
 Severity
 How bad is symptom at its worst?
 Course
 Does the symptom seem to be getting better, getting worse?
SYMPTOM ANALYSIS
P Q R S T
e. Timing
 Onset :
 On what date did the symptom first occur
Type of onset :
 How did the symptom start sudden? Gradually?
 Frequency :
 How often do you experience the symptom ; hourly ? Daily ? Weekly?
monthly
 Duration :
 How long does an episode of the symptom last
3-History of present illness
Gathering information relevant to the
chief complaint, and the client's
problem,
relevant
treatment.
61
including
data,
and
essential
self
and
medical
Component of Present Illness
Introduction: "client's summary and usual
health".
Investigation of symptoms: "onset, date, gradual
or sudden, duration, frequency, location, quality,
and alleviating or aggravating factors".
Negative information.
Relevant family information.
Disability "affected the client's total life".
62
4- Past Health History:
The purpose: (to identify all major past
health problems of the client)
This includes:
Childhood illness e.g. history of rheumatic
fever.
History of accidents and disabling injuries
63
Past Health History. Cont…
History of hospitalization (time of
admission, date, admitting complaint,
discharge diagnosis and follow up care.
History of operations "how and why this
done"
History of immunizations and allergies.
Physical examinations and diagnostic
tests.
64
5-Family
History
The purpose: to learn about the general health of
the client's blood relatives, spouse, and
children and to identify any illness of
environmental genetic, or familiar nature that
might have implications for the client's health
problems.
65
Family History. Cont…
Family history of communicable diseases.
Heredity factors associated with causes of some diseases.
Strong family history of certain problems.
Health of family members "maternal, parents, siblings,
aunts, uncles…etc.".
Cause of death of the family members "immediate and
extended family".
66
6-Environmental History:
Purpose
“To gather information about surroundings
of
the
client",
including
physical,
psychological, social environment, and
presence of hazards, pollutants and safety
measures."
67
7- Current Health Information
The purpose is to record major current health related
information.
Allergies: environmental, ingestion, drug, other.
Habits "alcohol, tobacco, drug, caffeine"
Medications taken regularly "by doctor or self prescription
Exercise patterns.
Sleep patterns (daily routine).
The pattern life (sedentary or active)
68
8- Psychosocial History:
Includes:
How client and his family cope with
disease or stress, and how they responses
to illness and health.
You can assess if there is psychological or
social problem and if it affects general
health of the client.
69
9- Review of Systems (ROS)
Collection of data about the past and the
present of each of the client systems.
(Review of the client’s physical, sociologic, and
psychological health status may identify
hidden problems and provides an opportunity
to indicate client strength and disabilities
70
Physical Systems
Which includes assessment of:-
General review of skin, hair, head, face, eyes, ears,
nose, sinuses, mouth, throat, neck nodes and breasts.
Assessment of respiratory and cardiovascular system.
Assessment of gastrointestinal system.
Assessment of urinary system.
Assessment of genital system.
Assessment of extremities and musculoskeletal system.
Assessment of endocrine system.
Assessment of heamatoboitic system.
Assessment of social system.
Assessment of psychological system.
10- Nutritional Health History
“Discussed Before”
72
11- Assessment of Interpersonal Factors.
This includes :Ethnic and cultural background, spoken language, values,
health habits, and family relationship.
Life style e.g. rest and sleep pattern
Self concept perception of strength, desired changes
Sexuality developmental level and concerns
Stress response coping pattern, support system, perceptions
of current anticipated stressors.
73
Chapter (6)
Functional Health Pattern
Islamic University of Gaza Strip
Definition of (NANDA)
The
North
American
Nursing
Diagnosis
Association (NANAD 1994) defines a nursing
diagnosis as “A clinical judgments about
individual, family or community response to
actual and potential health problems and life
responses”
75
Functional health pattern (NANDA)
1- Health Perception-Health Management Pattern
2- Nutritional—Metabolic Pattern
3- Elimination Pattern
4- Activity—Exercise Pattern
5- Sexuality—Reproduction Pattern
6- Sleep—Rest Pattern
7- Sensory—Perceptual Pattern
8- Cognitive Pattern
9- Role—Relationship Pattern
10- Self-Perception-Self-Concept Pattern
11- Coping-Stress Tolerance Pattern
12-Value—Belief Pattern
Health Perception-Health Management
Pattern
1- Determine how the client perceives and manages his or her
health.
2- Compliance with current and past nursing and, medical
recommendations.
3- The client's ability to perceive the relationship between
activities of daily living and health.
Subjective Data
Client's Perception of Health:
Describe your health.
Client's Perception of Illness
Describe your illness or current health problem.
Health Management and Habits
Tell me what you do when you have a health problem.
Compliance with Prescribed Medications and Treatments
Have you been able to take your prescribed medications?
If not, what caused your inability to do so?
Objective Data
Refer to General Physical Survey
Associated Nursing Diagnoses
Wellness Diagnoses
Effective Management of Therapeutic Regimen
Risk Diagnoses
Risk for Injury
Risk for Suffocation
Risk for Trauma
Actual Diagnoses
Altered Growth and Development
Ineffective Management of Therapeutic Regimen: Individual
Ineffective Management of Therapeutic Regimen: Family
Ineffective Management of Therapeutic Regimen: Community
Noncompliance.
Nutritional-Metabolic Pattern
Assessing the client's nutritional-metabolic pattern is to determine the
client's dietary habits and metabolic needs. The conditions of hair,
skin, nails, teeth and mucous membranes are assessed.
Subjective Data
Dietary and Fluid Intake
Describe the type and amount of food you eat at breakfast, lunch, and
supper on an average day
Do-you take any vitamin supplements? Describe.
Do you find it difficult to tolerate certain foods? Specify.
Do you ever experience nausea and vomiting? Describe.
Do you ever experience abdominal pains? Describe
Condition of Skin
Describe the condition of your skin.
How well and how quickly does your skin heal?
Do you have any skin lesions? DescribeDo you have any itching? What do you do for relief?
Condition of Hair and Nails
Have you had difficulty with scalp itching or sores?
Do you use any special hair or scalp care products?
Have you noticed any changes in your nails? Color Cracking? Shape?
Lines?
Metabolism
What would you consider to be your "ideal weight"?
Have you had any recent weight gains or losses?
Do you have any intolerance to heat or cold?
Have you noted any changes in your eating or drinking habits?
Explain.
Have you noticed any voice changes?
Objective Data
Assess the client's temperature, pulse, respirations, and height and
weight.
Wellness Diagnoses
0pportunity to enhance nutritional metabolic pattern
Opportunity to enhance effective breastfeeding
Opportunity to enhance skin integrity
Risk Diagnoses
Risk for Altered Body Temperature
Hypothermia
Risk for Infection
Risk for altered nutrition less than body requirements .
Risk for Aspiration
Actual Diagnoses
Fluid Volume Deficit
Fluid Volume Excess
Altered Nutrition: Less than body requirements
Altered Nutrition: More than body requirements
Ineffective Breastfeeding
Altered Oral Mucous Membrane
Impaired Skin Integrity.
Elimination Pattern
Adequacy of the client's bowel and bladder.
The client's bowel and urinary habits.
Bowel or urinary problems
Use of urinary or bowel elimination devices.
Subjective Data
Bowel Habits
How frequent are your bowel movements?
Do you use laxatives? What kind and how often do you use them?
Do you use enemas or suppositories? How often and what kind?
Do you have any discomfort with your bowel movements?
Describe.
Bladder Habits
How frequently do you urinate?
What is the amount and color of your urine?
Do you have any of the following problems with urinating:
 Pain? Blood in urine? Difficulty starting a stream? Incontinence?
Voiding frequently at night? Voiding frequently during day?
Bladder infections?
 Have you ever had a urinary catheter? Describe. When? How
long?
Objective Data
Refer to abdominal assessment, and the rectal assessment.
Associated nursing-Diagnoses
Wellness Diagnoses
Opportunity to enhance adequate bowel elimination pattern
Opportunity to enhance adequate urinary elimination pattern
Risk Diagnoses
Risk for constipation
Risk for altered urinary elimination
Actual Diagnoses
Altered Bowel Elimination Constipation
Diarrhea
Bowel Incontinence
Altered Urinary Elimination Patterns of Urinary Retention
Total Incontinence
Stress Incontinence
Activity-Exercise Pattern
Activities of daily living, including routines of exercise, leisure, and
recreation.
Activities necessary for personal hygiene, cooking, shopping, eating,
maintaining the home, and working.
An assessment is made of any factors that affect or interfere with the
client's routine activities of daily living.
Subjective Data
Describe your activities on a normal day. (Including hygiene activities,
eating activities.)
Do you have difficulty with any of these self-care activities? Explain.
Does anyone help you with these activities? How?
Do you use any special devices to help you with your activities?
Does your current physical health affect any of these activities e.g. dyspnea,
shortness of breath, palpations, chest pain. pain, stiffness, weakness)?
Explain.
Occupational Activities
Describe what you do to make a living.
Do you feel it has affected your health?
How has your health affected your ability to work?
Objective Data
Refer to Thoracic and Lung Assessment
Cardiac Assessment
PeripheralVascular Assessment
Musculoskeletal Assessment.
Associated Nursing Diagnoses
Wellness Diagnoses
Opportunity to enhance effective cardiac output
Opportunity to enhance effective self-care activities
Opportunity to enhance adequate tissue perfusion Opportunity to
enhance effective breathing pattern
Risk Diagnoses
Risk for Disorganized Infant Behavior
Risk for Peripheral Neurovascular Dysfunction
Risk for altered respiratory function
Actual Diagnoses
Activity Intolerance
Impaired Gas Exchange
Ineffective Airway Clearance
Ineffective Breathing Pattern
Disuse syndrome
Impaired Physical Mobility
Inability to Sustain Spontaneous Ventilation
Altered Tissue Perfusion
Sexuality-Reproduction Pattern
Subjective Data
1- Female
Menstrual history:
Last cycle begin?
Duration ?
Any change or abnormality ?
Describe any mood changes or discomfort before, during, or after
your cycle
Obstetric history
How many times have you been pregnant?
Describe the outcome of each of your pregnancies.
If you have children, what are the ages and sex of each?
Explain any health problems or concerns you had with each pregnancy.
If pregnant now .
Contraception
What do you or your partner do to prevent pregnancy?
Describe any discomfort or undesirable effects this method produces.
Have you had any difficulty with fertility? Explain
Special problems
Do you have or have you ever had a sexually transmitted disease?
Describe.
Describe any pain, burning, or discomfort you have while voiding.
Objective Data
Refer to Breast Assessment, d Abdominal Assessment, and urinaryReproductive Assessment
Associated nursing Diagnoses
Wellness Diagnosis:
Opportunity to enhance sexuality patterns
Risk-Diagnosis
Risk for altered sexuality pattern
Actual Diagnoses
Sexual Dysfunction, Altered Sexuality Patterns
Sleep-Rest Pattern
Subjective data
Sleep Habits:
How would you rate the quality of your sleep?
Special Problems
Do you ever experience difficulty with falling asleep? Remaining
asleep? Do you ever feel fatigued after a sleep period?
Sleep Aids
What helps you to fall asleep? medications? reading? relaxation
technique?WatchingTV? Listening to music?
Objective Data
1. Observe appearance
a. Pale b. Puffy eyes with dark circles
2. Observe behavior
a.Yawning
b. Dozing during day
c. Irritability
d. Short attention span
Associated nursing Diagnoses
Wellness Diagnosis:
Opportunity to enhance sleep
Risk Diagnosis
Risk for sleep pattern disturbance
Actual Diagnosis:
Sleep Pattern Disturbance.
Sensory-Perceptual Pattern
Subjective Data
Describe your ability to see, hear, feel, taste, and smell.
Describe any difficulty you have with your vision, hearing, and ability
to feel (e.g., touch, pain, heat, cold), taste (salty, sweet, bitter, sour),
or smell.
Pain Assessment
Complete Symptom Analysis
Special Aids:
What devices (e.g., glasses, contact lenses, hearing aids)
Describe any medications you take to help you with these problems.
Objective Data
Refer to the section on Nose and Sinus Assessment, Eye Assessment,
and Ear Assessment.
Associated Nursing Diagnoses
Wellness Diagnosis:
Opportunity to enhance comfort level
Risk Diagnoses
Risk for pain
Actual Diagnoses
Pain
Cognitive Pattern
Subjective Data
Ability to Understand:
Explain what your doctor has told you about your health.
Ability to Communicate:
Can you tell me how you feel about your current state of health?
Ability to Remember:
Are you able to remember recent events and events of long ago?
Explain.
Ability to Make Decisions:
Describe how you feel when faced with a decision.
Objective Data
Refer to the Mental Status Assessment
Associated nursing Diagnoses
Wellness Diagnosis: Opportunity to enhance cognition
Risk Diagnosis:
Risk for altered thought processes
Actual Diagnoses:
Acute confusion
Chronic Confusion
Knowledge Deficit (Specify)
Impaired Memory
Role-Relationship Pattern
Subjective Data
Perception of Major Roles and Responsibilities in Family
Describe your family.
Are there any major problems now?
Perception of Major Roles and Responsibilities at Work
Describe your occupation.
What is your major responsibility at work?
Perception of Major Social Roles and Responsibilities
Describe your neighborhood and the community in which you live.
Objective Data
1. Outline a family genogram for your client.
2. Observe your client's family members.
Associated Nursing Diagnoses
Wellness Diagnoses:
Opportunity to enhance effective relationships
Opportunity to enhance effective communication
Risk Diagnoses:
High risk for Loneliness
Risk for Altered Parent/Infant/Child Attachment
Actual Diagnoses:
Impaired Verbal Communication
Impaired Social Interaction: Social Isolation
Coping-Stress Tolerance Pattern
Subjective Data
Perception of Stress and Problems in Life
Describe what you believe to be the most stressful situation in your
Life.
How has your illness affected the stress you feel?
Coping Methods and Support Systems:
What do you usually do first when faced with a problem?
What helps you to relieve stress and tension?
Do you use medication, drugs, or alcohol to help relieve stress?
Explain.
Objective Data
Refer to the Mental Status Assessment.
Associated nursing Diagnoses
Wellness Diagnoses
Opportunity to enhance effective individual coping.
Opportunity to enhance family coping
Risk Diagnoses:
Risk for self-harm
Risk for suicide
Actual Diagnoses:
Ineffective Individual Coping
Ineffective Family Coping: Disabling
Value-Belief Pattern
Subjective Data
Values, Goals, and Philosophical Beliefs
Religious and Spiritual Beliefs:
Are there certain health practices or restrictions that are important
for you to follow while you are ill or hospitalized? Explain.
Objective Data
Observe religious practices
Bible , clergy
Observe client's behavior for signs of spiritual distress
Anxiety, Anger , Depression , Doubt, Hopelessness and Powerlessness
Associated Nursing Diagnoses
Wellness Diagnosis:
Potential for Enhanced Spiritual Well-Being
Risk diagnosis:
Risk for spiritual distress
Actual Diagnosis:
Spiritual disturbance (distress of the human spirit).
Chapter (7)
Physical Assessment Techniques
Islamic University of Gaza Strip
Indications for the Physical Exam
 Routine screening
 Eligibility prerequisite for health insurance, military
service, job, sports, school
 Admission to a hospital or long term care facility
112
STEPS OF ASSESSMENT
 Think
 Organize
Don’t forget…Nutrition / Height & Weight
 Environment:
 Accommodate special needs (cultural sensitivity)
 Equipment - clean surface & clean equipment Room - quiet,
warm & well lit
 Maintain privacy
 Observe & Listen
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DON’T FORGET
 REVIEWING GENERAL INFORMATION
 INTRODUCTION TO CLIENT
 OBTAINING THE HEALTH HISTORY
 PAIN ASSESSMENT
 THIS IS KEY TO HOLISTIC APPROACH
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Physical Assessment
 There are four techniques to use in performing physical assessment:
1.Inspection
2. Palpation
3. Percussion
4. Auscultation
Note: there are five addition skill known as olfaction
115
116
1. Inspection:
 Inspection is defined as “the use of the senses of vision, smell and
hearing to observe the normal condition or any deviations from
normal of various body parts.”
 The nurse inspects or looks body parts to detect normal
characteristics or significant physical sings.
 Inspection helps to know normal characteristics before trying to
distinguish abnormal findings in different ages.
 The quality of an inspection depends on the nurse's willingness to
spend time doing a thorough job.
117
Inspection
 Use vision, hearing & smell
 Always first
 Look for symmetry
 Use good lighting
 Use good exposure
118
Principles of Accurate Inspection
 Good lightening either day light or artificial light is suitable.
 Expose body parts being observed only.
 look before touching.
 warm room for examination of the client “not cold not hot".
 Observe for color, size, location, texture, symmetry, odors, and
sounds.
 Compare each area inspected with the opposite
possible.
 Use pen light to inspect body cavities.
119
side of body if
Palpation
 Touch & feel with hands to determine:
 Texture – use fingertips (roughness, smoothness).
 Temperature – use back of hand (warm, hot, cold).
 Moisture (dry, wet, or moist).
 Organ location and size
 Consistency of structure (solid, fluid, filled)
 Slow and systematic
 Light to deep
 Light palpation (tenderness)
 Deep palpation (abdominal organs/masses)
Principles for Accurate Palpation
 Examiner finger nails should be short.
 Use sensitive part of the hand.
 Light Palpation precedes deep palpation.
 Start with light then deep palpation
 Tender area are palpated last
 Tell client to take slow deep breath to enhance muscle relaxation.
 Examine condition of the abdominal organs
 Depressed areas must be approximately “2cm”
 Assess turger of skin measured by lightly grasping the body part
121
with finger tips.
Light palpation
122
Deep palpation
123
Percussion
Tap a portion of the body to elicit tenderness that varies with the
density of underlying structures.
Percussion denotes location, size and density of underlying
structures, percussion requires dexterity.
Methods of percussion:
Direct method: involving striking the body surface directly with
one or two fingers.
Indirect method: performed by placing the middle finger of the
examiner’s non dominant hand “pleximeter hand” firmly against
the body surface with palm and fingers remaining off the skin,
and the tip of the middle finger of the dominant hand “plexor”
strikes the base of the distal joint of the pleximeter. Use a
quick & sharp stroke
Percussion
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Description of sounds
 Sound produced by the body is characterized by intensity,
frequency, duration and quality.
 Intensity, or loudness, associated with physiologic sound is low;
thus, the use of the stethoscope is needed.
 Frequency, or pitch, of physiologic sound is in reality “noise” in
that most sounds consist of a frequency spectrum as opposed to
the single-frequency sounds that we associate with music or the
tuning fork.
 Duration relates to the time elapsed from the beginning of the
sound till the end of the sound.
 Quality of sound relates to overtones that allow one to
distinguish between different sounds.
126
Sounds produced by percussion
Sound
Tympany
Intensity
Loud
Pitch
High
Duration
Moderate
Quality
Drum like
Example
Large
pneumothorax
Resonance
Moderate
Low
Long
hollow
Normal lung
Very
Longer
Booming
Emphysematous
low
than
to loud
Hyper-
Very loud
resonance
lung
resonance
Dullness
Soft to
High
Moderate
Thud like
Liver
High
Short
Flat
Muscle
moderate
Flatness
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Soft
Five percussion sounds produced in different body regions
1. Resonant – normal lung
2. Hyper resonant: it’s a louder and lower pitched than resonant sounds.
Normally heard in children and very thin adults , and abnormally in
emphysema
3. Tympany : A hollow drum-like sound produced when a gas-containing cavity
is tapped sharply. Tympany is heard if the chest contains free air
(pneumothorax) or the abdomen is distended with gas air filled (stomach)
4. Dull or thud like sounds are normally heard over dense areas such as the
heart or liver. Dullness replaces resonance when fluid replaces air-containing
lung tissues, such as occurs with pneumonia, pleural effusions, or tumors
5. Flat: shown in no air areas such as thigh muscle, bone and tumor
Auscultation
“To listen for various breath, heart, and bowel sounds”
Direct or immediate auscultation is accomplished by the
unassisted ear that is without amplifying device. This form
of auscultation often involves the application of the ear
directly to a body surface where the sound is most
prominent.
Mediate auscultation: the use of sound augmentation
device such as a stethoscope in the detection of body
sounds.
Auscultation
 Listening to body sounds
 Movement of air (lungs)
 Blood flow (heart)
 Fluid & gas movement (bowels)
 Remember the sound changes in
the abdomen…
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HOW TO BEGIN…
 Positions for physical exam
 Using a stethoscope:
 Longer the tube – more sound has to travel
 Hold diaphragm firmly against client’s skin (NOT
THROUGH CLOTHING)
 If using bell – less pressure
 Warm in your hands first!
 Listen / Concentrate on the sounds
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Olfaction
Another skill that used during assessment, certain alteration is
body function create characteristic body odors, smelling can
detect abnormalities that unrecognized by other means.
Assessment of characteristic odors:
 Alcohol odor from oral cavity means ingestion of alcohol.
 Ammonia from urine means urinary tract infection.
 Body odor from skin, particularly in areas where body parts
rub together means poor hygiene, excess perspiration
(bromidrosis).
132
 Feces odor from wound site means wound abscess, but if this
odor from vomitus this means bowel obstruction, and if the
odor from rectal area this means fecal incontinence.
 Foul–smelling stools in infant from stool means mal absorption
syndrome.
 Halitosis from oral cavity means poor dental and oral hygiene,
gum disease.
 Sweet, fruity ketones from oral cavity may be from diabetic
acidosis.
 Musty odor from casted body part means infection inside cast.
 Fetid odor from tracheostomy or mucous secretions means
infection of bronchial tree (pseudomonas bacteria).
Basic Guidelines for physical Assessment
1. Obtain a nursing history and survey
2. Maintain privacy.
3. Explain the procedure
4. Always inspect, palpate, percuss, and then auscultate
5.
6.
7.
8.
except abdominal start with auscultate
Compare symmetrical sides
If abnormality (Symptom analysis )
Client teaching
Allow time for client’s questions.
"Remember: the most important guideline for adequate physical
assessment is conscious, continuous practice of physical assessment
skills".
Variation in physical assessment of the
pediatric client.
 Sequence of physical assessment is dependent upon the
developmental level of the client.
 Allowing time for interaction with the child prior to
beginning the examination helps to reduce fears.
 In certain age groups, portions of assessment will require
physical restraint of the client with the help of another adult.
 Distraction and play should be intermingled throughout the
examination to assist in maintaining rapport with the pediatric
client.
 Involving assistance from the child’s significant caregiver may
facilitate a more meaningful examination of the younger client.
 The examiner should be prepared to alter the order of the
assessment and approach to the child based on the child’s
response.
 Protest or an uncooperative attitude toward the examiner is a
normal finding in children from birth to early adolescence,
throughout parts or even all the assessment process.
Variations for physical assessment of the
geriatric client.
Remember: normal variation related to aging may be observed in
all parts of the physical examination.
 Dividing the physical assessment into parts in order to avoid
fatigue in the older client.
 Provide room with comfortable temperature and no drafts.
 Allow sufficient time for client to respond to directions.
 If possible assess the elderly clients in a setting where they have
an opportunity to perform normal activities of daily living in
order to determine the client’s optimum potential.
Chapter (8)
Vital Signs and General Assessment
Islamic University of Gaza Strip
Vital signs and general assessment
Equipment needed:
 Balance scale.
 Tape measure.
 Thermometer.
 Sphygmomanometer.
 Stethoscope.
Subjective Data:
 Reason for seeking health care and major concern about current
health, current age, height, and weight, recent weight changes,
fever, history of hypertension, hypertension, difficulty breathing,
changes impulse or heart rate.
139
Objective Data:
 Observe client from head to toe to note any gross abnormalities in
appearance or behaviors.
 Assess vital signs, temperature, pulse, respirations, and blood pressure
to detect any severe deviations and to acquire base line data.
 Weight the client and measure for height with shoes, and heavy clothing
removed.
140
Vital signs (assessment) include:
 Assessment of temperature, pulse, respiration and blood pressure are
known as life signs.
 Vital signs are indicators of the body’s physiologic status and response
to physical, environmental and physiologic stressors.
 Vital signs reveal the client’s current ability to maintain body
temperature regulation, to maintain local and systemic blood flow,
and to provide oxygenation of body tissues.
A.Temperature
 Body temperature is difference between heat produced and heat lost.
The hypothalamus acts as the body's thermostat to maintain between
the body's heat-producing function (metabolism, shivering, muscle
contraction, exercise and thyroid activity) and heat losing methods
(radiation, convection)
141
Method of measurement
a. Oral
b. Rectal
c. Axillary d. Forehead e.Tympanic
Remember
 Routinely, where accuracy is not crucial, an oral temp will sufficient.
 Rectal temperature is the most accurate.
 Unless contraindicated a rectal temperature is often preferred.
Factors influencing of temperature
 Biologic rhythms
 Gender: women has greater fluctuations in body temperature than
men because change of hormones
 Environmental effect (hot, cold), Physiologic change(exercise)
 Drugs and Age (child have slightly higher normal temperature,
elderly people have decrease body temperature).
B. Pulse
 The pulse reflects the force of the heart contracting. Also reflects
stroke volume, the mount of blood ejected with each contraction.
 A pulse deficit (a difference between the apical and radial pulse rate)
Factors influencing of pulse
1. Pain
2. Emotion
3. Exercise
4. Prolong heat application
5. Decrease BP, and increase temperature.
6. Poor oxygen in the blood.
Remember
 Palpate the radial pulse and count for at least "30" second.
 If the pulse is irregular, count for full minute and note the number of
irregular beats per minute.
 Note is the pulse against your finger strong or weak (Amplitude of
 Rhythm: regular or irregular
 Amplitude of rhythm
Absent 0
Thready 1
Weak
2
Normal 3
Bound
4
Site of pulse
 Temporal, Carotid, Brachial, Radial, Femoral, Dorsalis Pedis ,
Popliteal, Posterior Tibia and Apical.
 N.B pulse rate is "60-100 b/m" regular in rhythm. The normal
pulse rate varies from a low of 50 bpm in healthy, athletic young
adults to rates well in excess of 100 bpm after exercise or during
144 times of excitement
145
C. Respiration:
 Count the number of respiration (rate), in full minute Respiration:
normally "16-20 breath/minute" (for healthy adult person).
 Note rhythm (regular or irregular) and depth of breathing (reflects
the tidal volume, described as shallow or deep breathing).
Factors influencing of reparation
1. Age
Newborn 35 breath / minute ,
1 year 30 breath / minute ,
6 year 21 breath / minute,
10 year 19 breath / minute ,
18 year 16-18 breath / minute
2. Any disease
3. Exercise
4. Emotion
D. Blood pressure:
 Measure Blood Pressure in both arms.
 Pulse pressure: the difference between the systolic and the
diastolic pressures (normally is 30 to 40 mm Hg)
 Palpate the systolic pressure before using the stethoscope in
order to detect an auscultatory gap.
 Apply cuff firmly, if too tight (small) it will give falsely high
reading.
 Use cuff in appropriate size.
 Note position of client when measuring blood pressure.
 Monitor blood pressure after client is seated or supine quietly
for "10" minute.
 Repeat after two minutes.Then repeat with client standing.
Factors influencing the BP
1. Age
Newborn 40 mmHg/systolic / 20 diastole
1 month 84/54 mmHg
1 year 95 /65 mmHg
6 year 105 / 65 mmHg
10 – 13 year 120 / 80 mmHg
14- 17 year 120/80 mmHg
18 year 120/80 mmHg
 Normal range 100 – 140mmHg (systolic) and from 60-90
mmHg/( diastolic)
2. Sex
3. Emotion
4. Position: Laying down
4. After meal
5. Exercise
148
Instrumentation used in assessment
Instruments, or “equipments” used during physical assessment should
be readily accessible, clean, in proper working order.
 Ophthalmoscope: "lighted instrument for visualization of the
eye".
 Otoscope: for examination of the ear.
 Snellen eye chart: used as a screening test for vision.
 Nasal speculum: used for assessment of the nose.
 Vaginal speculum: examination of the vaginal canal and cervix.
 Tuning fork: for testing auditory function and vibratory
perception.
 Percussion hammer: “reflex hammer” used to test reflexes and
determine tissue density.
149
150
Positions
 Each position has it's specialty for parts of examination. Draping
during assessment is used to prevent unnecessary exposure. Drapes
may be paper, cloth, or bed linens
I. Sitting position
 Areas Assessed:
Head and neck, back, posterior thorax and lungs, anterior thorax
and lungs, breasts, axially, heart, vital signs, and upper extremities
 Rationale:
Sitting upright provides full expansion of lungs and provides better
visualization of symmetry of upper body parts.
 Limitations:
Physically weakened client may be unable to sit. Examiner should use
supine position with head of bed elevated instead.
II. Supine position
 Areas Assessed: Head and neck anterior thorax and lungs, breasts,
axillae, heart, abdomen, extremities, and pulses
 Rationale: This is most normally relaxed position. It prevents
contracture of abdominal muscles and provides easy access to pulse sites.
 Limitations: If client becomes short of breath easily, examiner may
need to raise head of bed.
III. Dorsal position:
 Areas Assessed: Head and neck, anterior thorax and lungs, Breasts,
axillae and heart.
 Rationale: Clients with painful disorders are more comfortable with
knees flexed.
 Limitations: Position is not used for abdominal assessment because it
promotes contracture of abdominal muscles
IV. Lithotomy position:
 Areas Assessed: Female genitalia and genital tract
 Rational: This position provides maximal exposure of genitalia and
facilitates insertion of vaginal speculum.
 Limitations:
Lithotomy position is embarrassing and uncomfortable, so examiner
minimizes time that client spends in it. Client is kept well draped.
Client with severe arthritis or other joint deformity may be unable to
assume this position.
V. Sims’ position:
 Areas Assessed: Rectum and vagina
 Rationale: Flexion of hip and knee improves exposure of rectal area.
 Limitations:
Joint deformities may hinder client’s ability to bend hip and knee.
VI. Prone position:
 Areas Assessed: Musculoskeletal system
 Rationale:
This position is used only to assess extension of hip joint.
 Limitations:
This position is intolerable for client with respiratory difficulties.
VII. Knee-chest position:
 Areas Assessed: Rectum.
 Rationale: This position provides maximal exposure of rectal area.
 Limitations:
 This position is embarrassing and uncomfortable.
 Clients with arthritis or other joint deformities may be unable to
assume this position.
155
Chapter (9)
Assessment of Skin, Hair and Nails
Islamic University of Gaza Strip
Structure of the Integument
 The skin is the largest organ of the body comprising 15 percent of total
body weight.
 Layers of the skin
A. Epidermis
B. Dermis
C. Subcutaneous tissue
Epidermal appendages
 Hair
 Nails
 Glands: two types of skin glands:
1. Sweat Gland
Eccrine sweat glands: are widely distributed and open directly onto the
skin surface
Apocrine sweat glands: open into hair follicle in axillary and genital
areas
2. Sebaceous glands: Produce sebum(oily secretion)
158
Functions of skin and epidermal appendages
 Barrier to water and electrolyte loss
 Regulation of body heat
 Sensory organ for touch, temperature, and Pain
 Production of protective skin film by eccrine and sebaceous
glands
 Participation in production of vitamin
 Wound repair
159
Assessing the Integument
1. Subjective data
 Skin infection, rashes, lesions, itching.
 Precipitating factors: stress, weather, drugs
 Changes in skin color, lesions
 Amount of sun exposure
 Scalp lesions, itching, and infections.
 Changes in texture and amount of hair.
 Changes in nails and cuticles nail breaking
160
2. History of current symptom
 Are you having experience of skin problem, such as rashes, lesion
 Describe any birthmarks, tattoos, or moles
 Have you noticed any changed in your ability to feel pain, pressure,
light touch, or temperature changed?
 Have you had any hair loss or change in the condition of your hair?
 Have you had any change in the condition or appearance of your
nails?
 Describe any previous problem within the skin, hair or nails ( past
history)
 Have you ever had any allergic skin reaction to food, medication,
plants?
 Has anyone in your family had a recent illness, rash, or other skin
problem? (Family history)
3. Physical Assessment
 Equipment
Penlight Tongue depressor
Magnifying glass Flashlight
Centimeter rule
Wood’s lamp
Gloves
 Technique to examination of skin
Inspection
Palpation
Inspections and palpation of skin
Color
Moisture
Temperature
Turgor
Vascular changes
Edema
Skin odors are usually noted in the skin fold.
162
Thickness
Lesions
163
Inspection color of skin
 Skin color varies from body part to body part and from person to
person.
 Assessment first involves area of skin not exposed to the sun e.g.
palms of the hands.
 Pallor easily perceived in the buccal “mouth” mucosa particularly in
individuals with dark skin.
 Cyanosis readily seen in area of least pigmentation e.g. lips, nail beds
conjunctiva and palm.
 Jaundice orYellow seen in client’s sclera.
 Erythema may indicate circulatory changes
164
165
Palpation moisture of skin
 Skin is normally smooth and dry.
 Skin folds e.g. axillae are normally moist.
 In presence of lesions or ooze fluid, nurse must wear gloves to
prevent exposure to infections drainage
 Moisture indicates:
1- Degree of client’s hydration
2- Condition of the outer lipid layer of the skin surface
Dry (xerosis):Vitamin A def. and Myxedema
Oily: Acne
166
Palpation of Temperature
 Temperature of skin depends on the amount of blood circulating
through dermis.
 Generalized warmth: (Fever, Hyperthyroidism)
 Local warmth: (Inflammation)
 Coolness: (Hypothyroidism, Frost bite, Hypothermia, Shock, Low
cardiac output)
 Palpation of skin with dorsum of the hand.
 Assessment of skin is critical point in some conditions such as: after
cast application, or after vascular surgery.
167
Palpation of Texture
 Texture of skin normally smooth, soft and flexible
 If any abnormalities in texture found you must ask the client is he
exposed to any recent injury to the skin?
 Nurse determines whether the client’s skin is smooth or rough, thin
or thick, tight or supple (flexible).
 Very Soft: (Thyrotoxicosis)
 Tight: (Scleroderma = hard skin)
 Rough: (Hypothyroidism)
168
Palpation of Turgor
 Turgor: is the skin elasticity




diminished by edema or
dehydration.
Assessment of turgor done by
pinching skin between the
thumb and forefinger and
released.
Normally
skin
return
immediately to its position.
Failure of this process means
dehydration.
Decrease in turgor predisposes
the client to skin breakdown.
Palpation of Vascularity
 Vascularity: Assessment of circulation of skin E.g. petechiae may indicate
serous blood clotting disorders, drug reactions or liver disease.
Inspection and Palpation of Edema
 Edema : "Build up of fluid in tissues“
 Inspected for location, color, and shape.
 Palpates areas of edema to determine mobility, consistency, and
tenderness
Inspection and Palpation of Lesions
 Normally skin free of lesions except common freckles.
 If lesion present, inspection must done for distribution, arrangement,
morphology, color and size
 Palpation for lesion’s mobility, contour (flat, raised or depressed) and
consistency (soft or hard are indicated).
 Cancerous lesions frequently undergo changes in color and size.
Hair and Scalp
 Assessment done for distribution, thickness, texture, and lubrication
of the hair.
 Some events which affect the distribution of hair over the body e.g.
client with hormone disorders, woman with hirsutism
 Amount of hair covering extremities may be reduced as a result of
aging and arterial insufficiency especially in lower limbs.
 Scaliness or dryness of the scalp is frequently caused by dandruff or
psoriasis.
171
Nails Assessment
 Nails reflect an individual's general




state of health, state of nutrition, and
occupation.
Nails are normally transparent,
smooth, and convex, with a nail bed
angle of about 160 degrees.
The surrounding cuticles are
smooth, intact and without
inflammation.
Nail bed is normally firm on
palpation.
Nails normally grow at a constant
rate.
Abnormal condition of nail
 Anonychia: complete absence of nails
 Platunychia: flatting nails
 Koilonychia : nails like spoon shape (iron deficiencies anemia)
 Racket nail: fattened and expanded nails
 Onycholysis: separation of nail form nail bed (thyrotoxicosis)
 Melanoychia: presence of brown color in nails plate
 Paronychia: inflammation of tissue surrounding the nail
173
174
Chapter (10)
Assessment of respiratory system
Islamic University of Gaza Strip
Anatomy of Respiratory System
The lung is a two cone-shaped, elastic structure suspended within the
thoracic cavity.
 Lung are paired, they are not complete symmetric, the right lung
contain three lobe, whereas the left lung contain only two lobes.
 The apex of each lung extended slightly above the clavicle, where the
base is at the level of diaphragm
 The thoracic cavity contains the nasopharynx, larynx, trachea, bronchi,
bronchioles, alveoli.
 The thoracic cavity is lined by a thin, double- layered serous membrane
176
collectively called the pleural membrane
177
178
Assessment of respiratory system
Subjective data: the nurse must ask the client about: Coughing (productive, non productive)
 Sputum (type & amount)
 Allergies, dyspnea or SOB (at rest or on exertion).
 Chest pain, history of asthma, bronchitis, emphysema, tuberculosis.
 Cyanosis, pallor.
 Exposure to environmental inhalants (chemicals, fumes).
 History of smoking (amount and length of time)
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Technique for Respiratory Exam
 Before beginning, if possible:
 Quiet environment
 Proper positioning (patient sitting for posterior thorax exam, supine for
anterior thorax exam)
 Expose skin for auscultation
 Patient comfort, warm hands and diaphragm of stethoscope, be
considerate of women (drape sheet to cover chest)
 After that the nurse should apply the four techniques;
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Inspection, Palpation, Percussion and Auscultation
Initial Respiratory Survey (Inspection)
 Observe the patient’s breathing pattern
 Rate (normal vs. increased/decreased)
 Depth (shallow vs. deep)
 Effort (any sign of accessory muscle use, inspect neck)
 Assess the patient’s color
 Cyanosis
 Normal Respiratory Rates
 Infant 30-60
 Toddler 24-40
 Preschooler 22-34
 School-age child 18-30
 Adolescent 12-16
 Adult 16-20
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Inspection and assessment of respiration patterns
 Assess the skin and overall symmetry and integrity of the thorax.
 Assess thoracic configuration.
 Client must be uncovered to the waist, and in sitting position without




support.
Observation of skin may give you knowledge about nutritional status
of the client.
Anterior- posterior diameter of thorax in normal person less than the
transverse diameter = (1:2).
Assess for abnormality of configuration, e.g. pigeon chest, funnel
chest, spinal deformities.
Assess ribs and inter spaces on respiration – may give information
about obstruction in air flow e.g. bulging of inter spaces on expiration
may be from obstruction to air out flow “tumor, aneurysm, cardiac
enlargement”
Assess pattern of respiration
 Normally:
men and children – breathe diaphragmatically and
Women breathe thoracically or costally.
 Tachypnea: respiratory rate over than 20/m for adult.
 Bradypnea: respiratory rate less than 10/m.
 Palpation: palpate areas of chest especially areas of abnormalities.
 If clients complains: all chest areas must palpated carefully for
tenderness, bulges, or any movements
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Assess thoracic expansion:
 Anterior: put your hands over anterior-lateral chest and thumbs
extended along costal margin pointing to xiphoid process.
 Posterior: thumbs placed at level of T 10 with palms placed on
posterior-lateral chest.
 By two ways you feel amount of thoracic expansion during quiet
and deep breathing, and symmetry of respiration between left
and right hemi thoraces.
 Assessment of fremitus: which is vibration perceptible on
palpation"
 In subcutaneous emphysema: you must palpate the tissue,
audible cracking sounds are heard – these sounds are termed
Crepitation
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185
Percussion of chest:
 Done to determine relative amounts of air, liquid, or solid material in the
underlying lung, and to determine positions and boundaries of organs.
 Percussion done for posterior and anterior and lateral aspects of chest with
all directions, and with about “5”cms intervals.
Auscultation:
 To obtains information about the function of respiratory system & to
detect any obstruction in the passages.
 Instruct the client to breathe through the mouth more deeply and slowly
than in usual respiration and then to hold the breath for a few seconds at
the end of inspiration to increase intrapleural pressure and reopen
collapsed alveoli.
 Auscultate all areas of chest for at least one complete respiration: 12
anterior locations and 14 posterior locations
 Auscultate symmetrically: Should listen to at least 6 locations anteriorly
and posteriorly
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 Breathe sounds: are analyzed according to pitch, intensity, quality,
and relative duration of inspiratory and expiratory phases.
 Bronchial breathe sounds: are normally heard over manubrium of
sternum
 If heard over lung tissue – indicate pathologic condition, these
sounds “high-pitched loud sounds with decrease inspiratory and
lengthened increase expiratory phases.
 Absent or decreased breath sounds can occur in:
 Foreign body.
 Bronchial obstruction.
 Shallow breathing.
 Emphysema
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Breath Sounds
 Normal breath sounds are distinguished by their location over a
specific area of the lung and are identified as tracheal, vesicular,
bronchovesicular, and bronchial (tubular) breath sounds as the next:
1.Tracheal
 Very loud, high pitched sound
 Inspiratory = Expiratory sound duration
 Heard over trachea in the neck
2. Bronchial
 Loud, high pitched sound
 Expiratory sounds > Inspiratory sounds
 Heard over manubrium of sternum
 If heard in any other location suggestive of consolidation
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3. Bronchovesicular
 Intermediate intensity, intermediate pitch
 Inspiratory = Expiratory sound duration
 Heard best 1st and 2nd ICS anteriorly, and between scapula
posteriorly
 If heard in any other location suggestive of consolidation
4.Vesicular
 Soft, low pitched sound
 Inspiratory > Expiratory sounds
 Major normal breath sound, heard over most of lungs
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Adventitious Breath Sounds
 An abnormal condition that affects the bronchial tree and alveoli may
produce adventitious (abnrmal= addtional) sounds. Adventitious sounds
are divided into two categories: discrete, noncontinuous sounds
(crackles) and continuous musical sounds (wheezes) as the next:
1. Crackles (Rales)
 Discontinuous, intermittent, nonmusical, brief sounds. Heard more
commonly with inspiration
 Classified as fine or coarse
 Its may associated with Prolonged recumbency
 Crackles caused by air moving through secretions and collapsed alveoli
and associated with the following conditions: pulmonary edema, early
CHF, and pnumonia
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2.Wheeze
 Continuous, high pitched, musical sound, longer than crackles
 Whistle quality, heard during expiration, however, can be heard on
inspiration
 Produced when air flows through narrowed airways
 Associated conditions: asthma, chronic bronchitis, and COPD
3. Rhonchi
 Similar to wheezes (subtype of wheeze)
 Low pitched, snoring quality, continuous, musical sounds
 Implies obstruction of larger airways by secretions
 Associated condition: acute bronchitis
192
4. Stridor
 Inspiratory musical wheeze
 Loudest over trachea
 Suggests obstructed trachea or larynx
 Medical emergency requiring immediate attention
 Associated condition
 inhaled foreign body
5. Pleural Friction Rub
 Pleural friction rubs are specific examples of crackles. Discontinuous or
continuous brushing sounds
 It is a loud dry, cracking or grating sound indicating of pleural irritation,
heard over lateral and anterior lung in sitting position that heard during
both inspiratory and expiratory phases
 Occurs when pleural surfaces are inflamed and rub against each other
 Associated conditions as pleural effusion, Pneumonothorax
Medical conditions associated with decreased or absent of
breath sounds
 Asthma
 COPD
 Pleural Effusion: fluid accumulating within the pleural space
 Pneumothorax: caused by accumulation of air or gas in the pleural
space.
 ARDS( adult respiratory distress syndrome)
 Atelectasis : is defined as a state in which the lung, in whole or in
part, is collapsed or without air entery
Five Main Symptoms of Respiratory Disease
 Cough
 Breathlessness
Sputum
Wheeze
Pain
Chapter (11)
Head Assessment, face and neck
Islamic University of Gaza Strip
Assessment of the Head
 Inspects the size, shape, and contour of head.
 The skull is generally round with anterior & posterior prominences.
 Large infant's head may be hydrocephalus.
 Large adult's head & facial bones resulting of acromegaly.
 Palpates the skull for nodules or masses
Assessment of the eye
 Assess external eye structures and pupils, visual acuity, ocular
movements, Peripheral vision.
 Assessment of external eye structures: position and alignment of
eyes, eye brow, eye lids, eye lashes, lacrimal glands, pupils and iris.
 Assessment of pupils done by using penlight which produce
constriction of pupils to show accommodation and convergence of
pupils.
 Assess internal eye structures e.g. iris , retina, macula etc
 Consider the following Factors:
 Age use of corrective lens, artificial eye, allergies, pain, visual
disturbances
 Health related factors such increase Blood Pressure, or Diabetes mellitus
 Using the following equipment to assess the eyes:
 Eye chart (Snellen chart), Chart or newsprint.
 Cover card.
 Penlight, and ophthalmoscope
 Ask the client about history of previous eye surgery, trauma, use
of corrective glasses or contact lenses, blurred vision, Diplopia,
strabismus, recent changes in vision, date of previous vision test,
allergies, eye redness, and frequent watering discharge
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Assess Visual Acuity:
 Done by placing the client 20 feet
from the Snellen eye chart and testing
each eye alone.
 Assess extra ocular movements by
asking client to hold his head and
follow movements of your forefinger.
 Assess peripheral vision: “Visual fields”
 Hemianopsia: blindness of 1/2 field in
one or both eyes.
 Quadrantanopsia: blindness of 1/4 of
visual field in one or both eyes.
 Ascotoma: Island like blindness in
visual field
Ear Assessment
 Take history of ear surgery, trauma, frequent infection, ear pain,
drainage, hearing loss, tinnitus, vertigo, ototoxic medications, and
last hearing examination
 Assess client in sitting position & inspects the auricle’s placement,
size, symmetry, and color.
 Redness: sign of inflammation or fever. Color of ears must be the
same as of the face.
 Pallor: indicate frost bite.
 Palpate the auricles for texture, tenderness, and skin lesion.
 If client complains of pain: pull the auricle and press on the tragus
and behind the ear over the mastoid process if pain increase, means
external ear infection, if pain is not increase, means middle ear
infection may be present.
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 Inspection the ear canal for size and discharge.
 Assessment of cerumen if it is yellow or green may indicate
infection.
 Assessment of hearing acuity: done simply by identification of voice
tones, with the client repeating testing words spoken by the nurse
(whisper test)
N.B: deeper structure and middle ear can be observed only by
otoscope.
 Whisper Test (patient with normal acuity can correctly repeat
what was whispered)
 Weber Test (uses bone conduction to test lateralization of sound by
a tuning fork)
 Rinne Test (useful for distinguishing between conductive and
sensorineural hearing losses)
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Weber Test: A tuning fork, set in motion by grasping it firmly by its stem and
tapping it on the examiner’s hand, is placed on the patient’s head.
 A person with normal hearing will hear the sound equally in both ears or
describe the sound as centered in the middle of the head.
 In an abnormal patient, the sound is heard louder in one ear (lateralization).
Rinne Test
 The examiner shifts the stem of a vibrating tuning fork between two
positions: 2 inches from the opening of the ear canal (for air conduction)
and against the mastoid bone (for bone conduction). Patient is asked to
indicate which tone is louder or when the tone is no longer audible.
 Normally, sound heard by air conduction is audible longer and louder than
sound heard by bone conduction.
 With a conductive hearing loss, bone-conducted sound is heard longer than
air-conducted sound
 With a sensorineural hearing loss, air-conducted sound is audible longer
than bone conducted sound.
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The Otoscope Examination
 Using the Otoscope :
 Otoscope should be held in the examiner’s right hand, in a pencil-hold
position, with the bottom of the scope pointing up. This position
prevents the examiner from inserting the otoscope too far into the
external canal. Choose the largest appropriate speculum
 Using the opposite hand, the auricle is grasped and gently pulled upper
and back to straighten the canal in the adult, while pulled down and back
in infant and child ( <3 age )
 The External Canal :
 Redness / swelling / lesion / foreign body / discharge
 Tympanic Membrane :
 Color / character / perforation
 The healthy tympanic membrane is shiny, translucent , pearl-gray color
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 Cone-shaped light reflex
204
Assessment of the nose
Functions of the nose
1. Identify odors (upper 1/3 of septum)
2. Air passageway (obligate in newborns)
3. Air conditioning: humidify, warms/cools air, cleans and filters air of
dust and most bacteria and voice resonance
Inspect and Palpate
External Nose
1) Symmetric, in the midline, skin lesion, pain
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Nostril patency:
 Inspect & observe symmetry, inflammation & deformity.
 In case of swelling or deformities of nose, the nose is palpated gently
for tenderness, swelling and underlying deviations.
 Normally the external nose is symmetrical, strait, non tender, and
without discharge.
 Assess mucosa which is normally pink in color.
 Yellowish or greenish discharge – means sinus infection.
 Pale mucosa with clear discharge – means allergy.
 For client with NGT, nurse should routinely checks for local
breakdown of skin “Excoriation” of the nostril that characterized by
redness and sloughing of the skin
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Assessment of the sinuses
 Frontal and maxillary sinuses are examined for pain and edema.
 Palpate sinuses both frontal (below the eyebrow) and maxillary
(below cheekbones) for tenderness, which verbalized by client
during exam.
 Percuss sinuses for resonance which is normally hollow tone, and
noting abnormality e.g. flat, dull tone elicited or expresses pain on
percussion
 Transillumination sinusitis: is the transmission of light through tissues
of the body. A common example is the transmission of a flash of light
through fingers, producing a red glow. This is because red blood cells
absorbed other colors of the beam and transmitted only the red
component. Absence of light indicates mucosal thickening or the
cavity is likely contain fluid or pus sinuses
207
208
Assessment of Mouth and pharynx
1. Assessment of oral cavity can be made during administration of oral
hygiene.
 Lips – inspected for color, texture, hydration, contour, and lesions.
 Inner and buccal mucosa, Gums and teeth inspected for color,
hydration, texture and lesions e.g. ulcers, abrasions or crusts.
 Tongue and floor of mouth can carefully inspect.
 Assessment of palate “soft and hard” by extending client’s backward,
assessment for color, shape, texture, and extra bony prominences or
defects
2. Assessment of Pharynx
 Assessment for pharynx done: by using tongue depressors.
 Pharyngeal tissues are normally pink and smooth.
 Edema, ulceration, or inflammation indicates infections or abnormal
lesions
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Assessment of Neck
 Assessment done by inspection and palpation that the client placed in a
sitting position
 Assess neck muscles, trachea, thyroid gland, carotid arteries and jugular
veins, cervical lymph nodes and cervical vertebrae.
 Assess neck size and position of trachea and thyroid
 Assess range of motion by asking the client to tilt the head backward
and side to side
 Assess lymph nodes and venous distention.
Normally:
 Neck should be symmetrical with full range of motion.
 No neck vein distention should be visible.
 Inspect and palpate cervical vertebrae
 Assess the posterior aspects of the neck for symmetry, tenderness,
masses or swelling.
 Thyroid gland is assessed by palpation, observation and auscultation.
 Normal thyroid gland is not palpable. The isthmus is the only portion of the
thyroid that is normally palpable
 Palpation – for gland itself. If enlargement of thyroid gland is detected,
the area over the gland is auscultated for a bruit
 Bruit: vibrations sound of blood flow through arteries. In enlarged gland,
heard with the diaphragm of stethoscope (This abnormal finding)
212
Trachea
 Trachea normally centered; (at the suprasternal notch)
 The cartilages should be smooth, non tender and move easily under
examiner’s fingers when the client swallow
 Palpation done by placing the thumb and forefinger on each side of the
trachea
Assessment of the lymphatic system
 Lymphatic System consists of a network of collecting ducts, lymph fluids
e.g. spleen, thymus, tonsils, adenoids--- etc
Functions of lymphatic system
 Movement and transportation of lymphocytes
 Production of lymphocytes.
 Production of antibodies.
 Phagocytosis
 Absorption of fat and fat soluble substances.
 Enlargement of lymph node: provides early indication of infection or malignancy.
Examination of lymphatic System : 2 steps
 Firstly inspection for enlarged lymph nodes, skin lesions and edema
 Secondly palpating gently the lymph nodes areas using pads of "2, 3, 4" fingers in
gentle circular motion.
 Press lightly and then increasing pressure gradually.
 Move skin lightly over the under lying tissues & not moving the examining fingers
over the skin.
 Large nodes due to malignancy are generally not tender vary in size, hard,
asymmetrical
Some Areas of lymph nodes
 Pre auricular: in front of the ear.
 Mastoid or posterior auricular – behind the ear. Above the mastoid process.
 Occipital – at the base of skull posterior.
 Parotid – near the angle of the jaw.
 Sub-mandibular – midway between angle
of jaw and the tip of the mandible.
 Submentum – in the midline posterior to
the tip of the mandible.
 Anterior superficial nodes – in the
anterior triangle of the neck.
 Posterior cervical nodes – in the
posterior triangle of the neck.
 Deep cervical nodes – very deep and
difficult to be examine.
 Supra clavicular or scalene nodes – In the
angle formed by clavicle and
Sternocleidomastoid muscle.
 Axilla, breast & Lower extremity
(inguinal and popliteal nodes)
215
Chapter (12)
Assessment of the breast
Islamic University of Gaza Strip
Assessment of the breast
 The breasts, or mammary glands, are highly specialized glands, which
extend laterally from edges of the sternum to the anterior axillary
fold.
 They are located between the third and seventh ribs on the anterior
chest wall. Each breast is divided into 15 to 20 irregularly shaped
lobes separated by fibro elastic and adipose tissues. The areola is a
roughened, segmented, circular formation, which surround the
nipple.
Subjective data
 Tenderness, pain, swelling, or change in size of breasts.
 Change in position of nipple or nipple discharge.
 Presence of cysts, lumps, and lesions.
 History of prior breast surgery
217
Female breast:
Inspection: Best done in sitting position with arms relaxed at sides
 Carefully observe the breasts for symmetry. The normal breasts may
be slightly different in size. If necessary, reassure the patient that any
difference in size is normal.
 Inspect Areola and nipples for position, pigmentation, inversion,
discharge, crusting & masses.
 Examine the breast tissue for size, shape, color, and contour
 Assess level of breasts, notes any retractions or dimpling of the skin.
 Ask client to elevate her hands over her head, repeat the observation.
 Ask client to press her hands to her hips and repeat observation.
 Inspect the axilla for: rashes, signs of infection and unusual
pigmentation
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Palpation: Best done in recumbent position:
 Raise the arm of client on the side of the breast being palpated above
client’s head.
 Palpate the breast from less painful or less diseased area (Use on
palpation palmer aspects of the fingers in a rotating motion,
compressing the breast tissue against the chest wall, this is done
quadrant by until the entire breast has been palpated.
 Note skin texture, moisture, temperature, or masses.
 Gently squeeze the nipple and note any expressible discharge.
"Normally not present in non lactating women".
 Repeat examination on the opposite breast & compare findings.
 If mass is palpated, its location, size, shape, consistency, mobility and
associated tenderness are reported
 Remember the breast may feel slightly more fibrotic or be somewhat
tender just prior to or during the menses.
Male Breast:
 Examination of male breast can be brief and should never be
omitted.
 Observe nipple & areola for ulceration, nodules, swelling or
discharge
 Instruct the patient to raise both arms, exposing the skin of the
axilla. Carefully inspect the axilla for: rashes, signs of infection and
unusual pigmentation
 Palpate the areola for nodules or tenderness
220
Chapter (13)
Assessment of Cardiovascular System
Islamic University of Gaza Strip
Anatomy of the Heart
 Right Atrium
 Right Ventricle
 Left Ventricle
 Left Atrium
 Superior and Inferior Vena Cava
 Pulmonary Artery
 Pulmonary Vein
 Aorta
TWO PUMPS
 Right side pumps blood to
lungs
 Left side pumps blood to body
FOUR VALVES
 Two Atrioventricular Valve (AV)
 Tricuspid Valve (right atrioventricular valve)
 Mitral (left atrioventricular valve)
 Two Semilunar Valve (SL)
 Aortic valve (left semilunar valve)
 Pulmonary valve (right semilunar valve)
Subjective data:
1. Assessment of chief complaints:
 Chest pain: location, quality, duration & associated symptoms.
 Irregular heart beat: too fast, jump etc.
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2. Assessment of risk factors: Ask about history of hypertension, diabetes, and rheumatic fever
 Ask about family history of heart attack, hypertension, stroke, and
diabetes
 Describe your nutritional intake: high cholesterol, triglyceride level.
 Do you smoke? How much? And for how long?
 How do you view yourself? What do you do to relax?
 How many hours a day do you work? How do cope with stress.
 Exercise: what do you do for exercise? How often?
 Pain in calves, feet, buttocks or legs? What aggravates the pain (walking,
sitting long periods, standing long periods, sleep) what relieves the pain
“elevating legs, rest, lying down”.
 In what type of chair does client usually sit?
 Does he/she cross legs frequently?
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Inspection:
 Assessment the client must be is in supine or sitting positing
according to his health
 By inspection and palpation you may detect ventricular hypertrophy.
 Use source of light to inspect subtle movements in chest e.g.:
pulsation, retraction etc.
 Apical pulse in left fifth intercostal space, if deviation in site observed
may indicate cardiac enlargement 6th intercostal space.
 Retractions may be seen around site of apical pulse, marked retraction
may indicate pericardial disease.
225
Palpation (supine position)
 Palpate from apex, moving to external border to base
 Detect abnormalities in site of palpation and abnormal sounds
especially for thrill “abnormal flow of blood”
 Describe in terms: locations of pulsation in relation to mid-sternal,
mid-clavicular or axillary lines.
 Palpation of apical pulse, strength differs from thin person to obese.
 Conditions such as anxiety, anemia, fever, and hyperthyroidism may
increase in force and duration of apical pulse (you feel lifting sensation
under your fingers).
 Palpation of pulse at base of the heart (putting your hand at
second left intercostal spaces at sternal borders).
Percussion: “not used in cardiac assessment”
Auscultation:
 All heart sounds are generally low pitched “low frequency” and difficult
for the human ear to hear.
 Auscultation can be started from base to apex or from apex to the base.
Assess:
 Rate and rhythm of the heart beat.
 Concentrates initially on sound "1", noting its intensity and variations,
possible duplication and effects of respiration.
 Sound 1 caused by the closing of the tricuspid and mitral valves.
 Systole begins with Sound "1" & extends to Sound "2"
Then listen to Sound "2" for same characteristics.
 Sound "2": results from closing of the aortic & pulmonary valves
 Diastole begins with Sound "2" and extends to next Sound "1"
 Sound "2" louder than Sound "1" at the base of heart, and is lighter than
Sound "1" at the apex.
Finally listen for extra sounds and for murmurs
 Sound "3": During diastole, rapid filling and distention of
ventricles occur causes vibrations of ventricular walls" and this
known as sound "3" ". Sound "3" best heard at the apex with
bell of stethoscope. Its indicate Pathological alterations in
ventricular filling in early diastole. it represents a normal finding
in children
 Sound "4": occur after Sound "3" (late diastolic filling), occur
from vibrations of ventricular wall or vibrations of the valves.
It’s usually associated with cardiac disease, often that with
altered ventricular compliance
 Gallop Sound: a gallop characterized by the superimposition of
abnormal third and fourth heart sounds, usually indicative of
myocardial disease.
 Heart
murmurs (abnormal sounds produced by
vibrations within the heart or in the walls of large vessels
“during systole or diastole”.
 Murmurs occurrence result from valve defects, changes in
the blood vessels or an increased flow of blood through a
normal structure (eg, with fever, pregnancy,
hyperthyroidism).
Special maneuvers for vascular assessment
 Check for deep phlebitis by quickly squeezing calf muscles
against tibia (normally no pain)
 Check Homan's sign by extending leg and dorsi-flexing
foot (normally no pain).
229
Arterial and venous insufficiency of lower extremities
230
Chapter (14)
Assessment of the abdomen
Islamic University of Gaza Strip
 Assessment of the abdomen
 The abdomen is the largest body
cavity that extends from the
diaphragm inferiorly to the inlet
of the true pelvis. Its contents are
partially protected:
 Superiorly by the lower ribs.
 Posterior by the lumbar vertebra.
 Laterally by the iliac bones
Abdomen Regions
 Divisions of the abdomen
 Four Quadrants.
 Nine regions.
Locating Abdominal Structure By Quadrant
1. Right Upper Quadrant (RUQ)
 Ascending and transverse colon
 Duodenum
Gallbladder
 Liver , head of pancreas
Right of adrenal gland
 The small intestine or ileum in all quadrant
 Right kidney (upper pole) and right ureter
2. Right Lower Quadrant (RLQ)
 Appendix
 Ascending colon , Cecum
 Right kidney lower pole
 Right ovary and tube, right ureter, and right spermatic cord
233
3. Left Upper Quadrant (LUQ) contains of:
 Left of adrenal gland
 Left kidney (upper pole)
 Left ureter
Pancreas (body and tail)
 Spleen
Stomach
 Transverse ascending colon
4. Left Lower Quadrant (LLQ) contains of:
 Left kidney (lower pole)
 Left ovary and tube
 Left spermatic cord
 Sigmoid colon
5. Midline
 Balder , Uterus , Prostate gland
Assessment Procedures
Subjective data: ask the client about:
 Nutritional history: appetite, weight loss or gain.
 Gastro intestinal symptoms: dysphagia, nausea, vomiting, and indigestion.
 Bowel habits: pattern, and stool characteristics.
 Pain: location, quality, pattern, and relationship to ingestion of food.
 Use of medications: Aspirin, Anti inflammatory drugs, and steroids.
 Gastro intestinal diagnostic tests and surgeries.
 The client is placed in the supine position, with small pillows under the head
and knees.
 The abdomen is exposed from the breast to the symphysis pubis
 Start assessment with inspection, auscultation, then percussion and
palpation.
 Stand the client right side and carry out assessment systematically, beginning
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with the left upper quadrant.The bladder should be empty.
Inspection:
 Under source of light you see exactly changes in contours.
 Assess the presence or absence of symmetry, distention, masses, visible
peristaltic waves and respiratory movement.
 Inspect the abdominal skin for pigmentation e.g. jaundice, lesions, striae
scars, dehydration, general nutritional status and condition of umbilicus,
this give information about general state health
 Contour of the normal abdomen is described as: flat, rounded, or
scaphoid. Normally contour is description of the profile line from the rib
margin to the pubic bone.
 Flat contour seen in the muscularly competent and well nourished
individual.
 Rounded abdomen: Normally in infant and toddler, but in the adult caused
by poor muscle tone and excessive Subcutaneous fat deposition.
 Scaphoid contour “Concave in horizontal line” seen in thin clients of all
ages.
 Inspect for respiratory movements especially for retraction of the
abdominal wall on inspiration which is called "Czerny's sign “associated
with some Central Nervous System diseases such as chorea”
Auscultation:
 Auscultate peristaltic sounds which are normally high pitched.
 Listen for at least "5" minutes before concluding that no bowel
sounds are present. "Peristaltic sounds may be quite irregular".
 Duration of single sound may be less than a second or more than it.
 Stimulation of peristalsis may be achieved by flicking the abdominal
wall with a finger “direct percussion
 Auscultate vascular sounds: Loud bruits detected over the aorta may
indicate presence of an aneurysm; the aorta is auscultated superior to
the umbilicus
 Listen for Peritoneal friction rub over the area of liver and spleen e.g.
spleen infection, abscess or tumor: best heard over the lower rib cage
in the anterior axillary line. (rough grating sound like sound of two
pieces of leather being rubbed together).
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Percussion:
 To detecting fluid or gaseous distention and masses and assessing solid
structures within the abdomen.
 Percussion of one for each quadrant to assess areas of tympany and
dullness. Potentially painful areas are always Percuss last
 Percussion allows you to identity borders of the liver to detect organ
enlargement.
 To detect liver size, start percussion at the right iliac crest and proceeds
up ward on the right mid-clavicular line, when dullness occur this is the
lower border of the liver.
 To detect upper border of the liver percuss, down from the nipple along
mid-clavicular line, then dullness occur “upper border” may be found in
(5,6,7) intercostals space, distance between points lower and upper is (612cm). Diseases e.g. cirrhosis, cancer, and hepatitis cause liver
enlargement
Stomach position:
 With percussion you can locate the tympanic air bubble of the stomach
by percussing over the left lower anterior rib cage.
Kidney Tenderness:
 In sitting or erect position, use direct or indirect percussion to assess for
kidney inflammation.
 Use ulnar surface of the partially closed fist and percuss the costo-vertebral
angle at the scapular line.
 If the kidneys are inflamed, client feels tenderness during percussion
Palpation:
 Detect abdominal tenderness and noting the quality of abnormal
distensions or masses.
 During palpation assess for muscular resistance, distention, tenderness and
superficial organs or masses.
 Assess for distended bladder if client has inability to void (Bladder lies
normally below the umbilicus and above symphysis pubis).
 In deep palpation depress hands (2.5-7.5 cm), "1-3 inch" Deep palpation
never used over a surgical incision or tender organs, or masses.
 If tenderness present, check for rebound tenderness, if it was positive
indicated peritoneal irritation e.g. appendicitis
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Palpation of liver:
 Right upper quadrant under the rib cage
 Place your left hand under client’s posterior thorax at the 11th and
12th ribs and by your right hand palpate in and up to feel the liver’s
edge as the client inhales.
 G.B normally not felt and if distended it felt under liver and may
indicate cholecystitis.
Palpation of spleen:
 Generally not palpable in normal adult person, but in case of spleen
enlargement you can palpate it below costal margin.
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Assessment of the anus and recto sigmoid region
 Events required rectal examination:
 Abdominal pain
 Alternation in bowel habits.
 Anal pain, anal spasm.
 Anal itching or burning.
 Black tary stool.
 Rectal bleeding.
 Positions for rectal examinations:
 Left lateral or SEM's position.
 Knee- chest position
 Standing position, most common use for prostate gland examination.
 Lithotomy position
 Squatting position.
 In all positions, before examination wear two gloves
Inspection:
 Spread buttocks carefully with both hands to examine the anus and skin
around it which is more pigmented, moist, and hairless.
 Assess lesions, scars, or inflammation, peri-rectal abscess, fissures, piles,
fistula opening, tumor and rectal prolapsed.
 Ask the client to strain down ward as in defecation.
 Inspect for pilonidal sinus or cyst at the sacro- coccygeal area, and give
description
Palpation: (PR examination)
 Spread the buttocks apart with your non dominant hand. Gloved index
gently placed against the anal verge, and with firm pressure in direction of
umbilicus as the rectal sphincter relaxes. Ask client to lighten the sphincter
around your finger to examine muscle strength.
 Mucosa of the anal canal is palpated for tumor or polyps.
 Assess normal cervix in female which felt as small round mass during P.R
examination
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Common diseases can be detected during rectal examination:
 Pilonidal cyst or sinus.
 Pruritus anus
 Rectal tenesmus:.
 Fecal impaction
 Anal fissure
 Fistula in anus
 Hemorrhoids: External painful & internal painless unless
complicated.
 Rectal polyps
 Rectal prolapse: e.g. in case of internal hemorrhoids
 Anal incontinence.
 Abscesses or masses e.g. Ischio rectal abscess, peri rectal obstruction
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Chapter (15)
Assessment of musculo-skeletal system
Islamic University of Gaza Strip
 The primary structures of the musculoskeletal system are the bones,
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muscles, cartilage, ligaments, tendons and joints.
The bony skeleton provides a sturdy framework to support body
structures. The bone matrix stores calcium, phosphorus, magnesium and
fluoride.
In addition, the red bone marrow located within bone cavities produces
red and white blood cells in a process of hematopoiesis.
There are 206 bones in the human body, divided into four categories.
Long bones (eg, femur)
Short bones (eg, metacarpals)
Flat bones (eg, sternum)
Irregular bones (eg, vertebrae)
Assessments are made of muscles, bones and joints. When assessing the
musculoskeletal system keep in mind that injury or inflammation of any
part of the system can cause pain, stiffness, or an alteration in motor
strength or mobility.
 Musculoskeletal assessment is conducted from head to toe with
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inspection and palpation
Assessment of musculo-skeletal system done firstly when the client
walks, moves in bed or performs any type of physical activity.
The nurse usually assesses the musculoskeletal system for:
Muscle – size, contractures, tremors, muscle tonicity, smoothness
of movement and muscle strength.
Bones – skeletal structure, tenderness, edema
Joints – swelling, tenderness, smoothness of movement,
crepitation, nodules, range of motion.
Terms used to describe joint movement:
 Flexion – bend that decrease angle between bones
 Extension – straightening a limb to increase the angle of joint
 Abduction – moving a limb away from the body’s midline
 Adduction – moving a limb towards the body or beyond it
 Internal rotation – turning a body part towards midline
 External rotation – turning a body part away from midline
 Circumduction – circular movement of a body part
 Supination – turning the palm upwards
 Pronation – turning the palm downwards
 Inversion – turning the hand or foot inward
 Eversion – turning the hand or foot outward
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Musculoskeletal Assessment
 Subjective data:
 Observer gait and posture as client walks into room. Normally the
client walks with arms swinging freely at sides and the head and the
face leading the body.
 Pain: assess pain at rest, with exercise, changes in shape or size of an
extremity, changes in mobility to carry out activities of daily living,
sports, and works.
 Stiffness of joint
 Decreased or altered or absent sensations.
 Redness or swelling of joints.
 History of fractures and orthopedic surgery.
 Occupational history
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Objective data
 Determine range of motion, muscle strength and tone, joint and muscle
condition.
 Muscle problems commonly are manifestations of neurological disease, so
you must do neurological assessment simultaneously.
 Joints vary in their degree of mobility, range from freely movable e.g. knee,
to slightly movable joints e.g. the spinal vertebra.
 During assessment of muscle groups: assess muscle weakness, or swelling,
and size, then compare between sides. Joints should not be forced into
painful positions.
 Loss of height is frequently the first clinical sign of osteoporosis. Small
amount of height loss expected with aging.
 Ask client to put each joint through its full range of motion, if there is
weakness, gently supporting & moving extremities through their Range of
motion, to assess abnormalities.
 Normal joints are non tender, without swelling and move freely.
 In elderly joints often become swollen & stiff, with reduced range of
motion, resulting from cartilage erosion and fibrosis of synovial membranes
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Chapter (16)
Assessment of Neurological system
Islamic University of Gaza Strip
 Assess this system when doing physical examination e.g. cranial nerve
function can be testing during the survey of the head and neck.
 The neurological assessment consists of six parts: (mental status,
cranial nerves, sensory functions, motor function, cerebellar
function, reflexes).
Subjective data:
 Loss of consciousness, dizziness, and fainting.
 Headache: precipitating factors and duration.
 Numbness and tingling or paralysis or neuralgia.
 Loss of memory, confusion, visual loss, blurring, and pain.
 Facial pain, weakness, twitching, speech problems e.g. aphasia.
 Swallowing problems and drooling.
 Neck weakness or spasm
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Mental and emotional
 Mental and emotional status is observed as the nursing history is
collected, and by simply interacting with client, e.g. “Nursing care
plan”
Level of consciousness
 Level of consciousness ranges from full a wakening, “alertness” to
unresponsiveness to any form of external stimuli.
 Alert client responds to questions spontaneously.
 Assess level of consciousness by using Glasgow coma scale
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Glasgow coma scale
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Assessment of behavior and Appearance
 Behavior, mood, hygiene, grooming and choice of dress reveal pertinent
information about client’s mental status.
 Appearance reflects how a client feels about the self.
 Personal hygiene such as unkempt hair, a dirty body, or broken, dirty
fingernails should be noted.
 Language: Assess ability of individual to understand spoken or written
words & how he speak or writes.
 Assess intellectual function, which includes: memory “recent, immediate,
past”, knowledge, abstract thinking, association and judgment.
Assess for sensory function:
 Assess sensitivity to light touch “cotton”
 Assess sensitivity to pain “pinprick”
 Assess sensitivity to vibrations “tuning fork”
 Assess sensitivity to positions.
 Don’t forget comparing both sides of body
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Chapter (17)
Assessment of Urinary System
Islamic University of Gaza Strip
 The main function of urinary system is regulation of the fluid and
electrolytes composition of the body fluids and removal of metabolic end
products from the blood
Nursing History:
 Normal voiding pattern and frequency (oliguria – urinary urgency –
poyluria – anuria - dysuria –hematuria - enuresis)
 Appearance of the urine, urine culture and any recent changes (amount –
color). Normal colure yellow-straw
 Family history of kidney problems (polycystic kidney and all types of
hereditary nephritis are genetically transmitted, kidney and bladder calculi
 The present illness such as pain or burning sensation, UTI, an ostomy.
 Past history and current problems with urination: (syphilis, gonorrhea,
sexual transmitted disease STD) DM and HTN .
 Factors influencing the elimination pattern
 Medications: Diuretics, Psychotropic agents , Anti-hypertensive
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Medical Terms related to urinary system
 Dysuria: painful or difficult voiding
 Hematuria: red blood cells in the urine
 Urgency: strong desired to urinate due to inflammation in bladder
, prostate , urethra
 Polyuria: abnormal large volume of urine voided in given time =
2500ml
 Oliguria: small volume of urine between 100-500 ml
 Anuria: absence of urine in bladder less than 50 ml
 Enuresis: involuntary voiding during sleeping.
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Physical Assessment of Urinary System
 Inspection
 Inspection including examination of abdomen and urethral meatus.
 Auscultation including renal arteries
 Percussion includes the kidneys to detect tenderness
 Palpation to detect any mass, lumps, tenderness
Percussion of the kidney
 To detect areas of tenderness by costovertebral test, normally will feel a
thudding sensation or pressure but not tenderness
Palpation of kidney
 Contour, size, tenderness, and lump.
 In adult normal the kidneys not be palpable because of their location deep
with abnormal.
 Elderly the right kidney is slightly lower than the left, it may be easier to
palpate
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Percussion of the bladder
 Percuss the area over the bladder (5cm) above the symphysis pubis.
 To detect difference in sound, percuss toward the base of the bladder.
 Percussion normally produces a tympanic sound
Palpation of bladder
 Normally feel firm and smooth.
 In adult bladdre may not be palpable
Inspection of the urethral meatus
 Look for swelling, discharge and inflammation
Assessment of Urine
 Urine assessment includes:
 Measure volume of urine
 Inspect colour, clarity, and volume
 Test the specific gravity, glucose, ketone bodies and blood and pH
 Normal urine volume 1-2 litter per 24 hours (normal adult)
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 Color: typically yellow-straw but varies according to recent diet and
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concentration of the urine. Drinking more water generally tends to
reduce the concentration of the urine and therefore cause it to have a
lighter color. (The converse is also true.)
Smell: Generally fresh urine has a mild smell but aged urine has a
stronger odor, similar to that of ammonia.
The smell urine may provide health information. For example, urine
of diabetics may have a sweet or fruity odor due to the presence of
ketones.
Acidity: PH is a measure of the acidity ( or alkalinity0 of a solution.
PH is a measure of the activity of hydrogen ions (H+) in a solution
95% Water, 5% chemical solutes. Urea from breakdown of amino
acids (protein) to give ammonia + C02 giving urea and creatinine
from breakdown of creatine phosphate in muscle
Collection of urine samples
 All urine tests are ideally performed on fresh specimemens:
 Urine container has been adequate protection agonist bacterial
contamination and chemical deterioration
 Identification or labeled should be provided.
 The patient should then be gowned for the physical examination
 Bring it into the dry room
 Urine specimens should collect from the patient means of the clean –catch
midstream technique.
 All specimens should be refrigerated as soon as possible they are obtained .
to avoid shifted the PH of urine to alkaline because contamination of ureasplitting bacteria from the environment
Consider the Developmental Stages
 Pediatric: difficulties, crying, change in urinary in childhood).
 Pregnant: Pain during urination, normal increase urine in volume and
frequency and decrease urine specific gravity
 Elderly: how much and how type of liquid do you drink in the evening? do
you ever lose of control of your bladder
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The End
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