Introduction in

Assessing Clients
Health

HEALTH
ASSESSMENT
NCM 101
KRISTHINE ABEGAIL M. GAMIAO, MAN, RN

Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND
TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED

COLLEGE OF NURSING
 HEALTH ASSESSMENT (NCM 101)

CREDIT UNIT/COURSE CREDIT: Theory : 3 units

Laboratory : 2 units
TIME DURATION: Theory : 54 hours
Laboratory : 102 hours
(Independent Study 20 – 30 hours)

COURSE DESCRIPTION:
The course deals with concepts, principles & techniques of history taking, head to
toe physical examination, psychosocial assessment using various tools and interpretation of
laboratory findings to arrive at a nursing diagnosis. The learners are expected to perform
holistic nursing assessment of an individual adult client.

INSTRUCTIONS ON HOW TO DO THIS MODULE

1. Begin reading and studying the Module. This Module is designed for individualized
instruction and is outcomes-based. Read the information at your own pace or
according to the timelines established by your subject teacher. In most cases, the
student will be studying the modules independently.
2. Read the learning objectives of each unit. These learning objectives specify what you
are expected to learn and what you will be expected to do as a result of studying this
Module.
3. Start to read and study. After each topic, you have to complete all the SELF-STUDY
GUIDE QUESTIONS immediately. Check your answers against the discussion part of
the Module. If you have incorrect answers, re-read the appropriate section of the
text in the Module, and then write the correct answer(s). All answers must be
written in a short bond paper. Then submit to your subject teacher.
4. You can now move onto the next Unit in the Module. Continue to read and study the
Module—repeating steps 2 & 3 of these instructions—until you reach the end of the
Module.
5. From time to time follow-up conference between you and your subject teacher will
take place for feedback on what you have learned. Follow-up conference can be in
the form of text, personal message, call, and video call.
6. If you have any questions about the module, please contact the subject teacher.

No part or portion of this module may be reproduced, copied or transmitted in any form or by
any means, electronic or mechanical including photocopying, recording, or any information
storage and retrieval system, without permission from the author of the module, College of
Nursing, and Nueva Ecija University of Science and Technology, Gen. Tinio St. Cabanatuan
City, Nueva Ecija.
 TABLE OF CONTENTS

UNIT 1. Introduction to Health Assessment 1

Overview of nursing process (ADOPIE) 1
Health assessment in nursing practice 7
Types of Assessment 7
Nurses’ role in Health Assessment 9

UNIT 2. Steps of Health Assessment 11

Collection of subjective data through interview and health history 11
Biographic data 11
Chief complaint or reasons for seeking health care 12
Present illness 12
Past health history 12
Family health history 12
Personal and social history 13
Collection of objective data 16
Physical examination 16
Preparation 17
Positioning 18
Techniques 19
Diagnostic test and procedures 20

UNIT 3. Holistic Nursing Assessment 39

General survey 39

Vital signs 45

Mental status 63
Psychosocial and cognitive development 69
Pain 71
Violence 78
Nutritional status 78

UNIT 4. Physical Assessment 83

Skin, hair and nails 83
Head 91
Eyes and vision 92
Ears and hearing 98
Nose and sinuses 101
Mouth and oropharynx 103
Neck 106
Thorax and lungs 107
Heart and the central blood vessels 115
Peripheral vascular system 118
Breast and axillae 120
Abdomen 123
Musculoskeletal system 127
Neurologic system 129
Male genitals and inguinal area 137
Female genitals and inguinal area 139
Anus 141

UNIT 5. Relevant Ethico-Legal Guidelines in Conducting Health Assessment 143

Informed consent 143
Patient’s bill of rights 144
Data privacy act 144

UNIT 6. Core Values of Nursing Conducting Health Assessment 147

REFERENCES 148
HEALTH ASSESSMENT (NCM 101)
 UNIT 1. INTRODUCTION TO HEALTH ASSESSMENT
Overview
Health assessment evaluates health status by performing a physical
examination after taking a health history. A health assessment is a plan of care that
identifies the specific needs and how those needs will be addressed by the healthcare
personnel using the nursing process.

Learning Objectives
Upon completion of this unit, I am able to do the following: 
1. describe the nursing process;
2. identify the types of health assessment in nursing practice; and
3. discuss the nurses’ role in health assessment.

OVERVIEW OF NURSING PROCESS

“The nursing process is a systematic, goal-directed, client-centered method for
structuring nursing care delivery” (Toney-Butler & Thayer, 2020).
Nursing Process is defined as a systematic, continuous, and dynamic method of
providing care to clients. It comprises series of sequential phases built upon the preceding
step. Each phase logically leads to the next. As one step leads to the next step, it results in
the ultimate achievement of mutually determined nursing outcomes/goals.
According to (Parihar, 2019), nursing practice is caring directed by how the nurses
view the client, the client’s environment, health, and nursing purpose.
To nurses, the nursing process provides a useful description of how nursing should
be performed.
As nurses remain in constant interaction with their clients, professional colleagues,
medical and health care team members, they have the best opportunity to assess the
patient’s needs and provide evidence-based care.

History of Nursing Process

 The term ‘Nursing Process’ was first used/mentioned by ‘Lydia Hall,’ a nursing
theorist, in 1955, wherein she introduced 3 STEPs: Observation, Administration of
care, and Validation.
 In 1967, Yura and Walsh added assessment to the three steps and described a four-
phase process (APIE).
 In the mid-1970s, an addition of the diagnostic phase resulted in a five-step process
(ADPIE).
 In clinical practice, the nursing process was started in 1973 by the American Nurses
Association (ANA) in Standards of Nursing Practice.
 In 1991, revisions were made to the standards to incorporate outcome
identification in the planning phase. Now a 6-step process (ADOPIE) Assessment,
Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation.

Characteristic of Nursing Process

 It is a G O S H approach (goal-oriented, organized, systematic, and humanistic) for
efficient and effective nursing care provision.
 Goal-oriented – The nurse makes her objective based on the client’s health
needs.
Note: Goals and plan of care should be based on the client’s problems/needs,
not according to your problem as the nurse.
 Organized and Systematic – The nursing process is composed of 6 sequential
and interrelated steps, and these 6 phases follow a logical sequence.
 Humanistic care or individualized care - plan to care is developed and
implemented considering the individual client's unique needs in providing
care, and it involves respect of human dignity. Therefore, it is individualized
(no two persons have the same health needs even with the same health
condition/illness).
 Other  (Aside from GOSH)
 Cyclic and Dynamic – data from each phase provides the input into the next
phase, so that it becomes a sequence of events (cycle) that are continually
changing (dynamic) base on the client’s health status.

HEALTH ASSESSMENT (NCM 101)

  Involves skill in Decision-making – nurse makes essential decisions related to
client care. She chooses the best action/steps to meet the desired goal or to
solve a problem. She must make decisions whenever several choices or
options are available.
 Uses Critical Thinking skills – the nurse may encounter new ideas or less-
than-routine or non-ordinary situations where decisions must be made
using critical thinking.

PURPOSE OF NURSING PROCESS

The purpose of the nursing process are:
 to identify a client’s health status and actual or potential health care problems or
needs
 to establish plans to meet the identified needs
 to deliver specific nursing interventions to meet those identified needs

Phases of Nursing Process

The nursing process functions as a systematic guide to client-centered care with
sequential steps. These are assessment, nursing diagnosis, outcome identification, planning,
implementation, and evaluation (Toney-Butler & Thayer, 2020).
I. Assessment
Assessment is the first step and involves critical thinking skills and data
collection; subjective and objective. Subjective data involves verbal statements from
the patient or caregiver. Objective data is measurable, tangible data such as vital
signs, intake and output, height, and weight. Data may come from the patient
directly or from primary caregivers who may or may not be in direct relation with
family members. The purpose of assessment is to establish a database.
Activities in Assessment
1. Collecting - gather information (physical, psychological, emotional, socio-
cultural, and spiritual factors)
2. Validating – accurate information.
3. Organizing - cluster facts into groups of information

II. Nursing Diagnosis

The North American Nursing Diagnosis Association (NANDA) provides
nurses with an up-to-date nursing diagnosis list. According to NANDA, a nursing
diagnosis is defined as a clinical judgment about responses to actual or potential
health problems on the part of the patient, family, or community.  
Components of a NANDA Nursing Diagnosis
A nursing diagnosis has three components:
1. Problem
2. Etiology
3. Signs and symptoms

Formulating Diagnostic Statements

1. Basic Two-Part Statements includes the following:
a) Problem (P): statement of the client’s response (NANDA label)
b) Etiology (E): factors contributing to or probable causes of the
responses.
The two parts are joined by the words related to.
Example: Constipation related to low fiber intake.
2. Basic Three-Part Nursing Diagnosis Statements is called the PES format and
includes the following:
a) Problem (P): statement of the client’s response (NANDA label)
b) Etiology (E): factors contributing to or probable causes of the
response
c) Signs and symptoms (S): defining characteristics manifested
by the client.
The PES format is especially recommended for beginning diagnosticians
because the signs and symptoms validate why the diagnosis was chosen and
make the problem statement.

HEALTH ASSESSMENT (NCM 101)

Types of Nursing Diagnoses
The table below are the different types of Nursing Diagnoses, its definition and
examples.
TYPES OF NURSING DEFINITION EXAMPLE
DIAGNOSES
Actual Nursing Health problem that is present at the time  Altered comfort: Pain
Diagnosis of nursing assessment.  Pain: Severe headache
Based on the presence of signs and related to fear of
symptoms addiction to narcotics.
Risk Nursing A clinical judgment that a problem does not  Risk for infection
Diagnosis exist, but the presence of risk factors  Risk for constipation
indicates that a problem is likely to develop
Possible Nursing  Is one in which evidence about a  Possible social isolation
Diagnosis health problem is unclear or the related to unknown
causative factors are unknown. etiology
 Requires more data either to  
support or to refute it.

III. Outcome Identification

Refers to formulating and documenting measurable, realistic, client-focused
goals. Provides the basis for evaluating nursing diagnosis and interventions.

Activities in Outcome Identification

Activities include:
1. Establish priorities
 Life-threatening should be given the highest priority
 ABC’s (airway, breathing, circulation)
 Maslow’s hierarchy of needs (physiologic needs over psychosocial)
 Unstable clients vs. clients with stable conditions
 Actual problems vs. potential concerns
2. Establish goals and outcome criteria
Goals: broad statements
Short-term goal
Long-term goal
Outcome criteria: should be SMART in the attainment of the goal
S – specific
M – measurable
A – attainable
R – realistic
T - time-framed
Purpose of Desired Goals/Outcomes Identification
Goals are considered to be met or not met while progress toward outcomes
can be described along a continuum compared to the previous status.
1. Provide direction for planning nursing interventions.
 Ideas for interventions come more easily if the desired outcomes
state clearly and specifically what the nurse hopes to achieve.
2. Serve as criteria for evaluating client progress.
 Although developed in the nursing process's planning step, desired
outcomes serve as the criteria for judging the effectiveness of
nursing interventions and client progress in the evaluation step.
3. Enable the client and nurse to determine when the problem has been
resolved.

4. Help motivate the client and nurse by providing a sense of achievement.

HEALTH ASSESSMENT (NCM 101)

  As goals are met, both client and nurse can see that their efforts have
been worthwhile. This provides motivation to continue following the
plan, especially when difficult lifestyle changes need to be made.

Example of short-term goal and long-term goal

 A short-term goal might be “Client will raise right arm to shoulder height by
Friday.”
 A long-term goal/outcome might be, “Client will regain full use of a right arm
in 6 weeks.”

Example of goal and desired outcome

1. Goal (broad): Improved nutritional status.
Desired outcome (specific): Gain 5 lb by April 25.
Improved nutritional status as evidenced by weight gain of 5 lbs. by April 25.
2. Goal: The client will be able to improve mobility and bear weight on the left
leg.
Desired outcomes:
a) By the end of the week, the client will be able to ambulate with
crutches
b) By the end of the month, the client will be able to stand without
assistance

IV. Planning
Involves determining beforehand the strategies or course of actions to be
taken before implementation of nursing care. Planning is the nurse’s responsibility.
Input from the client and support persons is essential if a plan is to be effective.

Types of Planning
1. Initial Planning
 The nurse who performs the admission assessment usually develops the
initial comprehensive plan of care.
 Planning should be initiated as soon as possible after the initial
assessment.
2. Ongoing Planning
 It is done by all nurses who work with the client.
 It also occurs at the beginning of a shift as the nurse plans the care to be
given that day.
 Using ongoing assessment data, the nurse carries out daily planning for
the following purposes:
a) To determine whether the client’s health status has changed
b) To set priorities for the client’s care during the shift
c) To decide which problems to focus on during the shift
d) Coordinate the nurse’s activities so that more than one problem
can be addressed at each client contact.

3. Discharge Planning
 Anticipating and planning for needs after discharge is a crucial part of
comprehensive health care and should be addressed in each client’s
care plan.
 Because clients' average stay in acute care hospitals has become shorter,
people are sometimes discharged still needing care.
 Although many clients are discharged to other agencies (e.g., long-term
care facilities), such care is increasingly being delivered in the home.
 Effective discharge planning begins at first client contact and involves
comprehensive and ongoing assessment to obtain information about
the client’s ongoing needs.

HEALTH ASSESSMENT (NCM 101)

 V. Implementation
Putting the nursing care plan into action. The nurse performs or delegates
the nursing activities for the interventions developed in the planning step and then
concludes the implementing step by recording nursing activities and the resulting
client responses.

Purpose of Intervention
To carry out planned nursing interventions to help the client attain goals
and achieve an optimal level of health

Activities in Intervention
Activities include:
 Set priorities.
 Perform nursing interventions
 Record actions. SOMETHING THAT IS NOT WRITTEN IS CONSIDERED NOT
DONE!!!

Types of Nursing Intervention

Nursing interventions include direct and indirect care and nurse-initiated,
physician-initiated, and other health provider-initiated treatments.
a) Direct care is an intervention performed by the nurse through interaction
with the client.
b) Indirect care is an intervention delegated by the nurse to another provider
or performed away from but on behalf of the client, such as interdisciplinary
collaboration or the care environment's management.
c) Independent interventions are those activities that nurses are licensed to
initiate based on their knowledge and skills.
 They include physical care, ongoing assessment, emotional support
and comfort, teaching, counseling, environmental management, and
referrals to other health care professionals.
 In performing an autonomous activity, the nurse determines that the
client requires specific nursing interventions, either carries these out
or delegates them to other nursing personnel, and is accountable or
answerable for the decision and the actions.
 An example of independent action is planning and providing special
mouth care for a client after diagnosing Impaired Oral Mucous
Membranes.
d) Dependent interventions are activities carried out under the orders or
supervision of a licensed physician or other health care provider authorized
to write orders to nurses.
 Primary care providers’ orders commonly direct the nurse to
provide medications, intravenous therapy, diagnostic tests,
treatments, diet, and activity.
e) Collaborative interventions are actions the nurse carries out in collaboration
with other health team members, such as physical therapists, social workers,
dietitians, and primary care providers.

VI. Evaluation
Evaluate the outcome. As with all nursing care, in evaluating, the nurse
determines the effectiveness of the plan and whether the initial purpose was
achieved.
Evaluation is assessing the client’s response to nursing intervention and
then comparing the response to predetermined standards or outcome criteria.

The evaluation phase has five components

1. Collecting data related to the desired outcomes
2. Comparing the data with desired outcomes
3. Relating nursing activities to outcomes
4. Drawing conclusions about problem status
5. Continuing, modifying, or terminating the nursing care plan

HEALTH ASSESSMENT (NCM 101)

 The utilization of the nursing process to guide care is clinically significant in this
dynamic, complex patient care world.
Critical thinking skills will play a vital role as we develop care plans for these patient
populations with multiple comorbidities and embrace this challenging healthcare arena.

Guidelines for Writing Nursing Care Plans

1. Date and sign the plan.
2. Use category headings.
 “Nursing Diagnoses,” “Goals/ Desired Outcomes,” “Nursing Interventions,”
and “Evaluation” are the common headings. Include a date for the evaluation
of each goal.
3. Use standardized/approved medical or English symbols and key words rather than
complete sentences to communicate your ideas unless the agency policy dictates
otherwise.
 For example, write “Turn and reposition q2h” rather than “Turn and
reposition the client every two hours.” Or, write “Clean wound ¯c H2O2 bid”
rather than “Clean the client’s wound with hydrogen peroxide twice a day,
morning and evening.”
4. Be specific.
 Because nurses are now working shifts of different lengths, with some
working 12-hour shifts and some working 8-hour shifts, it is even more
important to be specific about expected timing of an intervention.
 If the intervention reads “change incisional dressing q shift,” it could mean
either twice in 24 hours, or three times in 24 hours, depending on the shift
time.
 This miscommunication becomes even more serious when medications are
ordered to be given “q shift.”
 Writing down specific times during the 24-hour period will help clarify.
5. Tailor the plan to the unique characteristics of the client by ensuring that the client’s
choices, such as preferences about the times of care and the methods used, are
included.
 This reinforces the client’s individuality and sense of control.
 For example, the written nursing intervention “Provide prune juice at
breakfast rather than other juice” should indicate that the client was given a
choice of beverages.
 maintaining muscle strength and joint mobility.
6. Ensure that the nursing plan incorporates preventive and health maintenance
aspects as well as restorative ones.
 For example, carrying out the intervention “Provide active assistance ROM
(range-of-motion) exercises to affected limbs q2h” addresses the goal of
preventing joint contractures and maintaining muscle strength and joint
mobility.
7. Ensure that the plan contains ongoing assessment of the client (e.g., “Inspect incision
q8h”).
8. Include collaborative and coordination activities in the plan.
 For example, the nurse may write interventions to ask a nutritionist or
physical therapist about specific aspects of the client’s care.
9. Include plans for the client’s discharge and home care needs.
 The nurse begins discharge planning as soon as the client has been admitted.
 It is often necessary to consult and make arrangements with the community
health nurse, social worker, and specific agencies that supply client
information and needed equipment.
 Add teaching and discharge plans as addenda if they are lengthy and
complex.

HEALTH ASSESSMENT (NCM 101)

 HEALTH ASSESSMENT IN NURSING PRACTICE
To effectively determine a patient's diagnosis and treatment, nurses make four
assessments: initial, focused, time-lapsed, and emergency. One of the most important parts
of nursing education and the health care industry overall is the group of routine procedures
and processes involved with patient assessment and care. As a result, nurses and other
healthcare professionals can quickly assess and determine the best treatment for an ailing
patient (Kaur, 2009).

Types of Assessment
The table below are the types of assessment:
1. Initial Assessment
The initial assessment, also known as triage or admission assessment, is
performed when the client enters health care from a health care agency. The
purposes are to evaluate the client’s health status, identify functional health
patterns that are problematic, and provide an in-depth, comprehensive database,
which is critical for evaluating changes in the client’s health status in subsequent
assessments.
Components may include obtaining a patient's medical history or putting
him through a physical exam, or preparing a psychosocial assessment for a mental
health patient. Other components may include obtaining a patient's vital signs and
taking subjective statements from the patient, and double-checking the subjective
symptoms with the condition's objective signs.
2. Time-Lapsed or Ongoing Assessment
Time-lapsed assessment or ongoing assessment is another type of
assessment, takes place after the initial assessment to evaluate any changes in the
client's functional health. Nurses perform time-lapsed assessment when substantial
periods have elapsed between assessments (e.g., out-patient clinic visits, home
health visits, and health and development screenings).
Once treatment has been implemented, a time-lapsed assessment must be
conducted to ensure that the patient is recovering from his disease and his
condition has stabilized. Depending on the nature of the disease, the time-lapsed
assessment may span the length of one or two hours or a couple of months.
During the time-lapsed assessment, the patient's current status is compared
to the previous baseline before treatment.
3. Focused or Problem-oriented Assessment
The focused or problem-oriented assessment collects data about a problem
that has already been identified. This type of assessment has a narrower scope and a
shorter time frame than the initial assessment. In focus assessments, nurses
determine whether the problems still exist and whether the problem's status has
changed (i.e., improved, worsened, or resolved). This assessment also includes the
appraisal of any new, overlooked, or misdiagnosed problems. In intensive care units,
may perform focus assessment every few minutes.
Vital signs are continuously monitored because of their importance and
their ever-changing nature during all parts of the assessment. Part of the focused or
problem-oriented assessment goal is to diagnose and treat the patient to stabilize
her condition. Focused or problem-oriented assessments may also include X-rays or
other types of tests.
4. Emergency Assessments
The emergency assessment takes place in life-threatening situations in
which the preservation of life is the top priority. Time is of the essence rapid
identification of and intervention for the client’s health problems.
During emergency procedures, a nurse is focused on rapidly identifying the
root causes of concern for the patient and assessing the patient's airway, breathing,
and circulation (ABCs). Once the ABCs are stabilized, the emergency assessment
may turn into an initial or focused assessment, depending on the situation.
Suppose the nurse is not in a health care setting. In that case, emergency
assessments must also include an assessment for scene safety. No other individuals,
including the nurse himself, are hurt during the rescue and emergency response
process.

HEALTH ASSESSMENT (NCM 101)

 Table 1.1 Summary of Types of Assessment
TIME
TYPE PURPOSE EXAMPLE
PERFORMED
Initial Performed within  To establish a  Nursing
Assessment specified time complete admission
after admission to database for assess.
a health care problem
agency. identification,
reference, and
future
comparison.
Time-Lapsed Several days or  To compare the  Reassessment of
or Ongoing months after client’s current a client’s
Assessment initial assessment status to functional
baseline data health patterns
previously in a home care
obtained. or outpatient
setting or, in a
hospital, at shift
change.
Focused or Ongoing process  To determine  Hourly
Problem- integrated with the status of a assessment of
oriented nursing care. specific problem client’s fluid
Assessment identified in an intake and
earlier urinary output
assessment. in an ICU.
 Assessment of
client’s ability to
perform self-
care while
assisting a client
to bathe.
Emergency During any To identify life-  Rapid
Assessment physiological or threatening assessment of a
psychological problems. person’s airway,
crisis of the client.  To identify new breathing
or overlooked status, and
problems. circulation
during a cardiac
arrest.
 Assessment of
suicidal
tendencies or
potential for
violence.

NURSES’ ROLE IN HEALTH ASSESSMENT

Nurses assume several roles when they provide care to clients. Nurses often carry
out these roles concurrently, not exclusively of one another.
The roles required at a specific time depend on the client's needs and aspects of the
particular environment.
1. Caregiver
 The caregiver role activities assist the client physically, socially, psychologically,
developmental, cultural, and spiritual while preserving the client’s dignity.

2. Communicator
 Communication is integral to all nursing roles.

HEALTH ASSESSMENT (NCM 101)

  Nurses communicate with the client, support persons, other health
professionals, and people in the community.
 In the communicator role, nurses identify client problems and then
communicate these verbally or in writing to other members of the health team.
 The quality of a nurse’s communication is an essential factor in nursing care.

3. Teacher
 As a teacher, the nurse helps clients learn about their health and the health care
procedures they need to perform to restore or maintain their health.
 The nurse assesses the client’s learning needs and readiness to learn, sets
specific learning goals in conjunction with the client, enacts teaching strategies,
and measures learning.

4. Client Advocate
 A client advocate acts to protect the client. In this role, the nurse may represent
the client’s needs and wishes to other health professionals, such as relaying the
client’s request for information to the physician.
 They also assist clients in exercising their rights and help them speak up for
themselves.

5. Counselor
 Counseling is the process of helping a client to recognize and cope with stressful
psychological or social problems, develop improved interpersonal
relationships, and promote personal growth.
 It involves providing emotional, intellectual, and psychological support.

6. Case Manager
 Nurse case managers work with the multidisciplinary health care team to
measure the case management plan's effectiveness and monitor outcomes.
 Each agency or unit specifies the role of the nurse case manager.
 In some institutions, the case manager works with primary or staff nurses to
oversee a specific caseload's care.
 In other agencies, the case manager is the primary nurse or provides direct care
to the client and family.
 Insurance companies have also developed several roles for nurse case
managers, and responsibilities may vary from managing acute hospitalizations
to managing high-cost clients or case types.
 Regardless of the setting, case managers help ensure that care is oriented to the
client while controlling costs.

7. Change Agent
 The nurse acts as a change agent when assisting clients in making modifications
in their behavior.

8. Leader
 A leader influences others to work together to accomplish a specific goal.
 The leader role can be employed at different levels: individual client, family,
clients, colleagues, or the community.
 Effective leadership is a learned process requiring an understanding of the
needs and goals that motivate people, apply the leadership skills and
interpersonal skills to influence others.

9. Manager
 The nurse manages the nursing care of individuals, families, and communities.
 The nurse manager also delegates nursing activities to ancillary workers and
other nurses and supervises and evaluates their performance.

HEALTH ASSESSMENT (NCM 101)

  Managing requires knowledge about organizational structure and dynamics,
authority and accountability, leadership, change theory, advocacy, delegation,
and supervision and evaluation.

10. Research Consumer

 Nurses often use research to improve client care.
 In a clinical area, nurses need to (a) have some awareness of the process and
language of research, (b) be sensitive to issues related to protecting the rights
of human subjects, (c) participate in the identification of significant
researchable problems, and (d) be a discriminating consumer of research
findings.

11. Expanded Career Roles

 Nurses are fulfilling expanded career roles, such as nurse practitioners, clinical
nurse specialists, nurse midwives, nurse educators, nurse researchers, and
nurse anesthetists, all of which allow greater independence and autonomy.

SELF-STUDY GUIDE QUESTION

1. Cite an example of a case scenario where you can practice the nurses’ role in health
assessment.

HEALTH ASSESSMENT (NCM 101)

 UNIT 2. STEPS OF HEALTH ASSESSMENT
Overview
In this unit, you will learn data collection through interviews and observation,
physical examination techniques, and the different diagnostic tests and procedures.

Learning Objectives
Upon completion of this unit, I am able to do the following: 
1. collect subjective data and objective data of clients;
2. perform techniques in the physical examination; and
3. know the different diagnostic tests and procedures.

SUBJECTIVE DATA AND OBJECTIVE DATA

According to (Bickley & Szilagyi, Bates’ Guide to Physical Examination and History
Taking, 2017), symptoms are subjective concerns or what the patient tells you. Signs are
considered one type of objective information, or what you observe.

Table 2.1 Differences between Subjective Data and Objective Data

Subjective Data Objective Data
 What the patient tells you  What you detect during the
 The symptoms and history, from Chief examination, laboratory information,
Complaint through Review of Systems and test data
 All physical examination findings or
signs

Example: Mrs. G. is a 54-year-old Example: Mrs. G. is an older, overweight

hairdresser who reports pressure over her white female who is pleasant and
left chest “like an elephant sitting there,” cooperative. Height 5′4″, weight 150 lbs.,
which goes into her left neck and arm. BMI 26, BP 160/80, HR 96 and regular,
respiratory rate 24, temperature 97.5 °F

COLLECTION OF SUBJECTIVE DATA THROUGH INTERVIEW AND HEALTH HISTORY

Health History
The health history format provides an important framework for organizing the
patient’s story into various categories pertinent to the patient’s present, past, and family
health. The health history format is a structured framework for organizing patient
information in written or verbal form. This format focuses your attention on the specific
kinds of information you need to obtain, facilitates clinical reasoning, and clarifies patient
concerns, diagnoses, and plans to other health care providers involved in the patient’s care.
Initial information should include the date and time of history. The date is always
important. Be sure to document the time you evaluate the patient, especially in urgent,
emergent, or hospital settings.
The history or referral source can be the patient, a family member or friend, an
officer, a consultant, or the clinical record. Identifying the referral source helps you assess
the quality of the referral information, questions you may need to address in your
assessment, and written response.
The following are necessary information in health history.
1. Biographic data
 Client’s name
 Address
 Age
 Sex
 Marital status
 Occupation
 Religious preference
 Health care financing

2. Chief complaint or Reasons for seeking health care

 The answer was given to the question “What is troubling you?” or “Describe
the reason you came to the hospital or clinic today.”

HEALTH ASSESSMENT (NCM 101)

  The chief complaint should be recorded in the client’s own words. For
example, “My stomach hurts, and I feel awful.”

3. Present illness
 The present illness is a complete, clear, and chronologic description of the
problems prompting the patient’s visit, including the onset of the problem, the
setting in which it developed, its manifestations, and any treatments to date.
 Each principal symptom should be well characterized and should include the
seven attributes of a symptom: (1) location; (2) quality; (3) quantity or
severity; (4) timing, including onset, duration, and frequency; (5) the setting
in which it occurs; (6) factors that have aggravated or relieved the symptom;
and (7) associated manifestations.
 Patients often have more than one symptom or concern. Each symptom merits
its paragraph and a full description.
 Medications should be noted, including name, dose, route, and frequency of
use. Also, list home remedies, nonprescription drugs, vitamins, mineral or
herbal supplements, oral contraceptives, and medicines borrowed from family
members or friends. Ask patients to bring in all their medications so that you
can see exactly what they take.
 Allergies, including specific reactions to each medication, such as rash or
nausea, must be recorded, as well as allergies to foods, insects, or
environmental factors.
 Note tobacco use, including the type. Cigarettes are often reported in
packyears (a person who has smoked 1½ packs a day for 12 years has an 18-
pack/ year history). If someone has quit, note for how long.
 Alcohol and drug use should always be investigated and is often pertinent to
the Presenting Illness.

4. Past health history

 Childhood Illnesses: These include measles, rubella, mumps, whooping cough,
chickenpox, rheumatic fever, scarlet fever, and polio. Also included are any
chronic childhood illnesses.
 Adult Illnesses: Provide information relative to Adult Illnesses in each of the
four areas:
a) Medical: Illnesses such as diabetes, hypertension, hepatitis, asthma, and
human immunodeficiency virus (HIV); hospitalizations; number and
gender of sexual partners; and risk-taking sexual practices
b) Surgical: Dates, indications, and types of operations
c) Obstetric/Gynecologic: Obstetric history, menstrual history, methods of
contraception, and sexual function
d) Psychiatric: Illness and time frame, diagnoses, hospitalizations, and
treatments
 Health Maintenance: Cover selected aspects of Health Maintenance, especially
immunizations and screening tests. For immunizations, find out whether the
patient has received vaccines for tetanus, pertussis, diphtheria, polio, measles,
rubella, mumps, influenza, varicella, hepatitis B virus (HBV), human papilloma
virus (HPV), meningococcal disease, Haemophilus influenzae type B,
pneumococci, and herpes zoster. For screening tests, review tuberculin tests,
Pap smears, mammograms, stool tests for occult blood, colonoscopy, and
cholesterol tests, together with results and when they were last performed. If
the patient does not know this information, written permission may be
needed to obtain prior clinical records.

5. Family health history

 Under family history, outline or diagram the age and health, or age and cause
of death, of each immediate relative, including parents, grandparents, siblings,
children, and grandchildren.
 Review each of the following conditions and record whether they are present
or absent in the family: hypertension, coronary artery disease, elevated
cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis,
tuberculosis, asthma or lung disease, headache, seizure disorder, mental

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 illness, suicide, substance abuse, and allergies, as well as symptoms reported
by the patient.
 Ask about any history of breast, ovarian, colon, or prostate cancer.
 Ask about any genetically transmitted diseases.

6. Personal and Social History

 The personal and social history captures the patient’s personality and
interests, sources of support, coping style, strengths, and concerns.
 It should include occupation and the last year of schooling; home situation and
significant others; sources of stress, both recent and long-term; important life
experiences such as military service, job history, financial situation, and
retirement; leisure activities; religious affiliation and spiritual beliefs; and
activities of daily living (ADLs).
 The baseline level of function is particularly important in older or disabled
patients.
 Lifestyle habits that promote health or create risks, such as exercise and diet,
including frequency of exercise, usual daily food intake, dietary supplements
or restrictions, and use of coffee, tea, and other caffeinated beverages, and
safety measures, including use of seat belts, bicycle helmets, sunblock, smoke
detectors, and other devices related to specific hazards.
 Include sexual orientation and practices and any alternative health care
practices.
 Avoid restricting the Personal and Social History to only tobacco, drug, and
alcohol use.
 An expanded Personal and Social History personalizes your relationship with
the patient and builds rapport.

HEALTH ASSESSMENT (NCM 101)

Figure 2.1 Sample Nursing Assessment Form

HEALTH ASSESSMENT (NCM 101)

HEALTH ASSESSMENT (NCM 101)
 COLLECTION OF OBJECTIVE DATA
Physical Examination
A complete health assessment may be conducted starting at the head and
proceeding systematically downward (head-to-toe assessment). However, the procedure
can vary according to the individual's age, the severity of the illness, the preferences of the
nurse, the location of the examination, and the agency’s priorities and procedures.
Regardless of the procedure used, the client’s energy and time need to be considered.
The health assessment is therefore conducted in a systematic and efficient manner
that results in the fewest position changes for the client. Frequently, nurses assess a specific
body area instead of the entire body. These specific assessments are made with client
complaints, the nurse’s observation of problems, the client’s presenting problem, nursing
interventions provided, and medical therapies.

Order of Head-to-Toe Assessment

1. General survey
2. Vital signs
3. Head
 Hair, scalp, face
 Eyes and vision
 Ears and hearing
 Nose
 Mouth and oropharynx
 Cranial nerves
4. Neck
 Muscles
 Lymph nodes
 Trachea
 Thyroid gland
 Carotid arteries
 Neck veins
5. Upper extremities
 Skin and nails
 Muscle strength and tone
 Joint range of motion
 Brachial and radial pulses
 Sensation
6. Chest and back
 Skin
 Chest shape and size
 Lungs
 Heart
 Spinal column
 Breasts and axillae
7. Abdomen
 Skin
 Abdominal sounds
 Femoral pulses
8. External genitals
9. Anus
10. Lower extremities
 Skin and toenails
 Gait and balance
 Joint range of motion
 Popliteal, posterior tibial, and pedal pulses

These are some of the purposes of the physical examination:

a) To obtain baseline data about the client’s functional abilities
b) To supplement or confirm data obtained in the nursing history
c) To obtain data that will help establish nursing diagnoses and plans of care
d) To evaluate the physiological outcomes of health care and thus the progress of a
client’s health problem

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 e) To make clinical judgments about a client’s health status
f) To identify areas for health promotion and disease prevention

Preparation
Steps in Preparing for the Physical Examination
1. Reflect on your approach to the patient.
 Greet the patient and identify yourself
 Appear calm and organized even when you feel inexperienced
 Notes the wince or worried glance, and shares information that calms, explains, and
reassures.
 As a beginner, avoid interpreting your findings, your views may be premature or
wrong.
 If the patient has specific concerns, discuss them with your teachers.
 Always avoid showing distaste, alarm, or other negative reactions.
2. Adjust the lighting and the environment.
 “Set the stage” so that both you and the patient are comfortable.
 Awkward positioning makes assessing physical findings more difficult for both you
and the patient.
 Take the time to adjust the bed to a convenient height (but be sure to lower it when
finished), and ask the patient to move toward you, turn over, or shift position
whenever this makes the examination of selected areas of the body easier.
 Good lighting and a quiet environment enhance what you see and hear.
3. Check your equipment.
Equipment necessary for the physical examination includes the following:
 An ophthalmoscope and an otoscope. If you are examining children, the otoscope
could allow pneumatic otoscopy.
 A flashlight or penlight
 Tongue depressors
 A ruler and a flexible tape measure, preferably marked in centimeters
 Thermometer
 A watch with a second hand
 A sphygmomanometer
 A stethoscope with the following characteristics:
 Ear tips that fit snugly and painlessly. To get this fit, choose ear tips of the
proper size, align the ear pieces with the angle of your ear canals, and adjust
the spring of the connecting metal band to a comfortable tightness.
 Thick-walled tubing as short as feasible to maximize the transmission of
sound: ∼30 cm (12 inches), if possible, and no longer than 38 cm (15 inches)
 A bell and a diaphragm with a good changeover mechanism
 A visual acuity card
 A reflex hammer
 Tuning forks, both 128 Hz and 512 Hz
 Cotton swabs, safety pins, or other disposable objects for testing sensation and two-
point discrimination
 Cotton for testing the sense of light touch
 Two test tubes (optional) for testing temperature sensation
 Gloves and lubricant for oral, vaginal, and rectal examinations
 Vaginal specula and equipment for cytologic and bacteriologic studies
 Paper and pen or pencil, or desktop or laptop computer
4. Make the patient comfortable.
 Close nearby doors, draw the curtains in the hospital or examining room, and wash
your hands carefully before the examination begins.
 During the examination, be aware of the patient’s feelings and any discomfort.
 Respond to the patient’s facial expressions and even ask, “Are you okay?” or “Is this
painful?” to elicit unexpressed worries or sources of pain.
 Draping the patient.
Tips for Draping the Patient
a) Visualize one area of the body at a time, this preserves the patient’s modesty
and helps you focus on the area being examined.
b) With the patient sitting, for example, untie the gown in back to better listen
to the lungs.

HEALTH ASSESSMENT (NCM 101)

 c) For the breast examination, uncover the right breast but keep the left chest
draped. Redrape the right chest, then uncover the left chest and proceed to
examine the left breast and heart.
d) For the abdominal examination, only the abdomen should be exposed.
Adjust the gown to cover the chest and place the sheet or drape at the
inguinal level.
e) To help the patient prepare for potentially awkward segments of the
examination, briefly describe your plans before starting, for example, “Now I
am going to move your gown so I can check the pulse in your groin area.
 Make sure your instructions to the patient at each step in the examination are
courteous and clear. For example, “I would like to examine your heart now, so
please lie down,” or “Now I am going to check your abdomen.”
 Be sure to lower the bed to avoid risk of falls and raise the bedrails.
 As you leave, wash your hands, clean your equipment, and dispose of any waste
materials.
5. Observe standard and universal precautions.
 The Centers for Disease Control and Prevention (CDC) have issued several
guidelines to protect patients and examiners from the spread of infectious disease.
 Standard precautions are based on the principle that all blood, body fluids,
secretions, excretions (except sweat), non-intact skin, and mucous membranes may
contain transmissible infectious agents.
 Standard precautions apply to all patients in any setting.
 They include hand hygiene, use of personal protective equipment (gloves, gowns,
and mouth, nose, and eye protection), safe injection practices, safe handling of
contaminated equipment or surfaces, respiratory hygiene and cough etiquette,
patient isolation criteria, and precautions relating to equipment, toys, solid surfaces,
and laundry handling.
 Universal precautions are a set of guidelines designed to prevent parenteral,
mucous membrane, and noncontact exposures of health care workers to bloodborne
pathogens, including HIV and HBV.
 Immunization with the HBV vaccine for health care workers with exposure to blood
is an important adjunct to universal precautions.
 The following fluids are considered potentially infectious: all blood and other body
fluids containing visible blood, semen, and vaginal secretions and cerebrospinal,
synovial, pleural, peritoneal, pericardial, and amniotic fluids.
 All health care workers should follow the precautions for safe injections and
prevention of injury from needlesticks, scalpels, and other sharp instruments and
devices. Report to your health service immediately if such injury occurs.

Positioning
Several positions are frequently required during the physical assessment. It is
important to consider the client’s ability to assume a position. The client’s physical
condition, energy level, and age should also be taken into consideration. Some positions are
embarrassing and uncomfortable and therefore should not be maintained for long. The
assessment is organized so that several body areas can be assessed in one position, thus
minimizing the number of position changes needed.

HEALTH ASSESSMENT (NCM 101)

 Figure 2.2 Client Positions and Body Areas Assessed

Techniques
The cardinal techniques of examination are used in the physical examination. These
are:
1. Inspection
Close observation of the details of the patient’s appearance, behavior, and
movement such as facial expression, mood, body habitus and conditioning, skin
conditions such as petechiae or ecchymoses, eye movements, pharyngeal color,
symmetry of thorax, height of jugular venous pulsations, abdominal contour, lower
extremity edema, and gait.
2. Palpation
Tactile pressure from the palmar fingers or fingerpads to assess areas of skin
elevation, depression, warmth, tenderness, lymph nodes, pulses, contours and sizes
of organs and masses, distention of the urinary bladder and crepitus in the joints.
There are two types of palpation: light and deep palpation.
3. Percussion
Use of the striking or plexor finger, usually the third, to deliver a rapid tap or blow
against the distal pleximeter finger, usually the distal third finger of the left hand
laid against the surface of the chest or abdomen, to evoke a sound wave such as
resonance or dullness from the underlying tissue or organs. This sound wave also
generates a tactile vibration against the pleximeter finger.
Percussion elicits five types of sound:
a) Flatness is an extremely dull sound produced by very dense tissue, such as
muscle or bone.

HEALTH ASSESSMENT (NCM 101)

 b) Dullness is a thudlike sound produced by dense tissue such as the liver,
spleen, or heart.
c) Resonance is a hollow sound such as that produced by lungs filled with air.
d) Hyperresonance is not produced in the normal body. It is described as
booming and can be heard over an emphysematous lung.
e) Tympany is a musical or drumlike sound produced from an air-filled stomach.
4. Auscultation
Use of the diaphragm and bell of the stethoscope to detect the characteristics of
heart, lung, and bowel sounds, including location, timing, duration, pitch, and
intensity. For the heart, this involves sounds from closure of the four valves, extra
sounds from blood flow into the atria and ventricles, and murmurs. Auscultation
also permits detection of bruits or turbulence over arterial vessels.

DIAGNOSTIC TEST AND PROCEDURES

According to Berman & Snyder (2012), diagnostic and laboratory tests or commonly
called laboratory tests are tools that provide information about the client. Tests may be
used for basic screening as part of a wellness check. Frequently tests are used to help
confirm a diagnosis, monitor an illness, and provide valuable information about the client’s
response to treatment.
Nurses require knowledge of the most common laboratory and diagnostic tests
because one primary role of the nurse is to teach the client and family or significant other
how to prepare for the test and the care that may be required following the test.
Nurses must also know the implications of the test results in order to provide the
most appropriate nursing care for the client.

Diagnostic Testing Involves Three Phases:

1. Pretest
Pretest the major focus of the pretest phase is client preparation. A thorough
assessment and data collection (e.g. biologic, psychological, sociologic, cultural, and
spiritual) assist the nurse in determining communication and teaching strategies.
Prior to radiologic studies it is important to ask female clients if pregnancy
is possible. If pregnancy is suspected, special precautions may be necessary or the
test may need to be postponed.
The nurse also needs to know what equipment and supplies are needed for
the specific test. Common questions include the following:
a) What type of sample will be needed and how will it be collected?
b) Does the client need to stop oral intake for a certain number of hours prior
to the test?
c) Does the test include administration of dye (contrast media) and, if so, is it
injected or swallowed?
d) Are fluids restricted or forced?
e) Are medications given or withheld?
f) How long is the test?
g) Is a consent form required?
Answers to these types of questions can help avoid costly mistakes and
reduce inconvenience to all involved. Most facilities have information about the
tests available to the health care team. The laboratory at the facility can also act as a
resource for information.
2. Intratest
Intratest this phase focuses on specimen collection and performing or
assisting with certain diagnostic testing.
The nurse uses standard precautions and sterile technique as appropriate.
During the procedure the nurse provides emotional and physical support while
monitoring the client as needed (e.g., vital signs, pulse oximetry, ECG).

HEALTH ASSESSMENT (NCM 101)

 The nurse ensures correct labeling, storage, and transportation of the
specimen to avoid invalid test results.
3. Post-test
Post-Test the focus of this phase is on nursing care of the client and follow-
up activities and observations.
As appropriate, the nurse compares the previous and current test results
and modifies nursing interventions as needed. The nurse also reports the results to
appropriate health team members. The National Patient Safety Goals identify the
importance of reporting critical results of tests and diagnostic procedures.

Preparing for Diagnostic Testing

a) Instruct the client and family about the procedure for the diagnostic testing ordered
(e.g. whether food is allowed prior to or after testing, and the length of time of the
testing).
b) Explain the purpose of the test.
c) Instruct the client and family about activity restrictions related to testing (e.g.
remain supine for 1 hour after testing is completed).
d) Instruct the client and family on the reaction the diagnostic test may produce (e.g.
flushing when the dye is injected).
e) Provide the client with detailed information about the diagnostic testing equipment.
f) Inform the client and family of the time frame for when the results will be available.
g) Instruct the client and family to ask any questions so that the health care provider
can clarify information and allay any fears.

Blood tests
Blood tests are commonly used diagnostic tests that can provide valuable
information about the hematologic system and many other body systems. A venipuncture
(puncture of a vein for collection of a blood specimen) can be performed by various
members of the health care team.
A phlebotomist, a person from a laboratory who performs venipuncture, usually
collects the blood specimen for the tests ordered by the primary care provider. In some
institutions, nurses may draw blood samples. The nurse needs to know the guidelines for
drawing blood samples for the facility and also the state’s nurse practice act.
Complete blood count specimens of venous blood are taken for a complete blood
count (CBC), which includes hemoglobin and hematocrit measurements, erythrocyte (red
blood cells) count, leukocyte (white blood cell) count, red blood cell indices, and a
differential white cell count.
The CBC is a basic screening test and one of the most frequently ordered blood tests.
Hemoglobin is the main intracellular protein of erythrocytes. It is the iron-containing
protein in the red blood cells that transports oxygen through the body (Osborn, Wraa, &
Watson, 2010).
The hemoglobin test is a measure of the total amount of hemoglobin in the blood.
The hematocrit measures the percentage of RBCs in the total blood volume.
Normal values for both hemoglobin and hematocrit vary, with males having higher
levels than females. Hemoglobin and hematocrit are often ordered together and commonly
referred to as “H&H” when ordering laboratory tests.
Hemoglobin and hematocrit increase with dehydration as the blood becomes more
concentrated, and decrease with hypervolemia and resulting hemodilution.

HEALTH ASSESSMENT (NCM 101)

 Figure 2.3 Composition of Blood

HEALTH ASSESSMENT (NCM 101)

Table 2.2 CBC with Clinical Implications

HEALTH ASSESSMENT (NCM 101)

Serum Electrolytes
Serum electrolytes are often routinely ordered for any client admitted to a hospital
as a screening test for electrolyte and acid–base imbalances. Serum electrolytes also are
routinely assessed for clients at risk in the community, for example, clients who are being
treated with a diuretic for hypertension or heart failure.
The most commonly ordered serum tests are for sodium, potassium, chloride, and
bicarbonate ions.
Blood levels of two metabolically produced substances, urea and creatinine, are
routinely used to evaluate renal function. The kidneys, through filtration and tubular
secretion, normally eliminate both. Urea, the end product of protein metabolism, is
measured as blood urea nitrogen (BUN). Creatinine is produced in relatively constant
quantities by the muscles and is excreted by the kidneys. Thus, the amount of creatinine in
the blood relates to renal excretory function.

Table 2.3 Normal Values of Commonly Measured Electrolytes

Sodium 135–145 mEq/L
Potassium 3.5–5.3 mEq/L
Chloride 95–105 mEq/L
Calcium (total) (ionized) 4.5–5.5 mEq/L or 8.5–10.5 mg/dL 56% of total calcium
(2.5 mEq/L or 4.0–5.0 mg/dL)
Magnesium 1.5–2.5 mEq/L or 1.6–2.5 mg/dL
Phosphate 1.8–2.6 mEq/L (phosphorus)
Serum osmolality 280–300 mOsm/kg water

Arterial Blood Gases

Measurement of arterial blood gases is another important diagnostic procedure.
Specialty nurses, medical technicians, and respiratory therapists normally take specimens
of arterial blood from the radial, brachial, or femoral arteries. Because of the relatively great
pressure of the blood in these arteries, it is important to prevent hemorrhaging by applying
pressure to the puncture side for about 5 to 10 minutes after removing the needle.

Blood Chemistry
A number of other tests may be performed on blood serum (the liquid portion of the
blood). These are often referred to as a blood chemistry. In addition to serum electrolytes,
common chemistry examinations include determining certain enzymes that may be present
(including lactic dehydrogenase [LDH], creatine kinase [CK], aspartate aminotransferase
[AST], and alanine aminotransferase [ALT]), serum glucose, hormones such as thyroid
hormone, and other substances such as cholesterol and triglycerides.
These tests provide valuable diagnostic cues. For example, cardiac markers (e.g.,
CPK-MB, myoglobin, troponin T, and troponin I) are released into the blood during a
myocardial infarction (MI, or heart attack).
Elevated levels of these markers in the venous blood can help differentiate between
an MI and chest pain that is caused by angina and pleuritic pain.
A common laboratory test is the glycosylated hemoglobin or hemoglobin A1C
(HbA1C), which is a measurement of blood glucose that is bound to hemoglobin.
Hemoglobin A1C is a reflection of how well blood glucose levels have been controlled
during the prior 3 to 4 months. The normal range is 4.0% to 5.5%. An elevated HbA1C
reflects hyperglycemia in diabetics.
The first specific blood test to detect and guide treatment for heart failure is the
brain natriuretic peptide or B-type natriuretic peptide (BNP) test. B-type natriuretic
peptide is secreted primarily by the left ventricle in response to increased ventricular
volume and pressure. BNP levels increase as heart failure becomes more severe.

HEALTH ASSESSMENT (NCM 101)

Table 2.4 Normal Values of Common Blood Chemistry Tests

HEALTH ASSESSMENT (NCM 101)

Metabolic Screening
Newborns are routinely screened for congenital metabolic conditions. Tests for
phenylketonuria (PKU) and congenital hypothyroidism are required in all states in the
United States.
Other conditions that are frequently screened for include sickle cell disease and
galactosemia. Screening involves collecting peripheral venous blood (via a heel-stick) on
prepared blotting paper and sending the specimen to the state laboratory for analysis.
Discovered abnormalities allow the provider and parents to plan early care (e.g., special
diets for children with PKU) that can prevent long-term complications.

Capillary Blood Glucose

A capillary blood specimen is often taken to measure blood glucose when frequent
tests are required or when a venipuncture cannot be performed. This technique is less
painful than a venipuncture and easily performed. Hence, clients can perform this technique
on themselves.

HEALTH ASSESSMENT (NCM 101)

 The development of home glucose test kits and reagent strips has simplified the
testing of blood glucose and greatly facilitated the management of home care by clients with
diabetes.
If a client has a physical impairment, an available meter can rest on the arm and
perform the lancing and testing automatically. It is important to instruct a client who is
using one of these devices that forearm testing may not be as accurate as fingertip testing.
Capillary blood specimens are commonly obtained from the lateral aspect or side of
the finger in adults. This site avoids the nerve endings and calloused areas at the fingertip.
The earlobe may be used if the client is in shock or the fingers are edematous. Some newer
monitors allow for obtaining specimens from less sensitive areas on the arms, legs, or
abdomen.

Specimen Collection and Testing

The nurse contributes to the assessment of a client’s health status by collecting
specimens of body fluids. All hospitalized clients have at least one laboratory specimen
collected during their stay at the health care facility. Laboratory examination of specimens
such as urine, blood, stool, sputum, and wound drainage provides important adjunct
information for diagnosing health care problems and also provides a measure of the
responses to therapy.
Nurses often assume the responsibility for specimen collection. Depending on the
type of specimen and skill required, the nurse may be able to delegate this task to
unlicensed assistive personnel (UAP) under the supervision of the nurse.

Nursing responsibilities associated with specimen collection include the following:

1. Provide client comfort, privacy, and safety. Clients may experience embarrassment or
discomfort when providing a specimen. The nurse should provide the client with as
much privacy as possible and handle the specimen discreetly. The nurse needs to be
nonjudgmental and sensitive to possible sociocultural beliefs that may affect the
client’s willingness to participate in the specimen collection procedure.
2. Explain the purpose of the specimen collection and the procedure for obtaining the
specimen. Clients may experience anxiety about the procedure, especially if it is
perceived as being intrusive or if they fear an unknown test result. A clear explanation
will facilitate the client’s cooperation in the collection of the specimen. With proper
instruction, many clients are able to collect their own specimen, which promotes
independence and reduces or avoids embarrassment.
3. Use the correct procedure for obtaining a specimen or ensure that the client or staff
follows the correct procedure. Aseptic technique is used in specimen collection to
prevent contamination that can cause inaccurate test results. A nursing procedure or
laboratory manual is often available if the nurse is unfamiliar with the procedure. If
there is any question about the procedure, the nurse calls the laboratory for
directions before collecting the specimen.
4. Note relevant information on the laboratory requisition slip, for example, medications
the client is taking that may affect the results.
5. Transport the specimen to the laboratory promptly. Fresh specimens provide more
accurate results.
6. Report abnormal laboratory findings to the health care provider in a timely manner
consistent with the severity of the abnormal results.

HEALTH ASSESSMENT (NCM 101)

Stool Specimens
Analysis of stool specimens can provide information about a client’s health condition.
Some of the reasons for testing feces include the following:
1. To determine the presence of occult (hidden) blood. Bleeding can occur as a result of
gastrointestinal ulcers, inflammatory disease, or tumors. The test for occult blood,
often referred to as the guaiac test, can be readily performed by the nurse in the
clinical area or by the client at home. Guaiac paper used in the test is sensitive to fecal
blood content.
2. To analyze for dietary products and digestive secretions. For example, an excessive
amount of fat in the stool (steatorrhea) can indicate faulty absorption of fat from the
small intestine.
3. A decreased amount of bile can indicate obstruction of bile flow from the liver and
gallbladder into the intestine. For these kinds of tests, the nurse needs to collect and
send the total quantity of stool expelled at one time instead of a small sample.
4. To detect the presence of ova and parasites. When collecting specimens for parasites,
it is important that the sample be transported immediately to the laboratory while it
is still warm. Usually three stool specimens, over a period of days, are evaluated to
confirm the presence of and to identify the organism so that appropriate treatment
can be ordered.
5. To detect the presence of bacteria or viruses. Only a small amount of feces is required
because the specimen will be cultured. Collection containers or tubes must be sterile
and aseptic technique used during collection. Stools need to be sent immediately to
the laboratory. The nurse needs to note on the laboratory requisition if the client is
receiving any antibiotics.

Collecting Stool Specimens

The nurse is responsible for collecting stool specimens ordered for laboratory
analysis. Before obtaining a specimen, the nurse needs to determine the reason for
collecting the stool specimen and the correct method of obtaining and handling it (i.e., how
much stool to obtain, whether a preservative needs to be added to the stool, and whether it
needs to be sent immediately to the laboratory). It may be necessary to confirm this
information by checking with the agency laboratory. In many situations only a single
specimen is required; in others, timed specimens are necessary, and every stool passed is
collected within a designated time period.
Nursing assistant may obtain and collect stool specimen(s). The nurse, however,
needs to consider the collection process before delegating this task. For example, a random
stool specimen collected in a specimen container may be delegated, but a stool culture
requiring a sterile swab in a test tube should be done by the nurse. An incorrect collection
technique can cause inaccurate test results.
The task of obtaining and testing a stool specimen for occult blood may be
performed by nursing assistant. It is important that the nurse instruct the nursing assistant
to tell the nurse if blood is detected and/or whether the test is positive. In addition, the
stool specimen should be saved to allow the nurse to repeat the test.

Nurses need to give clients the following instructions:

1. Defecate in a clean bedpan or bedside commode.
2. If possible, do not contaminate the specimen with urine or menstrual discharge. Void
before the specimen collection.
3. Do not place toilet tissue in the bedpan after defecation. Contents of the paper can
affect the laboratory analysis.
4. Notify the nurse as soon as possible after defecation, particularly for specimens that
need to be sent to the laboratory immediately.

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 Wear clean gloves to prevent hand contamination and take care not to contaminate
the outside of the specimen container. Use one or two clean tongue blades to transfer the
specimen to the container and then wrap them in a paper towel before disposing of them in
the waste container. This practice reduces the chance of contact with other articles and the
spread of microorganisms.
The amount of stool to be sent depends on the purpose for which the specimen is
collected. Usually about 2.5 cm (1 in.) of formed stool or 15 to 30 mL of liquid stool is
adequate. For some timed specimens, however, the entire stool passed may need to be sent.
Visible pus, mucus, or blood should be included in sample specimens. For a stool culture,
the nurse dips a sterile swab into the specimen, preferably where purulent fecal matter is
present and, using sterile technique, places the swab in a sterile test tube.
Ensure that the specimen label and the laboratory requisition have the correct
information on them and are securely attached to the specimen container. Inappropriate
identification of the specimen risks errors of diagnosis or therapy for the client.
Because fresh specimens provide the most accurate results, the nurse sends the
specimen to the laboratory immediately. If this is not possible, the nurse follows the
directions on the specimen container. In some instances, refrigeration is indicated because
bacteriologic changes take place in stool specimens left at room temperature. To prevent
contamination, never place a stool specimen in a refrigerator that contains food or
medication.
Document all relevant information. Record the collection of the specimen on the
client’s chart and on the nursing care plan. Include in the recording the date and time of the
collection and all nursing assessments (e.g., color, odor, consistency, and amount of feces);
presence of abnormal constituents, such as blood or mucus; results of test for occult blood if
obtained; discomfort during or after defecation; status of perianal skin; and any bleeding
from the anus after defecation.

Fecal Occult Blood Testing

Fecal occult blood testing (FOBT) is the most frequently performed fecal analysis.
There are two types of FOBT: (1) the traditional guaiac smear (Hemoccult) and (2) flushable
reagent pads (EZ Detect or Colocare).
A commonly used test product to measure occult blood is the Hemoccult test, which
uses a chemical reagent (substance used in a chemical reaction to detect a specific
substance). This reagent detects the presence of the enzyme peroxidase in the hemoglobin
molecule. To perform the test, the nurse or client uses a tongue blade to place a small
amount of stool on a slide or card and then closes the card. The card is turned over and two
drops of a reagent are placed onto each smear on the back of the card.
The nurse then observes for a color change. A blue color indicates a guaiac positive
result, that is, the presence of occult blood. No color change or any color other than blue is a
negative finding, indicating the absence of blood in the stool.
Certain foods, medications, and vitamin C can produce inaccurate test results. False-
positive results can occur if the client has recently ingested (a) red meat (beef, lamb, liver,
and processed meats); (b) raw vegetables or fruits, particularly radishes, turnips,
horseradish, and melons; or (c) certain medications that irritate the gastric mucosa and
cause bleeding, such as aspirin or other nonsteroidal anti-inflammatory drugs, steroids, iron
preparations, and anticoagulants. False-negative results can occur if the client has taken
more than 250 mg per day of vitamin C from all sources (dietary and supplemental) up to 3
days before the test—even if bleeding is present.
Another method used for FOBT is the flushable reagent pads to detect pre-
symptomatic occult bleeding caused by gastrointestinal diseases. There is no handling of
stool, which is often a major objection by clients when using the traditional occult blood
test.

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 The companies for this product claim that there are fewer false-positive results and
that it is more cost effective (i.e., no chemical developers and no laboratory processing).
Urine Specimens
The nurse is responsible for collecting urine specimens for a number of tests: clean
voided urine specimens for routine urinalysis, clean-catch or midstream urine specimens
for urine culture, and timed urine specimens for a variety of tests that depend on the client’s
specific health problem. Urine specimen collection may require collection via straight
catheter insertion.

Clean Voided Urine Specimen

A clean voided specimen is usually adequate for routine examination. Many clients
are able to collect a clean voided specimen and provide the specimen independently with
minimal instructions. Male clients generally are able to void directly into the specimen
container, and female clients usually sit or squat over the toilet, holding the container
between their legs during voiding.
Routine urine examination is usually done on the first voided specimen in the
morning because it tends to have a higher, more uniform concentration and a more acidic
pH than specimens later in the day.
At least 10 ml of urine is generally sufficient for a routine urinalysis. Clients who are
seriously ill, physically incapacitated, or disoriented may need to use a bedpan or urinal in
bed; others may require supervision or assistance in the bathroom. Whatever the situation,
clear and specific directions are required:
1. The specimen must be free of fecal contamination, so urine must be kept separate
from feces.
2. Female clients should discard the toilet tissue in the toilet or in a waste bag rather
than in the bedpan because tissue in the specimen makes laboratory analysis more
difficult.
3. Put the lid tightly on the container to prevent spillage of the urine and
contamination of other objects.
4. If the outside of the container has been contaminated by urine, clean it with a
disinfectant.

The nurse must (a) make sure that the specimen label and the laboratory requisition
carry the correct information and (b) attach them securely to the specimen. Inappropriate
identification of the specimen can lead to errors of diagnosis or therapy for the client.
Nursing assistant may be assigned to collect a routine urine specimen. Provide the
nursing assistant with clear directions on how to instruct the client to collect his or her own
urine specimen or how to correctly collect the specimen for the client who may need to use
a bedpan or urinal.

Clean-Catch or Midstream Urine Specimen

Clean-catch or midstream voided specimens are collected when a urine culture is
ordered to identify microorganisms causing urinary tract infection. Although some
contamination by skin bacteria may occur with a clean-catch specimen, the risk of
introducing microorganisms into the urinary tract through catheterization is more
significant. Care is taken to ensure that the specimen is as free as possible from
contamination by microorganisms around the urinary meatus. Clean-catch specimens are
collected in a sterile specimen container with a lid.

Timed Urine Specimen

Some urine examinations require collection of all urine produced and voided over a
specific period of time, ranging from 1 to 2 hours to 24 hours. Timed specimens generally
either are refrigerated or contain a preservative to prevent bacterial growth or

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decomposition of urine components. Each voiding of urine is collected in a small, clean
container and then emptied immediately into the large refrigerated bottle or carton.
Timed urine specimens tests are performed for the following purposes:
1. To assess the ability of the kidney to concentrate and dilute urine
2. To determine disorders of glucose metabolism, for example, diabetes mellitus
3. To determine levels of specific constituents, for example, albumin, amylase,
creatinine, urobilinogen, or certain hormones (e.g., estriol or corticosteroids), in the
urine.

Indwelling Catheter Specimen

Sterile urine specimens can be obtained from closed drainage systems by inserting a
sterile needle attached to a syringe through a drainage port in the tubing. Aspiration of
urine from catheters can be done only with self-sealing rubber catheters—not plastic,
silicone, or Silastic catheters. When self-sealing rubber catheters are used, the needle is
inserted just above the location where the catheter is attached to the drainage tubing.

Figure 2.4 Urine collection on self-sealing rubber catheters.

Closed drainage urinary systems now have needleless ports, which means that
needles are not needed to obtain a sample. This protects the nurse from a needlestick injury
and maintains the integrity and sterility of the catheter system by eliminating the need to
puncture the tubing.

Figure 2.5 Closed drainage urinary systems.

Specific Gravity
Specific gravity is an indicator of urine concentration, or the amount of solutes
(metabolic wastes and electrolytes) present in the urine. The specific gravity of distilled
water is 1.00; the specific gravity of urine normally ranges from 1.010 to 1.025. As urine
becomes more concentrated, its specific gravity increases. Excess fluid intake or diseases
affecting the ability of the kidneys to concentrate urine can result in low specific gravity
readings. A high specific gravity may indicate fluid deficit or dehydration, or excess solutes
such as glucose in the urine. Specific gravity can be measured with the use of a multiple-test
dipstick that has a separate reagent area for specific gravity.

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Urinary pH
Urinary pH is measured to determine the relative acidity or alkalinity of urine and
assess the client’s acid–base status. Quantitative measurements of urine pH can be
performed in the laboratory, but dipsticks or litmus paper often are used on nursing units
or in clinics to obtain less precise pH measurements. Urine normally is slightly acidic, with
an average pH of 6 (7 is neutral, less than 7 is acidic, greater than 7 is alkaline). Because the
kidneys play a critical role in regulating acid–base balance, assessment of urine pH can be
useful in determining whether the kidneys are responding appropriately to acid–base
imbalances. In metabolic acidosis, urine pH should decrease as the kidneys excrete
hydrogen ions; in metabolic alkalosis, the pH should increase.

Glucose
Urine is tested for glucose to screen clients for diabetes mellitus and to assess
clients during pregnancy for abnormal glucose tolerance. Normally, the amount of glucose
in the urine is negligible, although individuals who have ingested large amounts of sugar
may show small amounts of glucose in their urine.
Testing urine for glucose is not a measure of current blood glucose level and is
considered an inadequate measurement. It is important for clients to understand that urine
testing is considered an inadequate measurement of blood glucose.

Ketones
Ketone bodies, a product of the breakdown of fatty acids, normally are not present
in the urine. They may, however, be found in the urine of clients with poorly controlled
diabetes. Urine testing for ketone level is advised for type 1 diabetics who are at home and
not feeling well, who are running a fever, or who have blood glucose consistently over 300
mg/dL (American Diabetes Association, n.d.). Urine ketone testing with reagent tablets or a
dipstick is also used to evaluate ketoacidosis in clients who are alcoholic, fasting, starving,
or consuming high-protein diets.

Protein
Protein molecules normally are too large to escape from glomerular capillaries into
the filtrate. If the glomerular membrane has been damaged, however (e.g., because of an
inflammatory process such as glomerulonephritis), it can become “leaky,” allowing proteins
to escape. Urine testing for the presence of protein generally is done with a reagent strip
(commonly referred to as a dipstick).

Occult Blood
Normal urine is free from blood. When blood is present, it may be clearly visible or
not visible (occult). Commercial reagent strips are used to test for occult blood in the urine.

Sputum Specimens
Sputum is the mucous secretion from the lungs, bronchi, and trachea. It is important
to differentiate it from saliva, the clear liquid secreted by the salivary glands in the mouth,
sometimes referred to as “spit.” Healthy individuals do not produce sputum. Clients need to
cough to bring sputum up from the lungs, bronchi, and trachea into the mouth in order to
expectorate it into a collecting container.
Sputum specimens are usually collected for one or more of the following reasons:
1. For culture and sensitivity to identify a specific microorganism and its drug
sensitivities.

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 2. For cytology to identify the origin, structure, function, and pathology of cells.
Specimens for cytology often require serial collection of three early-morning
specimens and are tested to identify cancer in the lung and its specific cell type.
3. For acid-fast bacillus (AFB), which also requires serial collection, often for 3
consecutive days, to identify the presence of tuberculosis (TB). Some agencies use a
special glass container when the presence of AFB is suspected.
4. To assess the effectiveness of therapy.

Sputum specimens are often collected in the morning. Upon awakening, the client
can cough up the secretions that have accumulated during the night. Sometimes specimens
are collected during postural drainage, when the client can usually produce sputum. When a
client cannot cough, the nurse must sometimes use pharyngeal suctioning to obtain a
specimen.

Throat Culture
A throat culture sample is collected from the mucosa of the oropharynx and tonsillar
regions using a culture swab. The sample is then cultured and examined for the presence of
disease-producing microorganisms. Obtaining a throat culture is an invasive procedure that
requires the application of scientific knowledge and potential problem solving to ensure
client safety. Thus, it is best for the nurse to perform this procedure.
To obtain a throat culture specimen, the nurse applies clean gloves, then inserts the
swab into the oropharynx and runs the swab along the tonsils and areas on the pharynx that
are reddened or contain exudate. The gag reflex, active in some clients, may be decreased by
having the client sit upright if health permits, open the mouth, extend the tongue, and say
“ah,” and by taking the specimen quickly. The sitting position and extension of the tongue
help expose the pharynx; saying “ah” relaxes the throat muscles and helps minimize
contraction of the constrictor muscle of the pharynx (the gag reflex). If the posterior
pharynx cannot be seen, use a light and depress the tongue with a tongue blade.

Figure 2.6 Depressing the tongue to view the pharynx.

Visualization Procedures
Visualization procedures include indirect visualization (noninvasive) and direct
visualization (invasive) techniques for visualizing body organ and system functions.

Clients with Gastrointestinal Alterations

Direct visualization techniques include anoscopy, the viewing of the anal canal;
proctoscopy, the viewing of the rectum; proctosigmoidoscopy, the viewing of the rectum
and sigmoid colon; and colonoscopy, the viewing of the large intestine.

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 Indirect visualization of the gastrointestinal tract is achieved by roentgenography.
X-rays of the gastrointestinal tract can detect strictures, obstructions, tumors, ulcers,
inflammatory disease, or other structural changes such as hiatal hernias.
Visualization of the tract is enhanced by the introduction of a radiopaque substance
such as barium. For examination of the upper gastrointestinal tract or small bowel, the
client drinks the barium sulfate.
This examination is often referred to as a barium swallow. For examination of the
lower gastrointestinal tract, the client is given an enema containing the barium. This
examination is commonly referred to as a barium enema. These x-rays usually include
fluoroscopic examination; that is, projection of the xray films onto a screen, which permits
continuous observation of the flow of barium. Nurses are responsible for preparing clients
before these studies and for follow-up care.

Clients with Urinary Alterations

Visualization procedures also may be used to evaluate urinary function. An x-ray of
the kidneys/ureters/bladder is commonly referred to as a KUB. Intravenous pyelography
(IVP) and retrograde pyelography also are radiographic studies used to evaluate the urinary
tract. In an IVP, contrast medium is injected intravenously; during retrograde pyelography,
the contrast medium is instilled directly into the kidney pelvis via the urethra, bladder, and
ureters. Following injection or instillation of the contrast medium, x-rays are taken to
evaluate urinary tract structures. Renal ultrasonography is a noninvasive test that uses
reflected sound waves to visualize the kidneys.
During a cystoscopy, the bladder, ureteral orifices, and urethra can be directly
visualized using a cystoscope, a lighted instrument inserted through the urethra. Nurses are
responsible for preparing clients before these studies and for follow-up care.

Clients with Cardiopulmonary Alterations

A number of visualization procedures can be done to examine the cardiovascular
system and respiratory tract. Electrocardiography provides a graphic recording of the
heart’s electrical activity. Electrodes placed on the skin transmit the electrical impulses to
an oscilloscope or graphic recorder. With the wave forms recorded, the electrocardiogram
(ECG) can then be examined to detect dysrhythmias and alterations in conduction indicative
of myocardial damage, enlargement of the heart, or drug effects.
Stress electrocardiography uses ECGs to assess the client’s response to an increased
cardiac workload during exercise. As the body’s demand for oxygen increases with
exercising, the cardiac workload increases, as does the oxygen demand of the heart muscle
itself. Clients with coronary artery disease may develop chest pain and characteristic ECG
changes during exercise.
Angiography is an invasive procedure requiring informed consent of the client. A
radiopaque dye is injected into the vessels to be examined. Using fluoroscopy and x-rays,
the flow through the vessels is assessed and areas of narrowing or blockage can be
observed.
Coronary angiography is performed to evaluate the extent of coronary artery
disease; pulmonary angiography may be performed to assess the pulmonary vascular
system, particularly if pulmonary emboli are suspected. Other vessels that may be studied
include the carotid and cerebral arteries, the renal arteries, and the vessels of the lower
extremities.
An echocardiogram is a noninvasive test that uses ultrasound to visualize structures
of the heart and evaluate left ventricular function. Images are produced as ultrasound
waves
reflect back to a transducer after striking cardiac structures. The nurse should tell the client
that this test causes no discomfort, although the conductive gel used may be cold.

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 X-ray examination of the chest is done both to diagnose disease and to assess the
progress of a disease. For an x-ray examination, the nurse needs to inform the client that
jewelry and clothing from the waist up must be removed.
A lung scan, also known as a V/Q (ventilation/perfusion) scan, records the
emissions from radioisotopes that indicate how well gas and blood are traveling through
the lungs. The
perfusion scan (Q scan—P usually stands for “pulmonary,” so apparently the next letter in
the alphabet was used for “perfusion”) is used to assess blood flow through the pulmonary
vascular system. For this, the radioisotope is injected intravenously and measured as it
circulates through the lung. The ventilation scan (V scan) detects ventilation abnormalities,
particularly in clients with emphysema. For this scan, the client inhales a radioactive gas
through a mask and then exhales it into room air.
The client needs to be informed that no radiation precautions are necessary because
the amount of radioactivity is very small. The scan may take 20 to 40 minutes.
Laryngoscopy and bronchoscopy are sterile procedures that are conducted with a
laryngoscope and bronchoscope, respectively. Tissue samples may also be taken for biopsy.
A local anesthetic is usually given before the examination. A local anesthetic is sprayed on
the client’s pharynx to prevent gagging; alternatively, the client gargles with an anesthetic
to anesthetize the throat. The bronchoscope is then inserted to visualize the larynx or
bronchi. Informed consent is required for these procedures.

Computed Tomography
Computed tomography (CT), also called CT scanning, computerized tomography, or
computerized axial tomography (CAT), is a painless, noninvasive x-ray procedure that has
the unique capability of distinguishing minor differences in the density of tissues. The CT
produces a three-dimensional image of the organ or structure, making it more sensitive
than the x-ray machine.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is a noninvasive diagnostic scanning technique
in which the client is placed in a magnetic field. Clients with implanted metal devices (e.g.,
pacemaker, metal hip prosthesis) cannot undergo an MRI because of the strong magnetic
field. There is no exposure to radiation.
If a contrast media is injected during the procedure, it is not an iodine contrast.
Another advantage to the MRI is that it provides a better contrast between normal and
abnormal tissue than the CT scan. It is, however, more costly.
All removable metallic objects (e.g., rings, watches, cell phones, body jewelry)
should be removed before entering the area of the magnet. Body jewelry made of titanium,
niobium, or surgical stainless steel, however, will not be attracted to the magnet. Recent
reports have shown that, in very few instances, people with tattoos or permanent cosmetics
experience edema or burning in the tattoo during an MRI. Advise clients to inform the
radiologist if they have a tattoo because sometimes the tattoo pigment can interfere with
the quality of the
MRI image (DeBoer, Seaver, Angel, & Armstrong, 2009, p. 38).
Transdermal patches containing a foil backing may cause burning or injury (Pullen,
2008). It is important to ask clients if they are using a transdermal patch so it can be
removed
before undergoing an MRI. Because the patch may lose its adhesiveness, advise the client to
apply a new patch after the MRI.
The MRI is commonly used for visualization of the brain, spine, limbs and joints,
heart, blood vessels, abdomen, and pelvis. The procedure involves the client lying on a
platform that moves into either a narrow, closed, high magnet scanner, or into an open, low-
magnet scanner. The client must lie very still. A two-way communication system is used to

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monitor the client’s response and to help relieve feelings of claustrophobia. Earplugs are
offered to the client to reduce the discomfort from the loud noises that occur during the
test. The procedure lasts between 60 and 90 minutes.

Nuclear Imaging Studies

Nuclear imaging studies involve the therapeutic use of radioactive isotopes for
diagnostic purposes. A radiopharmaceutical, a pharmaceutical (targeted to a specific organ)
with an embedded radioisotope, is administered through various routes for the test. The
distribution of the isotope is different in normal tissue than it is in diseased tissue. For
example, the distribution of the isotope in normal tissue is equal, uniform, and gray.
Hyperfunction of an organ shows darker images that are referred to as “hot” spots.
In contrast, hypofunctioning of an organ appears as lighter images that are called
“cold” spots (Kee, 2009).
Positron emission tomography (PET) is a noninvasive radiologic study that involves
the injection or inhalation of a radioisotope. Images are created as the radioisotope is
distributed in the body. This allows study of various aspects of organ function and may
include evaluation of blood flow and tumor growth.

Aspiration/Biopsy
Aspiration is the withdrawal of fluid that has abnormally collected (e.g., pleural
cavity, abdominal cavity) or to obtain a specimen (e.g., cerebrospinal fluid). A biopsy is the
removal and examination of tissue. Biopsies are usually performed to determine a diagnosis
or to detect malignancy. Both aspiration and biopsy are invasive procedures and require
strict sterile technique.

Lumbar Puncture
In a lumbar puncture (LP, or spinal tap), cerebrospinal fluid (CSF) is withdrawn
through a needle inserted into the subarachnoid space of the spinal canal between the third
and fourth lumbar vertebrae or between the fourth and fifth lumbar vertebrae. At this level
the needle avoids damaging the spinal cord and major nerve roots.
The client is positioned laterally with the head bent toward the chest, the knees
flexed onto the abdomen, and the back at the edge of the bed or examining table. In this
position the back is arched, increasing the spaces between the vertebrae so that the spinal
needle can be inserted readily.

Figure 2.7 Position in lumbar puncture.

During a lumbar puncture, the primary care provider frequently takes CSF pressure
readings using a manometer, a glass or plastic tube calibrated in millimeters.

Figure 2.8 Manometer used in CSF pressure readings

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HEALTH ASSESSMENT (NCM 101)
Abdominal Paracentesis
Normally the body creates just enough peritoneal fluid for lubrication. The fluid is
continuously formed and absorbed into the lymphatic system. However, in some disease
processes, a large amount of fluid accumulates in the abdominal cavity; this condition is
called ascites. Normal ascitic fluid is serous, clear, and light yellow in color. An abdominal
paracentesis is carried out to obtain a fluid specimen for laboratory study and to relieve
pressure on the abdominal organs due to the presence of excess fluid. A primary care
provider performs the procedure with the assistance of a nurse. Strict sterile technique is
followed. A common site for abdominal paracentesis is midway between the umbilicus and
the symphysis pubis on the midline.
If the purpose of the paracentesis is to obtain a specimen, the primary care provider
may use a long aspirating needle attached to a syringe rather than making an incision and
using a trocar and cannula. Normally about 1,500 ml is the maximum amount of fluid
drained at one time to avoid hypovolemic shock.

Thoracentesis
Normally, only sufficient fluid to lubricate the pleura is present in the pleural cavity.
However, excessive fluid can accumulate as a result of injury, infection, or other pathology.
In such a case or in the case of pneumothorax, a primary care provider may perform a
thoracentesis to remove the excess fluid or air to ease breathing.
Thoracentesis is also performed to introduce chemotherapeutic drugs
intrapleurally. The nurse assists the client to assume a position that allows easy access to
the intercostal spaces. This is usually a sitting position with the arms above the head, which
spreads the ribs and enlarges the intercostal space.

Two positions commonly used in thoracentesis

1. the arm is elevated and stretched
forward
2. the client leans forward over a pillow

A chest x-ray prior to the procedure will help pinpoint the best insertion site. The
primary care provider and the assisting nurse follow strict sterile technique.

Bone Marrow Biopsy

Another type of diagnostic study is the biopsy. A biopsy is a procedure whereby
tissue is obtained for examination. Biopsies are performed on many different types of
tissues, for example, bone marrow, liver, breast, lymph nodes, and lung. A bone marrow
biopsy is the removal of a specimen of bone marrow for laboratory study. The biopsy is
used to detect specific diseases of the blood, such as pernicious anemia and leukemia. The
bones of the body commonly used for a bone marrow biopsy are the sternum, iliac crests,
anterior or posterior iliac spines, and proximal tibia in children. The posterior superior iliac
crest is the preferred site with the client placed prone or on the side.
Once the needle is in the marrow space, the stylet is removed and a 10-mL syringe is
attached to the needle. The plunger is withdrawn until 1 to 2 mL of marrow has been
obtained. The primary care provider replaces the stylet in the needle, withdraws the needle,
and places the specimen in test tubes and/or on glass slides.

Liver Biopsy
A liver biopsy is a short procedure, generally performed at the client’s bedside, in
which a sample of liver tissue is aspirated. A primary care provider inserts a needle in the

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intercostal space between two of the right lower ribs and into the liver or through the
abdomen below the right rib cage (subcostally).
The client exhales and is instructed to hold his or her breath while the primary care
provider inserts the biopsy needle, injects a small amount of sterile normal saline to clear
the needle of blood or particles of tissue picked up during insertion, and aspirates liver
tissue by drawing back on the plunger of the syringe.
After the needle is withdrawn, the nurse applies pressure to the site to prevent
bleeding, often by positioning the client on the biopsy site. Because many clients with liver
disease have blood clotting defects and are prone to bleeding, prothrombin time and
platelet count are normally taken well in advance of the test. If the test results are abnormal,
the biopsy may be contraindicated.

SELF-STUDY GUIDE QUESTIONS

1. What are the step by step order of assessment?
2. Enumerate the steps in preparing for the physical examination.
3. Explain the cardinal techniques of examination. In assessing abdomen, what is the
step by step techniques of examination?
4. Make an interview with one member of your family using the Nursing Assessment
Form.
5.

HEALTH ASSESSMENT (NCM 101)

 UNIT 3. HOLISTIC NURSING ASSESSMENT
OVERVIEW
A holistic nursing assessment focuses not only on physical health of an individual. It
also addresses emotional, mental, social and spiritual health. The whole condition of the
patient is taken into consideration for ongoing wellness across the lifespan. A holistic
nursing assessment allows the nurse to gain information essential for diagnosis, planning
and implementation. It shows respect for the patient’s preferences and preserves the
patient’s dignity.

LEARNING OBJECTIVES 
Upon completion of this unit, I am able to do the following: 
1. assess the general status and vital signs;
2. discuss the mental status of children, adolescent, and adults;
3. define the psychosocial, cognitive and moral development;
4. know how to assess pain and violence;
5. recognize the importance of culture, ethnicity, spirituality and religious practices of a
client; and
6. explain how to assess nutritional status of a client.

GENERAL SURVEY
According to Jarvis (2011), the general survey of the patient’s appearance, height,
and weight begins with the opening moments of the patient encounter, but you will find
that your observations of the patient’s appearance crystallize as you start the physical
examination.
The best clinicians continually sharpen their powers of observation and description.
As you talk with and examine the patient, heighten your focus on the patient’s mood, build,
and behavior. These details enrich and deepen your emerging clinical impression.
A skilled observer describes the distinguishing features of the patient’s appearance
so well that colleagues can spot the patient in a crowd of strangers. Many factors contribute
to the patient’s body habitus: socioeconomic status, nutrition, genetic makeup, degree of
fitness, mood state, early illnesses, gender, geographic location, and age cohort.
Recall that the patient’s nutritional status affects many of the characteristics you
scrutinize during the General Survey: height and weight, blood pressure, posture, mood and
alertness, facial coloration, dentition and condition of the tongue and gingiva, color of the
nail beds, and muscle bulk, to name a few. Be sure to make the assessment of height, weight,
BMI, and risk for obesity a routine part of your clinical practice.
Now is the time to recall the observations you have been making since the first
moments of your interaction, refining them throughout your assessment.
The following observation should raise questions or hypotheses for you to consider as you
assess.
 Does the patient hear you when greeted in the waiting room or examination room?
 Rise with ease?
 Walk easily or stiffly?
 If hospitalized when you first meet, what is the patient doing—sitting up and
enjoying television?... or lying in bed?...
 What do you see on the bedside table—a magazine?... a flock of “get well” cards?. .. a
Bible or a rosary?. .. an emesis basin?... or nothing at all?

ASSESSMENT OF GENERAL APPEARANCE

The general appearance and behavior of an individual must be assessed in
relationship to culture, educational level, socioeconomic status, and current circumstances.
For example, an individual who has recently experienced a personal loss may appropriately
appear depressed (sad expression, slumped posture).
The client’s age, sex, and race are also useful factors in interpreting findings that suggest
increased risk for known conditions.
Observe the following throughout the encounter with the client:
 Apparent State of Health
a) Try to make a general judgment based on observations throughout the
encounter. Support it with the significant details.
b) Is the patient acutely or chronically ill, frail, or fit and robust?

HEALTH ASSESSMENT (NCM 101)

 Level of Consciousness
a) Level of consciousness primarily reflects the patient’s capacity for arousal,
or wakefulness. It is determined by the level of activity that the patient can
be aroused to perform in response to escalating stimuli from the examiner.

Table 3.1 Five Clinical Levels of Consciousness

Level of Definition Assessment Technique
Consciousness
Alertness A fully alert patient respondsSpeak to the patient in a normal
to questions spontaneously. tone of voice. An alert patient
opens the eyes, looks at you, and
responds fully and appropriately
to stimuli (arousal intact).
Lethargy A lethargic patient appears Speak to the patient in a loud
drowsy but opens the eyes voice. For example, call the
and looks at you, responds to patient’s name or ask “How are
questions, and then falls you?”
asleep.
Obtundation An obtunded patient opens Shake the patient gently as if
the eyes and looks at you but awakening a sleeper.
responds slowly and is
somewhat confused.
Stupor A stuporous patient arouses Apply a painful stimulus. For
from sleep only after painful example, pinch a tendon, rub the
stimuli. Verbal responses are sternum, or roll a pencil across a
slow or even absent. The nail bed. (No stronger stimuli
patient lapses into an needed!)
unresponsive state when the
stimulus ceases. There is
minimal awareness of self or
the environment.
Coma A comatose patient remains Apply repeated painful stimuli.
unarousable with eyes closed.
There is no evident response
to inner need or external
stimuli, may not respond to
verbal stimuli.

b) The Glasgow Coma Scale, according to Knapp (2020), was originally

developed to predict recovery from a head injury; however, it is used by
many professionals to assess LOC. It tests in three major areas: eye
response, motor response, and verbal response. An assessment totaling 15
points which is the highest possible score indicates the client is alert and
completely oriented. A comatose client scores 7 or less. The lowest possible
GCS score is 3.

Figure 3.1 Abnormal postures

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 Table 3.2 Glasgow Coma Scale
Behavior Response Score
Eye Opening (E)  spontaneous 4
 to sound 3
 pressure 2
 none 1
Verbal Response (V)  orientated 5
 confused 4
 words, but not 3
coherent 2
 sounds, but no words 1
 none
Motor Response (M)  obeys command 6
 localizing 5
 normal flexion 4
 abnormal flexion 3
(decorticate posture)
 Extension 2
(decerebrate posture)
 none 1

 Signs of Distress
Does the patient show evidence of the problems listed below?
a) cardiac or respiratory distress
(Is there clutching of the chest, pallor, diaphoresis, or labored breathing,
wheezing, and coughing?)
b) pain
(Is there wincing, sweating, protectiveness of a painful area, facial grimacing,
or an unusual posture favoring one limb or body area?)
c) anxiety or depression
(Are there anxious facial expressions, fidgety movements, cold and moist
palms, inexpressive or flat affect, poor eye contact, or psychomotor
slowing?)

 Skin Color and Obvious Lesions

a) Assess any changes in skin color, scars, plaques (an elevated, solid,
superficial lesion that is typically more than one centimeter in diameter (a
little more than half an inch) and associated with a number
of skin conditions, most commonly psoriasis, or nevi (birthmark or mole).
b) Abnormal skin colors
1. pallor = pale
2. cyanosis = bluish
3. jaundice or icterus = yellowish
4. hyperpigmentation = brown

 Dress, Grooming, and Personal Hygiene

a) How is the patient dressed? Is the clothing appropriate for the temperature
and weather? Is it clean and appropriate to the setting?
(Excess clothing may reflect the cold intolerance of hypothyroidism, hide
skin rash or needle marks, mask anorexia, or signal personal lifestyle
preferences.)
b) Glance at the patient’s shoes. Are there cut-outs or holes? Are the shoes run-
down?
(Excess clothing may reflect the cold intolerance of hypothyroidism, hide
skin rash or needle marks, mask anorexia, or signal personal lifestyle
preferences.)
c) Is the patient wearing unusual jewelry? Are there body piercings?
(Copper bracelets are sometimes worn for arthritis. Piercing may appear on
any part of the body.)

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 d) Note the patient’s hair, fingernails, and use of cosmetics. They may be clues
to the patient’s personality, mood, lifestyle, and self-regard.
(”Grown-out” hair and nail polish can help you estimate the length of an
illness. Fingernails chewed to the quick may reflect stress.)
e) Do personal hygiene and grooming seem appropriate to the patient’s age,
lifestyle, occupation, and stage of life?
(Unkempt appearance may be seen in depression and dementia, but this
appearance must be compared with the patient’s probable norm.)

 Facial Expression
a) Observe the facial expression at rest, during conversation about specific
topics, during the physical examination, and in interaction with others.
Watch for eye contact. Is it natural? Sustained and unblinking? Averted
quickly? Absent?
(Watch for the stare of hyperthyroidism; the immobile face of Parkinsonism;
the flat or sad affect of depression. Decreased eye contact may be cultural or
may suggest anxiety, fear, or sadness.)

 Odors of the Body and Breath

a) Odors can be important diagnostic clues, like the fruity odor of diabetes or
the scent of alcohol.
(Breath odors can indicate the presence of alcohol, acetone (diabetes),
pulmonary infections, uremia, or liver failure.)
b) Never assume that alcohol on a patient’s breath explains changes in mental
status or neurologic findings.
(People with alcoholism may have other serious and potentially correctable
problems such as hypoglycemia, subdural hematoma, or postictal state
(altered state of consciousness after an epileptic seizure.)

 Posture, Gait, and Motor Activity

a) What is the patient’s preferred posture?
(There is a preference for sitting upright in left-sided heart failure and for
leaning forward with arms braced in chronic obstructive pulmonary
disease.)
b) Is the patient restless or quiet? How often does the patient change position?
(Anxious patients appear agitated and restless. Patients in pain often avoid
movement.)
c) Is there any involuntary motor activity? Are some body parts immobile?
Which ones?
(Look for tremors, other involuntary movements, or paralysis.)
d) Does the patient walk smoothly, with comfort, self-confidence, and balance,
or is there a limp or discomfort, fear of falling, loss of balance, or any
movement disorder?
(An impaired gait increases risk of falls.)

 Height and Weight

In adults, the ratio of weight to height provides a general measure of health.
By asking clients about their height and weight before actually measuring them, the
nurse obtains some idea of the person’s self-image.
Excessive discrepancies between the client’s responses and the
measurements may provide clues to actual or potential problems in self-concept.
Take note of any unintentional weight gain or loss lasting or progressing over
several weeks.
a) The nurse measures height with a measuring stick attached to weight scales
or to a wall. The client should remove the shoes and stand erect, with heels
together, and the heels, buttocks, and back of the head against the measuring
stick; eyes should be looking straight ahead. The nurse raises the L-shaped
sliding arm until it rests on top of the client’s head, or places a small flat
object such as a ruler or book on the client’s head. The edge of the flat object
should touch the measuring guide.

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 Figure 3.2 Measuring height

b) Weight is usually measured when a client is admitted to a health agency and

often regularly, for example, each morning before breakfast. Scales measure
in pounds (lb) or kilograms (kg), and the nurse may need to convert
between the two systems. (1 kilogram = 2.2 pounds). When accuracy is
essential, the nurse should use the same scale each time (because every
scale weighs slightly differently), take the measurements at the same time
each day, and make sure the client has on a similar kind of clothing and no
footwear. The weight is read from a digital display panel or a balancing arm.
Clients who cannot stand are weighed on chair or bed scales. The bed scales
have canvas straps or a stretcher-like apparatus to support the client. A
machine lifts the client above the bed, and the weight is reflected either on a
digital display panel or on a balance arm like that of a standing scale. Some
agencies may have beds with built-in scales.

Figure 3.3 Chair Scale and Bed Scale

c) Calculating the BMI

BMI is a person’s weight in kilograms or pounds divided by the
square of height in meters. Use your measurements of height and weight to
calculate the body mass index or BMI.
A healthy BMI is between 18.5 and 24.9 kg/m 2. A high BMI can be an
indicator of high body fatness. BMI can be used as a screening tool but is not
diagnostic of the body fatness or health of an individual. To determine if a
high BMI is a health risk, a healthcare provider would need to perform
further assessments. These assessments might include skinfold thickness
measurements, evaluations of diet, physical activity, family history, and
other appropriate health screenings.
There are several ways to calculate the BMI, as shown in the table
below. Choose the method best suited to your practice.
Classify the BMI according to the national guidelines, if the BMI is
above25 kg/m2, assess the patient for additional risk factors for heart
disease and other obesity-related diseases: hypertension, high low-density

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 lipoprotein (LDL) cholesterol, low high-density lipoprotein (HDL)
cholesterol, high triglycerides, high blood glucose, family history of
premature heart disease, physical inactivity, and cigarette smoking. Patients
with a BMI over 25 kg/m2 and two or more risk factors should pursue
weight loss—especially if the waist circumference is elevated.
Table 3.3 BMI Computation
Measurement Formula and Calculation
Units
Kilograms and Formula: weight (kg) / [height (m)]2
meters (or With the metric system, the formula for BMI is weight in
centimeters) kilograms divided by height in meters squared.
Because height is commonly measured in centimeters, divide
height in centimeters by 100 to obtain height in meters.
Example: Weight = 68 kg, Height = 165 cm (1.65 m)
Calculation: 68 ÷ (1.65)2 = 24.98
Pounds and Formula: weight (lb) / [height (in)]2 x 703
inches Calculate BMI by dividing weight in pounds (lbs) by height in
inches (in) squared and multiplying by a conversion factor of
703.
Example: Weight = 150 lbs, Height = 5’5″ (65″)
Calculation: [150 ÷ (65)2] x 703 = 24.96
About Adult BMI. (2020, June 30). Retrieved August 04, 2020, from
https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html

Figure 3.4 BMI Chart

Table 3.4 Classification of Overweight and Obesity by BMI

Obesity Class BMI (kg/m2)
Underweight <18.5
Normal 18.5 - 24.9
Overweight 25.0 – 29.9
Obesity I 30.0 – 34.9
II 35.0 – 39.9
Extreme Obesity III >40

d) Waist circumference

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 If the BMI is 35 or greater, measure the patient’s waist circumference just
above the hips. Risk for diabetes, hypertension, and cardiovascular disease
increases significantly if the waist circumference is 35 inches or more in
women and 40 inches or more in men.

VITAL SIGNS
Vital signs are clinical measurements, specifically blood pressure, pulse rate,
temperature and respiration rate, that indicate the state of an individual’s essential body
functions. Many agencies have designated pain as a fifth vital sign. Oxygen saturation is also
commonly measured at the same time as the traditional vital signs (Berman & Snyder,
Kozier & Erb’s Fundamentals of Nursing, 2012).
Monitoring a client’s vital signs should not be an automatic or routine procedure; it
should be a thoughtful, scientific assessment.

When to Assess Vital Signs

A nurse should assess vital signs:
1. On admission to a health care agency to obtain baseline data.
2. When a client has a change in health status or reports symptoms such as chest pain
or feeling hot or faint.
3. Before and after surgery or an invasive procedure.
4. Before and/or after the administration of a medication that could affect the
respiratory or cardiovascular systems, for example, before giving a digitalis
preparation.
5. Before and after any nursing intervention that could affect the vital signs (e.g.,
ambulating a client who has been on bed rest).

TEMPERATURE
Body temperature reflects the balance between the heat produced and the heat lost
from the body, and is measured in heat units called degrees.

Kinds of Body Temperature

There are two kinds of body temperature:
1. Core temperature is the temperature of the deep tissues of the body, such as the
abdominal cavity and pelvic cavity. It remains relatively constant.
2. The surface temperature is the temperature of the skin, the subcutaneous tissue,
and fat. It, by contrast, rises and falls in response to the environment.

The body continually produces heat as a by-product of metabolism. When the

amount of heat produced by the body equals the amount of heat lost, the person is in heat
balance.

Factors Affect the Body’s Heat Production

The most important are:
1. Basal metabolic rate. The basal metabolic rate (BMR) is the rate of energy utilization
in the body required to maintain essential activities such as breathing.

2. Metabolic rates decrease with age. In general, the younger the person, the higher the
BMR.
3. Muscle activity. Muscle activity, including shivering, increases the metabolic rate.
4. Thyroxine output. Increased thyroxine output increases the rate of cellular
metabolism throughout the body.
5. Epinephrine, norepinephrine, and sympathetic stimulation/ stress response. These
hormones immediately increase the rate of cellular metabolism in many body
tissues.
6. Fever. Fever increases the cellular metabolic rate and thus increases the body’s
temperature further.

Causes of Heat Lost

Heat is lost from the body through:

HEALTH ASSESSMENT (NCM 101)

 1. Radiation is the transfer of heat from the surface of one object to the surface of
another without contact between the two objects, mostly in the form of infrared
rays.
2. Conduction is the transfer of heat from one molecule to a molecule of lower
temperature. Conductive transfer cannot take place without contact between the
molecules and normally accounts for minimal heat loss except, for example, when a
body is immersed in cold water. The amount of heat transferred depends on the
temperature difference and the amount and duration of the contact.
3. Convection is the dispersion of heat by air currents. The body usually has a small
amount of warm air adjacent to it. This warm air rises and is replaced by cooler air,
so people always lose a small amount of heat through convection.
4. Evaporation is continuous vaporization of moisture from the respiratory tract and
from the mucosa of the mouth and from the skin. This continuous and unnoticed
water loss is called insensible water loss, and the accompanying heat loss is called
insensible heat loss. Insensible heat loss accounts for about 10% of basal heat loss.
When the body temperature increases, vaporization accounts for greater heat loss.

Regulation of Body Temperature

The system that regulates body temperature has three main parts: (1) sensors in the
periphery and in the core, (2) an integrator in the hypothalamus, and (3) an effector system
that adjusts the production and loss of heat.
1. Most sensors or sensory receptors are in the skin. The skin has more receptors for
cold than warmth. Therefore, skin sensors detect cold more efficiently than warmth.
When the skin becomes chilled over the entire body, three physiological processes
to increase the body temperature take place:
a) Shivering increases heat production.
b) Sweating is inhibited to decrease heat loss.
c) Vasoconstriction decreases heat loss.
2. The hypothalamic integrator is the center that controls the core temperature. When
the integrator detects heat, it sends out signals intended to reduce the temperature,
that is, to decrease heat production and increase heat loss. In contrast, when the
cold sensors are stimulated, the integrator sends out signals to increase heat
production and decrease heat loss. The signals from the cold-sensitive receptors of
the hypothalamus initiate effectors, such as vasoconstriction, shivering, and the
release of epinephrine, which increases cellular metabolism and hence heat
production.
3. When the warmth-sensitive receptors in the hypothalamus are stimulated, the
effector system sends out signals that initiate sweating and peripheral
vasodilatation. Also, when this system is stimulated, the person consciously makes
appropriate adjustments, such as putting on additional clothing in response to cold
or turning on a fan in response to heat.

Factors Affecting Body Temperature

Among the factors that affect body temperature are the following:
1. Age. The infant is greatly influenced by the temperature of the environment and
must be protected from extreme changes. Children’s temperatures vary more than
those of adults until puberty. Many older people, particularly those over 75 years,
are at risk of hypothermia (temperatures below 36°C, or 96.8°F) for a variety of
reasons, such as inadequate diet, loss of subcutaneous fat, lack of activity, and
reduced thermoregulatory efficiency. Older adults are also particularly sensitive to
extremes in the environmental temperature due to decreased thermoregulatory
controls.
2. Diurnal variations (circadian rhythms). Body temperatures normally change
throughout the day, varying as much as 1.0°C (1.8°F) between the early morning and
the late afternoon. The point of highest body temperature is usually reached
between 1600 and 1800 hours (4:00 PM and 6:00 PM), and the lowest point is
reached during sleep between 0400 and 0600 hours (4:00 AM and 6:00 AM).
3. Exercise. Hard work or strenuous exercise can increase body temperature to as high
as 38.3°C to 40°C (101°F to 104°F) measured rectally.

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 4. Hormones. Women usually experience more hormone fluctuations than men. In
women, progesterone secretion at the time of ovulation raises body temperature by
about 0.3°C to 0.6°C (0.5°F to 1.0°F) above basal temperature.
5. Stress. Stimulation of the sympathetic nervous system can increase the production
of epinephrine and norepinephrine, thereby increasing metabolic activity and heat
production. Nurses may anticipate that a highly stressed or anxious client could
have an elevated body temperature for that reason.
6. Environment. Extremes in environmental temperatures can affect a person’s
temperature regulatory systems. If the temperature is assessed in a very warm
room and the body temperature cannot be modified by convection, conduction, or
radiation, the temperature will be elevated. Similarly, if the client has been outside
in cold weather without suitable clothing, or if there is a medical condition
preventing the client from controlling the temperature in the environment (e.g., the
client has altered mental status or cannot dress self), the body temperature may be
low.

Alterations in Body Temperature

The normal range for adults is considered to be between 36°C and 37.5°C (96.8°F to
99.5°F). There are two primary alterations in body temperature:
1. Pyrexia
A body temperature above the usual range is called pyrexia, hyperthermia,
or (in lay terms) fever. A very high fever, such as 41°C (105.8°F), is called
hyperpyrexia. The client who has a fever is referred to as febrile; the one who does
not is afebrile.

Types of Fevers
Four common types of fevers are:
a) Intermittent fever is when the body temperature alternates at regular
intervals between periods of fever and periods of normal or subnormal
temperatures. An example is with the disease malaria.
b) Remittent fever such as with a cold or influenza, a wide range of
temperature fluctuations (more than 2°C [3.6°F]) occurs over a 24-hour
period, all of which are above normal.
c) Relapsing fever is a short febrile periods of a few days are interspersed with
periods of 1 or 2 days of normal temperature.
d) Constant fever is when the body temperature fluctuates minimally but
always remains above normal. This can occur with typhoid fever.

A temperature that rises to fever level rapidly following a normal

temperature and then returns to normal within a few hours is called a fever spike.
Bacterial blood infections often cause fever spikes. In some conditions, an elevated
temperature is not a true fever. Two examples are heat exhaustion and heat stroke.
a) Heat exhaustion is a result of excessive heat and dehydration. Signs of heat
exhaustion include paleness, dizziness, nausea, vomiting, fainting, and a
moderately increased temperature (38.3°C to 38.9°C [101°F to 102°F]).
b) Persons experiencing heat stroke generally have been exercising in hot
weather, have warm, flushed skin, and often do not sweat. They usually have
a temperature of 41.1°C (106°F) or higher, and may be delirious,
unconscious, or having seizures.

Very high temperatures, such as 41°C to 42°C (106°F to 108°F), damage the
parenchyma of cells throughout the body, particularly in the brain where
destruction of neuronal cells is irreversible. Damage to the liver, kidneys, and other
body organs can also be great enough to disrupt functioning and eventually cause
death.

Clinical Manifestations of Fever

The clinical signs of fever vary with the onset, course, and abatement stages of the
fever.
Onset (Cold or Chill Phase)
 Increased heart rate

HEALTH ASSESSMENT (NCM 101)

  Increased respiratory rate and depth
 Shivering
 Pallid, cold skin
 Complaints of feeling cold
 Cyanotic nail beds
 “Gooseflesh” appearance of the skin
 Cessation of sweating
Nursing interventions at this stage is to help the client decrease heat loss.

Course (Plateau Phase)

 Absence of chills
 Skin that feels warm
 Photosensitivity
 Glassy-eyed appearance
 Increased pulse and respiratory rates
 Increased thirst
 Mild to severe dehydration
 Drowsiness, restlessness, delirium, or convulsions
 Herpetic lesions of the mouth
 Loss of appetite (if the fever is prolonged)
 Malaise, weakness, and aching muscles
Nursing interventions at this stage is the safety of the client.

Defervescence (Fever Abatement/Flush Phase)

 Skin that appears flushed and feels warm
 Sweating
 Decreased shivering
 Possible dehydration
Nursing interventions is to increase heat loss and decrease heat production.

Nursing Interventions for Clients with Fever

During the course of a fever, the nurse needs to:
a) Monitor vital signs.
b) Assess skin color and temperature.
c) Monitor white blood cell count, hematocrit value, and other pertinent
laboratory reports for indications of infection or dehydration.
d) Remove excess blankets when the client feels warm, but provide extra
warmth when the client feels chilled.
e) Provide adequate nutrition and fluids (e.g., 2,500–3,000 mL per day) to meet
the increased metabolic demands and prevent dehydration.
f) Measure intake and output.
g) Reduce physical activity to limit heat production, especially during the flush
stage.
h) Administer antipyretics (drugs that reduce the level of fever) as ordered.
i) Provide oral hygiene to keep the mucous membranes moist.
j) Provide a tepid sponge bath to increase heat loss through conduction.
k) Provide dry clothing and bed linens.

2. Hypothermia
Hypothermia is a core body temperature below the lower limit of normal.
The three physiological mechanisms of hypothermia are (a) excessive heat loss, (b)
inadequate heat production to counteract heat loss, and (c) impaired hypothalamic
thermoregulation. If skin and underlying tissues are damaged by freezing cold, this
results in frostbite. Frostbite most commonly occurs in hands, feet, nose, and ears.

Clinical Manifestations of Hypothermia

 Decreased body temperature, pulse, and respirations
 Severe shivering (initially)
 Feelings of cold and chills
 Pale, cool, waxy skin
 Frostbite (discolored, blistered nose, fingers, toes)

HEALTH ASSESSMENT (NCM 101)

  Hypotension
 Decreased urinary output
 Lack of muscle coordination
 Disorientation
 Drowsiness progressing to coma

Nursing Interventions for Clients with Hypothermia

During hypothermia the nurse needs to:
a) Provide a warm environment.
b) Provide dry clothing.
c) Apply warm blankets.
d) Keep limbs close to body.
e) Cover the client’s scalp with a cap or turban.
f) Supply warm oral or intravenous fluids.
g) Apply warming pads.
Assessing Body Temperature
The most common sites for measuring body temperature are oral, rectal, axillary,
tympanic membrane, and skin/temporal artery.
1. Oral temperature. If a client has been taking cold or hot food or fluids or smoking,
the nurse should wait 30 minutes before taking the temperature orally to ensure
that the temperature of the mouth is not affected by the temperature of the food,
fluid, or warm smoke.
2. Rectal temperature readings are considered to be very accurate. Rectal
temperatures are contraindicated for clients who are undergoing rectal surgery,
have diarrhea or diseases of the rectum, are immunosuppressed, have a clotting
disorder, or have significant hemorrhoids.
3. Axillary temperatures are lower than rectal temperatures. The axilla is often the
preferred site for measuring temperature in newborns because it is accessible and
safe. Some clinicians recommend rechecking an elevated axillary temperature with
one taken from another site to confirm the degree of elevation.
4. The tympanic membrane, or nearby tissue in the ear canal, is a frequent site for
estimating core body temperature.
5. The temperature may also be measured on the forehead using a chemical
thermometer or a temporal artery thermometer. Forehead temperature
measurements are most useful for infants and children where a more invasive
measurement is not necessary.

Types of Thermometers
The different types of thermometer are discussed on the table below.

Table 3.5 Types of Thermometer

Type Discussion Example
Electronic Electronic thermometers can provide a reading in
thermometer only 2 to 60seconds, depending on the model. The
equipment consists of an electronic base, a probe, and
a probe cover, which is usually disposable.
Chemical Chemical thermometers have liquid crystal dots or
thermometer bars that change color to indicate temperature. Some
of these are single use and others may be reused
several times.
Temperature- Temperature-sensitive tape may also be used to
sensitive tape obtain a general indication of body surface
temperature. It does not indicate the core
temperature. The tape contains liquid crystals that
change color according to temperature. When applied
to the skin, usually of the forehead or abdomen, the
temperature digits on the tape respond by changing
color. The skin area should be dry. After the length of
time specified by the manufacturer (e.g., 15 seconds),
a color appears on the tape. This method is
particularly useful at home and for infants whose
temperatures are to be monitored.

HEALTH ASSESSMENT (NCM 101)

 Infrared Infrared thermometers sense body heat in the form of
thermometer infrared energy given off by a heat source, which, in
the ear canal, is primarily the tympanic membrane.
The infrared thermometer makes no contact with the
tympanic membrane.
Temporal artery Temporal artery thermometers determine
thermometer temperature using a scanning infrared thermometer
that compares arterial temperature in the temporal
artery of the forehead to the temperature in the room
and calculates the heat balance to approximate the
core temperature of the blood in the pulmonary
artery. The probe is placed in the middle of the
forehead and then drawn laterally to the hairline. If
the client has perspiration on the forehead, the probe
is also touched behind the earlobe so the
thermometer can compensate for evaporative
cooling.
Temperature Scales
Sometimes a nurse needs to convert a body temperature reading in Celsius
(centigrade) to Fahrenheit, or vice versa. To convert from Fahrenheit to Celsius, deduct 32
from the Fahrenheit reading and then multiply by the fraction 5/9; that is:
C = (Fahrenheit temperature – 32) X 5/9
For example, when the Fahrenheit reading is 100:
C = (100 – 32) X 5/9 = (68) X 5/9 = 37.8
To convert from Celsius to Fahrenheit, multiply the Celsius reading by the fraction
9/5 and then add 32; that is:
F = (Celsius temperature X 9/5) + 32
For example, when the Celsius reading is 40:
F = (40 X 9/5) + 32 = (72 + 32) = 104

Lifespan Considerations
Infants
1. The body temperature of newborns is extremely labile, and newborns must be kept
warm and dry to prevent hypothermia.
2. Using the axillary site, you need to hold the infant’s arm against the chest.
3. The axillary route may not be as accurate as other routes for detecting fevers in
children.
4. The tympanic route is fast and convenient. Place the infant supine and stabilize the
head. Pull the pinna straight back and slightly downward. Remember that the pinna
is pulled upward for children over 3 years of age and adults, but downward for
children younger than age 3. Direct the probe tip anteriorly and insert far enough to
seal the canal. The tip will not touch the tympanic membrane.
5. Avoid the tympanic route in a child with active ear infections or tympanic
membrane drainage tubes.
6. The tympanic membrane route may be more accurate in determining temperature
in febrile infants.
7. When using a temporal artery thermometer, touching only the forehead or behind
the ear is needed.
8. The rectal route is least desirable in infants.

Children
1. Tympanic or temporal artery sites are preferred.
2. For the tympanic route, have the child held on an adult’s lap with the child’s head
held gently against the adult for support. Pull the pinna straight back and upward
for children over age 3.
3. Avoid the tympanic route in a child with active ear infections or tympanic
membrane drainage tubes.
4. The oral route may be used for children over age 3, but non-breakable, electronic
thermometers are recommended.
5. For a rectal temperature, place the child prone across your lap or in a side-lying
position with the knees flexed. Insert the thermometer 2.5 cm (1 in.) into the
rectum.

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Older Adults
1. Older adults’ temperatures tend to be lower than those of middle-aged adults.
2. Older adults’ temperatures are strongly influenced by both environmental and
internal temperature changes. Their thermoregulation control processes are not as
efficient as when they were younger, and they are at higher risk for both
hypothermia and hyperthermia.
3. Older adults can develop significant buildup of ear cerumen that may interfere with
tympanic thermometer readings.
4. Older adults are more likely to have hemorrhoids. Inspect the anus before taking a
rectal temperature.
5. Older adults’ temperatures may not be a valid indication of the seriousness of the
pathology of a disease. They may have pneumonia or a urinary tract infection and
have only a slight temperature elevation. Other symptoms, such as confusion and
restlessness, may be displayed and need follow-up to determine if there is an
underlying process.
PULSE
The pulse is a wave of blood created by contraction of the left ventricle of the heart.
Generally, the pulse wave represents the stroke volume output or the amount of blood that
enters the arteries with each ventricular contraction.
Compliance of the arteries is their ability to contract and expand. When a person’s
arteries lose their distensibility, as can happen with age, greater pressure is required to
pump the blood into the arteries.
Cardiac output is the volume of blood pumped into the arteries by the heart and
equals the result of the stroke volume (SV) times the heart rate (HR) per minute. For
example, 65 mL x 70 beats per minute = 4.55 L per minute. When an adult is resting, the
heart pumps about 5 liters of blood each minute.
In a healthy person, the pulse reflects the heartbeat; that is, the pulse rate is the
same as the rate of the ventricular contractions of the heart. However, in some types of
cardiovascular disease, the heartbeat and pulse rates can differ. For example, a client’s heart
may produce very weak or small pulse waves that are not detectable in a peripheral pulse
far from the heart. In these instances, the nurse should assess the heartbeat and the
peripheral pulse.
A peripheral pulse is a pulse located away from the heart, for example, in the foot or
wrist. The apical pulse, in contrast, is a central pulse; that is, it is located at the apex of the
heart. It is also referred to as the point of maximal impulse (PMI).

Factors Affecting the Pulse

The rate of the pulse is expressed in beats per minute (beats/min). A pulse rate
varies according to a number of factors. The nurse should consider each of the following
factors when assessing a client’s pulse:
1. Age. As age increases, the pulse rate gradually decreases overall.
2. Sex. After puberty, the average male’s pulse rate is slightly lower than the female’s.
3. Exercise. The pulse rate normally increases with activity. The rate of increase in the
professional athlete is often less than in the average person because of greater
cardiac size, strength, and efficiency.
4. Fever. The pulse rate increases in response to the lowered blood pressure that
results from peripheral vasodilation associated with elevated body temperature and
because of the increased metabolic rate.
5. Medications. Some medications decrease the pulse rate, and others increase it. For
example, cardiotonics (e.g., digitalis preparations) decrease the heart rate, whereas
epinephrine increases it.
6. Hypovolemia/dehydration. Loss of blood from the vascular system increases pulse
rate. In adults, the loss of circulating volume results in an adjustment of the heart
rate to increase blood pressure as the body compensates for the lost blood volume.
7. Stress. In response to stress, sympathetic nervous stimulation increases the overall
activity of the heart. Stress increases the rate as well as the force of the heartbeat.
Fear and anxiety as well as the perception of severe pain stimulate the sympathetic
system.
8. Position. When a person is sitting or standing, blood usually pools in dependent
vessels of the venous system. Pooling results in a transient decrease in the venous

HEALTH ASSESSMENT (NCM 101)

 blood return to the heart and a subsequent reduction in blood pressure and increase
in heart rate.
9. Pathology. Certain diseases such as some heart conditions or those that impair
oxygenation can alter the resting pulse rate.

Pulse Sites
The following are the nine pulse sites:
1. Temporal, where the temporal artery passes over the temporal bone of the head.
The site is superior (above) and lateral to (away from the midline of) the eye.
2. Carotid, at the side of the neck where the carotid artery runs between the trachea
and the sternocleidomastoid muscle.
SAFETY ALERT Never press both carotids at the same time because this can cause a
reflex drop in blood pressure or pulse rate.
3. Apical, at the apex of the heart. In an adult, this is located on the left side of the chest,
about 8 cm (3 in.) to the left of the sternum (breastbone) at the fifth intercostal
space (area between the ribs). In older adults, the apex may be further left if there
are conditions that have led to an enlarged heart. Before 4 years of age, the apex is
left of the midclavicular line (MCL); between 4 and 6 years, it is at the MCL. For a
child 7 to 9 years of age, the apical pulse is located at the fourth or fifth intercostal
space.
4. Brachial, at the inner aspect of the biceps muscle of the arm or medially in the
antecubital space.
5. Radial, where the radial artery runs along the radial bone, on the thumb side of the
inner aspect of the wrist.
6. Femoral, where the femoral artery passes alongside the inguinal ligament.
7. Popliteal, where the popliteal artery passes behind the knee.
8. Posterior tibial, on the medial surface of the ankle where the posterior tibial artery
passes behind the medial malleolus.
9. Pedal (dorsalis pedis), where the dorsalis pedis artery passes over the bones of the
foot, on an imaginary line drawn from the middle of the ankle to the space between
the big and second toes.
Figure 3.5 Pulse Sites

The radial site is most commonly used in adults. It is easily found in most people and
readily accessible. Some reasons for use of each site are given in Table 3.6.

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 Table 3.6 Reasons for Using Specific Pulse Site
Pulse Site Reasons for Use
Radial  Readily accessible
Temporal  Used when radial pulse is not accessible
Carotid  Used during cardiac arrest/shock in adults
 Used to determine circulation to the brain
Apical  Routinely used for infants and children up to 3 years of
age
 Used to determine discrepancies with radial pulse
 Used in conjunction with some medications
Brachial  Used to measure blood pressure
 Used during cardiac arrest for infants
Femoral  Used in cases of cardiac arrest/shock
 Used to determine circulation to a leg
Popliteal  Used to determine circulation to the lower leg
Posterior tibial  Used to determine circulation to the foot
Dorsalis pedis  Used to determine circulation to the foot
Assessing the Pulse
A pulse is commonly assessed by palpation (feeling) or auscultation (hearing). The
middle three fingertips are used for palpating all pulse sites except the apex of the heart. A
stethoscope is used for assessing apical pulses.
A pulse is normally palpated by applying moderate pressure with the three middle
fingers of the hand. The pads on the most distal aspects of the finger are the most sensitive
areas for detecting a pulse. With excessive pressure, one can obliterate a pulse, whereas
with too little pressure one may not be able to detect it.
Before the nurse assesses the resting pulse, the client should assume a comfortable
position. The nurse should also be aware of the following:
a) Any medication that could affect the heart rate.
b) Whether the client has been physically active. If so, wait 10 to 15 minutes until the
client has rested and the pulse has slowed to its usual rate.
c) Any baseline data about the normal heart rate for the client. For example, a
physically fit athlete may have a resting heart rate below 60 beats/min.
d) Whether the client should assume a particular position (e.g., sitting). In some clients,
the rate changes with the position because of changes in blood flow volume and
autonomic nervous system activity.

When assessing the pulse, the nurse collects the following data: the rate, rhythm,
volume, arterial wall elasticity, and presence or absence of bilateral equality.
a) An excessively fast heart rate (e.g., over 100 beats/min in an adult) is referred to as
tachycardia. A heart rate in an adult of less than 60 beats/min is called bradycardia.
If a client has either tachycardia or bradycardia, the apical pulse should be assessed.
b) The pulse rhythm is the pattern of the beats and the intervals between the beats.
Equal time elapses between beats of a normal pulse. A pulse with an irregular
rhythm is referred to as a dysrhythmia or arrhythmia. It may consist of random,
irregular beats or a predictable pattern of irregular beats (documented as “regularly
irregular”). When a dysrhythmia is detected, the apical pulse should be assessed. An
electrocardiogram (ECG) is necessary to define the dysrhythmia further.
c) Pulse volume, also called the pulse strength or amplitude, refers to the force of
blood with each beat. Usually, the pulse volume is the same with each beat. It can
range from absent to bounding. A normal pulse can be felt with moderate pressure
of the fingers and can be obliterated with greater pressure. A forceful or full blood
volume that is obliterated only with difficulty is called a full or bounding pulse. A
pulse that is readily obliterated with pressure from the fingers is referred to as
weak, feeble, or thready.
d) The elasticity of the arterial wall reflects its expansibility or its deformities. A
healthy, normal artery feels straight, smooth, soft, and pliable. Older adults often
have inelastic arteries that feel twisted (tortuous) and irregular on palpation.
e) When assessing a peripheral pulse to determine the adequacy of blood flow to a
particular area of the body (perfusion), the nurse should also assess the
corresponding pulse on the other side of the body. The second assessment gives the

HEALTH ASSESSMENT (NCM 101)

 nurse data with which to compare the pulses. For example, when assessing the
blood flow to the right foot, the nurse assesses the right dorsalis pedis pulse and
then the left dorsalis pedis pulse. If the client’s right and left pulses are the same
volume and elasticity, the client’s dorsalis pedis pulses are bilaterally equal. The
pulse rate does not need to be counted when assessing for perfusion and equality.
When a peripheral pulse is located, it indicates that pulses more proximal to that
location will also be present. For example, if the dorsalis pedis, the most distal pulse
of the lower extremity, cannot be felt, the nurse next palpates for the posterior tibial
pulse. If it is not felt, the popliteal pulse must be assessed. If the popliteal pulse is
found, it is not necessary to assess the femoral pulse since it must also be present in
order for the more distal pulse to exist.

Apical Pulse Assessment

Assessment of the apical pulse is indicated for clients whose peripheral pulse is
irregular or unavailable as well as for clients with known cardiovascular, pulmonary, and
renal diseases. It is commonly assessed prior to administering medications that affect heart
rate. The apical site is also used to assess the pulse for newborns, infants, and children up to
2 to 3 years old.

Apical-Radial Pulse Assessment

An apical-radial pulse may need to be assessed for clients with certain
cardiovascular disorders. Normally, the apical and radial rates are identical. An apical pulse
rate greater than a radial pulse rate can indicate that the thrust of the blood from the heart
is too weak for the wave to be felt at the peripheral pulse site, or it can indicate that
vascular disease is preventing impulses from being transmitted.
Any discrepancy between the two pulse rates is called a pulse deficit and needs to
be reported promptly. In no instance is the radial pulse greater than the apical pulse. An
apical-radial pulse can be taken by two nurses or one nurse, although the two-nurse
technique may be more accurate.

Lifespan Considerations
Infants
1. Use the apical pulse for the heart rate of newborns, infants, and children 2 to 3 years
old to establish baseline data for subsequent evaluation, to determine whether the
cardiac rate is within normal range, and to determine if the rhythm is regular.
2. Place a baby in a supine position, and offer a pacifier if the baby is crying or restless.
Crying and physical activity will increase the pulse rate. For this reason, take the
apical pulse rate of infants and small children before assessing body temperatures.
3. Locate the apical pulse in the fourth intercostal space, lateral to the midclavicular
line during infancy.
4. Brachial, popliteal, and femoral pulses may be palpated. Due to a normally low
blood pressure and rapid heart rate, infants’ other distal pulses may be hard to feel.
5. Newborn infants may have heart murmurs that are not pathologic, but reflect
functional incomplete closure of fetal heart structures (ductus arteriosus or
foramen ovale).

Children
1. To take a peripheral pulse, position the child comfortably in the adult’s arms, or
have the adult remain close by. This may decrease anxiety and yield more accurate
results.
2. To assess the apical pulse, assist a young child to a comfortable supine or sitting
position.
3. Demonstrate the procedure to the child using a stuffed animal or doll, and allow the
child to handle the stethoscope before beginning the procedure. This will decrease
anxiety and promote cooperation.
4. The apex of the heart is normally located in the fourth intercostal space in young
children; fifth intercostal space in children 7 years of age and over.
5. Locate the apical impulse along the fourth intercostal space, between the MCL and
the anterior axillary line.
6. Count the pulse prior to other uncomfortable procedures so that the rate is not
artificially elevated by the discomfort.

HEALTH ASSESSMENT (NCM 101)

Older Adults
1. If the client has severe hand or arm tremors, the radial pulse may be difficult to
count.
2. Cardiac changes in older adults, such as decrease in cardiac output, sclerotic
changes to heart valves, and dysrhythmias, often indicate that obtaining an apical
pulse will be more accurate.
3. Older adults often have decreased peripheral circulation, so pedal pulses should also
be checked for regularity, volume, and symmetry.
4. The pulse returns to baseline after exercise more slowly than with other age groups.

RESPIRATION
Respiration is the act of breathing. Inhalation or inspiration refers to the intake of
air into the lungs. Exhalation or expiration refers to breathing out or the movement of gases
from the lungs to the atmosphere. Ventilation is also used to refer to the movement of air in
and out of the lungs.
There are basically two types of breathing: costal (thoracic) breathing and
diaphragmatic (abdominal) breathing. Costal breathing involves the external intercostal
muscles and other accessory muscles, such as the sternocleidomastoid muscles. It can be
observed by the movement of the chest upward and outward. By contrast, diaphragmatic
breathing involves the contraction and relaxation of the diaphragm, and it is observed by
the movement of the abdomen, which occurs as a result of the diaphragm’s contraction and
downward movement.

Mechanics and Regulation of Breathing

During inhalation, the following processes normally occur:
a) The diaphragm contracts (flattens), the ribs move upward and outward, and the
sternum moves outward, thus enlarging the thorax and permitting the lungs to
expand.
b) During exhalation, the diaphragm relaxes, the ribs move downward and inward, and
the sternum moves inward, thus decreasing the size of the thorax as the lungs are
compressed.
Normal breathing is automatic and effortless. A normal adult inspiration lasts 1 to
1.5 seconds, and an expiration lasts 2 to 3 seconds. Respiration is controlled by (a)
respiratory centers in the medulla oblongata and the pons of the brain and (b)
chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic
bodies.

Considerations in Assessing Respirations

Before assessing a client’s respirations, a nurse should be aware of the following:
1. The client’s normal breathing pattern
2. The influence of the client’s health problems on respirations
3. Any medications or therapies that might affect respirations
4. The relationship of the client’s respirations to cardiovascular function.

The rate, depth, rhythm, quality, and effectiveness of respirations should be

assessed. The respiratory rate is normally described in breaths per minute. Breathing that is
normal in rate and depth is called eupnea. Abnormally slow respirations are referred to as
bradypnea, and abnormally fast respirations are called tachypnea or polypnea. Apnea is the
absence of breathing.

Factors Affecting Respirations

Respiratory rate increases due to the following:
1. exercise (increases metabolism)
2. stress (readies the body for “fight or flight”)
3. increased environmental temperature
4. lowered oxygen concentration at increased altitudes.

Respiratory rate decreases due to the following:

1. decreased environmental temperature
2. certain medications (e.g., narcotics)

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 3. increased intracranial pressure.

CLINICAL ALERT An adult sleeping client’s respirations can fall to fewer than 10 shallow
breaths per minute. Use other vital signs to validate the client’s condition.

The depth of a person’s respirations can be established by watching the movement

of the chest. Respiratory depth is generally described as normal, deep, or shallow. Deep
respirations are those in which a large volume of air is inhaled and exhaled, inflating most
of the lungs. Shallow respirations involve the exchange of a small volume of air and often
the minimal use of lung tissue.
Hyperventilation refers to very deep, rapid respirations; hypoventilation refers to
very shallow respirations.
Respiratory rhythm refers to the regularity of the expirations and the inspirations.
Normally, respirations are evenly spaced. Respiratory rhythm can be described as regular
or irregular.
Respiratory quality or character refers to those aspects of breathing that are
different from normal, effortless breathing. Two of these aspects are the amount of effort a
client must exert to breathe and the sound of breathing. Usually, breathing does not require
noticeable effort. Sometimes, however, clients can breathe only with substantial effort—this
is referred to as labored breathing.
The sound of breathing is also significant. Normal breathing is silent, but a number
of abnormal sounds such as a wheeze are obvious to the nurse’s ear. Many sounds occur as
a result of the presence of fluid in the lungs and are most clearly heard with a stethoscope.

Breathing Patterns
Rate
 Tachypnea—quick, shallow breaths
 Bradypnea—abnormally slow breathing
 Apnea—cessation of breathing
Volume
 Hyperventilation—overexpansion of the lungs characterized by rapid and deep
breaths
 Hypoventilation—underexpansion of the lungs, characterized by shallow
respirations
Rhythm
 Cheyne-Stokes breathing—rhythmic waxing and waning of respirations, from very
deep to very shallow breathing and temporary apnea
Ease or Effort
 Dyspnea—difficult and labored breathing during which the individual has a
persistent, unsatisfied need for air and feels distressed
 Orthopnea—ability to breathe only in upright sitting or standing positions

Breath Sounds
Audible without Amplification
 Stridor—a shrill, harsh sound heard during inspiration with laryngeal obstruction
 Stertor—snoring or sonorous respiration, usually due to a partial obstruction of the
upper airway
 Wheeze—continuous, high-pitched musical squeak or whistling sound occurring on
expiration and sometimes on inspiration when air moves through a narrowed or
partially obstructed airway
 Bubbling—gurgling sounds heard as air passes through moist secretions in the
respiratory tract
Chest Movements
 Intercostal retraction—indrawing between the ribs
 Substernal retraction—indrawing beneath the breastbone
 Suprasternal retraction—indrawing above the clavicles
Secretions and Coughing
 Hemoptysis—the presence of blood in the sputum
 Productive cough—a cough accompanied by expectorated secretions
 Nonproductive cough—a dry, harsh cough without secretions

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 The effectiveness of respirations is measured in part by the uptake of oxygen from
the air into the blood and the release of carbon dioxide from the blood into expired air. The
amount of hemoglobin in arterial blood that is saturated with oxygen can be measured
indirectly through pulse oximetry. A pulse oximeter provides a digital readout of both the
client’s pulse rate and the oxygen saturation.

Lifespan Considerations
Infants
1. An infant or child who is crying will have an abnormal respiratory rate and rhythm
and needs to be quieted before respirations can be accurately assessed.
2. Infants and young children use their diaphragms for inhalation and exhalation. If
necessary, place your hand gently on the infant’s abdomen to feel the rapid rise and
fall during respirations.
3. Most newborns are complete nose breathers, and nasal obstruction can be life
threatening.
4. Some newborns display “periodic breathing” in which they pause for a few seconds
between respirations. This condition can be normal, but parents should be alert to
prolonged or frequent pauses (apnea) that require medical attention.
5. Compared to adults, infants have fewer alveoli and their airways have a smaller
diameter. As a result, infants’ respiratory rate and effort of breathing will increase
with respiratory infections.

Children
1. Because young children are diaphragmatic breathers, observe the rise and fall of the
abdomen. If necessary, place your hand gently on the abdomen to feel the rapid rise
and fall during respirations.
2. Count respirations prior to other uncomfortable procedures so that the respiratory
rate is not artificially elevated by the discomfort.

Older Adults
1. Ask the client to remain quiet, or count respirations after taking the pulse.
2. Older adults experience anatomic and physiological changes that cause the
respiratory system to be less efficient. Any changes in rate or type of breathing
should be reported immediately.

BLOOD PRESSURE
Arterial blood pressure is a measure of the pressure exerted by the blood as it flows
through the arteries. Because the blood moves in waves, there are two blood pressure
measures:
1. systolic pressure is the pressure of the blood as a result of contraction of the
ventricles, that is, the pressure of the height of the blood wave.
2. diastolic pressure is the pressure when the ventricles are at rest. Diastolic pressure,
then, is the lower pressure, present at all times within the arteries.
The difference between the diastolic and the systolic pressures is called the pulse
pressure. A normal pulse pressure is about 40 mmHg but can be as high as 100 mmHg
during exercise.
A consistently elevated pulse pressure occurs in arteriosclerosis. A low pulse
pressure (e.g., less than 25 mmHg) occurs in conditions such as severe heart failure.
Blood pressure is measured in millimeters of mercury (mmHg) and recorded as a
fraction: systolic pressure over the diastolic pressure. A typical blood pressure for a healthy
adult is 120/80 mmHg (pulse pressure of 40).

Determinants of Blood Pressure

Arterial blood pressure is the result of several factors:
1. Pumping Action of the Heart
When the pumping action of the heart is weak, less blood is pumped into arteries
(lower cardiac output), and the blood pressure decreases. When the heart’s
pumping action is strong and the volume of blood pumped into the circulation
increases (higher cardiac output), the blood pressure increases.
2. Peripheral Vascular Resistance

HEALTH ASSESSMENT (NCM 101)

 Peripheral vascular resistance is the resistance supplied by the blood vessels
through which the blood flows which can increase blood pressure. The diastolic
pressure especially is affected. Some factors that create resistance in the arterial
system are the capacity of the arterioles and capillaries, the compliance of the
arteries, and the viscosity of the blood. The internal diameter or capacity of the
arterioles and the capillaries determines in great part the peripheral resistance to
the blood in the body. The smaller the space within a vessel, the greater the
resistance. Normally, the arterioles are in a state of partial constriction. Increased
vasoconstriction, such as occurs with smoking, raises the blood pressure, whereas
decreased vasoconstriction lowers the blood pressure. If the elastic and muscular
tissues of the arteries are replaced with fibrous tissue, the arteries lose much of
their ability to constrict and dilate. This condition, most common in middle aged and
older adults, is known as arteriosclerosis.
3. Blood Volume
When the blood volume decreases (for example, as a result of a hemorrhage or
dehydration), the blood pressure decreases because of decreased fluid in the
arteries. Conversely, when the volume increases (for example, as a result of a rapid
intravenous infusion), the blood pressure increases because of the greater fluid
volume within the circulatory system.
4. Blood Viscosity
Blood pressure is higher when the blood is highly viscous (thick), that is, when the
proportion of red blood cells to the blood plasma is high. This proportion is referred
to as the hematocrit. The viscosity increases markedly when the hematocrit is more
than 60% to 65%.

Factors Affecting Blood Pressure

Among the factors influencing blood pressure are:
1. Age. Newborns have a mean systolic pressure of about 75 mmHg. The pressure rises
with age, reaching a peak at the onset of puberty, and then tends to decline
somewhat. In older adults, elasticity of the arteries is decreased—the arteries are
more rigid and less yielding to the pressure of the blood. This produces an elevated
systolic pressure. Because the walls no longer retract as flexibly with decreased
pressure, the diastolic pressure may also be high.
2. Exercise. Physical activity increases the cardiac output and hence the blood
pressure. For reliable assessment of resting blood pressure, wait 20 to 30 minutes
following exercise.
3. Stress. Stimulation of the sympathetic nervous system increases cardiac output and
vasoconstriction of the arterioles, thus increasing the blood pressure reading;
however, severe pain can decrease blood pressure greatly by inhibiting the
vasomotor center and producing vasodilatation.
4. Race. African Americans over 35 years tend to have higher blood pressures than
European Americans of the same age (Ong, Cheung, Man, Lau, & Lam, 2007).
5. Sex. After puberty, females usually have lower blood pressures than males of the
same age; this difference is thought to be due to hormonal variations. After
menopause, women generally have higher blood pressures than before.
6. Medications. Many medications, including caffeine, may increase or decrease the
blood pressure.
7. Obesity. Both childhood and adult obesity predispose to hypertension.
8. Diurnal variations. Pressure is usually lowest early in the morning, when the
metabolic rate is lowest, then rises throughout the day and peaks in the late
afternoon or early evening.
9. Medical conditions. Any condition affecting the cardiac output, blood volume, blood
viscosity, and/or compliance of the arteries has a direct effect on the blood pressure.
10. Temperature. Because of increased metabolic rate, fever can increase blood
pressure. However, external heat causes vasodilation and decreased blood pressure.
Cold causes vasoconstriction and elevates blood pressure.

Hypertension
A blood pressure that is persistently above normal is called hypertension. A single
elevated blood pressure reading indicates the need for reassessment. Hypertension cannot
be diagnosed unless an elevated blood pressure is found when measured twice at different

HEALTH ASSESSMENT (NCM 101)

times. It is usually asymptomatic and is often a contributing factor to myocardial infarctions
(heart attacks).
An elevated blood pressure of unknown cause is called primary hypertension. An
elevated blood pressure of known cause is called secondary hypertension.
Individuals with diastolic blood pressures of 80 to 89 mmHg or systolic blood
pressures of 120 to 139 mmHg should be considered prehypertensive and, without
intervention, may develop cardiac disease. Hypertension is when either the diastolic blood
pressure is 90 mmHg or higher or when the systolic blood pressure is higher than 140
mmHg. The stage of hypertension is determined by the higher of the two values. For
example, if either of the systolic or diastolic values falls in the stage 2 range, stage 2
hypertension is assigned.

Hypotension
Hypotension is a blood pressure that is below normal, that is, a systolic reading
consistently between 85 and 110 mmHg in an adult whose normal pressure is higher than
this.

Orthostatic Hypotension
Orthostatic hypotension is a blood pressure that falls when the client sits or stands.
It is usually the result of peripheral vasodilation in which blood leaves the central body
organs, especially the brain, and moves to the periphery, often causing the person to feel
faint.
When assessing for orthostatic hypotension:
1. Place the client in a supine position for 10 minutes.
2. Record the client’s pulse and blood pressure.
3. Assist the client to slowly sit or stand. Support the client in case of faintness.
4. Immediately recheck the pulse and blood pressure in the same sites as previously.
5. Repeat the pulse and blood pressure after 3 minutes.
6. Record the results. A rise in pulse of 15 to 30 beats per minute or a drop in blood
pressure of 20 mmHg systolic or 10 mmHg diastolic indicates orthostatic
hypotension.

Assessing Blood Pressure

Blood pressure is measured with a blood pressure cuff, a sphygmomanometer, and a
stethoscope. The blood pressure cuff consists of a rubber bag that can be inflated with air
called the bladder. It is covered with cloth and has two tubes attached to it. One tube
connects to a rubber bulb that inflates the bladder. A small valve on the side of this bulb
traps and releases the air in the bladder. The other tube is attached to a
sphygmomanometer. The sphygmomanometer indicates the pressure of the air within the
bladder.

Figure 3.6 Parts of blood pressure cuff

HEALTH ASSESSMENT (NCM 101)

 There are two types of sphygmomanometers: aneroid and digital. The aneroid
sphygmomanometer has a calibrated dial with a needle that points to the calibrations. Many
agencies use digital (electronic) sphygmomanometers, which eliminate the need to listen
for the sounds of the client’s systolic and diastolic blood pressures through a stethoscope.
Electronic blood pressure devices should be calibrated periodically to check accuracy. All
health care facilities should have manual blood pressure equipment available as backup.

Figure 3.7 Types of Sphygmomanometers

Blood pressure cuffs come in various sizes because the bladder must be the correct
width and length for the client’s arm. If the bladder is too narrow, the blood pressure
reading will be erroneously elevated; if it is too wide, the reading will be erroneously low.

Figure 3.8 Different sizes of BP cuff

The width should be 40% of the circumference, or 20% wider than the diameter of
the midpoint, of the limb on which it is used. The arm circumference, not the age of the
client, should always be used to determine bladder size.
The nurse can determine whether the width of a blood pressure cuff is appropriate:
Lay the cuff lengthwise at the midpoint of the upper arm, and hold the outermost side of the
bladder edge laterally on the arm. With the other hand, wrap the width of the cuff around
the arm, and ensure that the width is 40% of the arm circumference.

Figure 3.9 Determining 40% of BP Cuff of the arm circumference or 20% wider than the
diameter of the midpoint of the limb.

HEALTH ASSESSMENT (NCM 101)

 The length of the bladder also affects the accuracy of measurement. The bladder
should be sufficiently long to cover at least two-thirds of the limb’s circumference. Blood
pressure cuffs are made of non-distensible material so that an even pressure is exerted
around the limb. Most cuffs are held in place by hooks, snaps, or Velcro. Others have a cloth
bandage that is long enough to encircle the limb several times; this type is closed by tucking
the end of the bandage into one of the bandage folds.

Blood Pressure Assessment Sites

The blood pressure is usually assessed in the client’s upper arm using the brachial
artery and a standard stethoscope. Assessing the blood pressure on a client’s thigh is
indicated in these situations:
1. The blood pressure cannot be measured on either arm (e.g., because of burns or
other trauma).
2. The blood pressure in one thigh is to be compared with the blood pressure in the
other thigh.

Blood pressure is not measured on a particular client’s limb in the following situations:
1. The shoulder, arm, or hand (or the hip, knee, or ankle) is injured or diseased.
2. A cast or bulky bandage is on any part of the limb.
3. The client has had surgical removal of breast or axillary (or inguinal) lymph nodes
on that side.
4. The client has an intravenous infusion or blood transfusion in that limb.
5. The client has an arteriovenous fistula (e.g., for renal dialysis) in that limb.

Methods in Assessing Blood Pressure

Blood pressure can be assessed:
1. Direct (invasive monitoring) measurement involves the insertion of a catheter into
the brachial, radial, or femoral artery. Arterial pressure is represented as wavelike
forms displayed on a monitor. With correct placement, this pressure reading is
highly accurate.
2. Indirect methods (noninvasive monitoring) of measuring blood pressure:
a) Auscultatory method is most commonly used in all healthcare settings.
External pressure is applied to a superficial artery and the nurse reads the
pressure from the sphygmomanometer while listening with a stethoscope.
When taking a blood pressure using a stethoscope, the nurse heard a series
of sounds called Korotkoff’s sounds. The systolic pressure is the point where
the first tapping sound is heard. In adults, the diastolic pressure is the point
where the sounds become inaudible.
b) Palpatory method is sometimes used when Korotkoff’s sounds cannot be
heard and electronic equipment to amplify the sounds is not available. In
the palpatory method of blood pressure determination, instead of listening
for the blood flow sounds, the nurse uses light to moderate pressure to
palpate the pulsations of the artery as the pressure in the cuff is released.
The pressure is read from the sphygmomanometer when the first pulsation
is felt. A single whiplike vibration, felt in addition to the pulsations, identifies
the point at which the pressure in the cuff nears the diastolic pressure. This
vibration is no longer felt when the cuff pressure is below the diastolic
pressure.

Common Errors in Assessing Blood Pressure

Some reasons for erroneous blood pressure readings and their effect are given in
table below.
Table 3.7 Errors in blood pressure readings and their effect
ERROR EFFECT
Bladder cuff too narrow Erroneously high

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 Bladder cuff too wide Erroneously low
Arm unsupported Erroneously high
Insufficient rest before the assessment Erroneously high
Repeating assessment too quickly Erroneously high systolic or low diastolic
readings
Cuff wrapped too loosely or unevenly Erroneously high
Deflating cuff too quickly Erroneously low systolic and high diastolic
readings
Deflating cuff too slowly Erroneously high diastolic reading
Failure to use the same arm consistently Inconsistent measurements
Arm above level of the heart Erroneously low
Assessing immediately after a meal or while Erroneously high
client smokes or has pain
Failure to identify auscultatory gap Erroneously low systolic pressure and
erroneously low diastolic pressure

Life Considerations
Infants
1. Use a pediatric stethoscope with a small diaphragm.
2. The lower edge of the blood pressure cuff can be closer to the antecubital space of
an infant.
3. Use the palpation method if auscultation with a stethoscope or DUS is unsuccessful.
4. Arm and thigh pressures are equivalent in children under 1 year of age.
5. The systolic blood pressure of a newborn ranges between 50 and 80 mmHg; the
diastolic between 25 and 55 mmHg.

Children
1. Blood pressure should be measured in all children over 3 years of age and in
children less than 3 years of age with certain medical conditions (e.g., congenital
heart disease, renal malformation, medications that affect blood pressure).
2. Explain each step of the process and what it will feel like. Demonstrate on a doll.
3. Use the palpation technique for children under 3 years old.
4. Cuff bladder width should be 40% and length should be 80% to 100% of the arm
circumference.
5. Take the blood pressure prior to other uncomfortable procedures so that the blood
pressure is not artificially elevated by the discomfort.
6. In children, the thigh pressure is about 10 mmHg higher than the arm.
7. One quick way to determine the normal systolic blood pressure of a child is to use
the following formula: Normal systolic BP = 80 + (2 x child’s age in years)

Older Adults
1. Skin may be very fragile. Do not allow cuff pressure to remain high any longer than
necessary.
2. Determine if the client is taking antihypertensives and, if so, when the last dose was
taken.
3. Medications that cause vasodilation (antihypertensive medications) along with the
loss of baroreceptor efficiency in older clients place them at increased risk for
having orthostatic hypotension. Measuring blood pressure while the client is in the
lying, sitting, and standing positions— and noting any changes—can determine this.
4. If the client has arm contractures, assess the blood pressure by palpation, with the
arm in a relaxed position. If this is not possible, take a thigh blood pressure.

OXYGEN SATURATION
A pulse oximeter is a noninvasive device that estimates a client’s arterial blood
oxygen saturation (SaO2) by means of a sensor attached to the client’s finger, toe, nose,
earlobe, or forehead (or around the hand or foot of a neonate).
The oxygen saturation value is the percent of all hemoglobin binding sites that are
occupied by oxygen. The pulse oximeter can detect hypoxemia (low oxygen saturation)
before clinical signs and symptoms, such as a dusky color to skin and nail beds develop.
Normal oxygen saturation is 95% to 100%, and below 70% is life threatening.

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Factors Affecting Oxygen Saturation Readings
Among the factors influencing oxygen saturation readings are hemoglobin levels,
circulation, activity, and exposure to carbon monoxide.
1. Hemoglobin. If the hemoglobin is fully saturated with oxygen, the SpO2 will appear
normal even if the total hemoglobin level is low. Thus, the client could be severely
anemic and have inadequate oxygen to supply the tissues but the pulse oximeter
would return a normal value.
2. Circulation. The oximeter will not return an accurate reading if the area under the
sensor has impaired circulation.
3. Activity. Shivering or excessive movement of the sensor site may interfere with
accurate readings.
4. Carbon monoxide poisoning. Pulse oximeters cannot discriminate between
hemoglobin saturated with carbon monoxide versus oxygen. In this case, other
measures of oxygenation are needed.

Figure 3.10 Pulse Oximeter

Lifespan Considerations
Infants
1. If an appropriate-sized finger or toe sensor is not available, consider using an
earlobe or forehead sensor.
2. The high and low SpO2 levels are generally preset at 95% and 80%, respectively, for
neonates.
3. The high and low pulse rate alarms are usually preset at 200 and 100, respectively,
for neonates.
4. The oximeter may need to be taped, wrapped with an elastic bandage, or covered by
a stocking to keep it in place.

Children
1. Instruct the child that the sensor does not hurt. Disconnect the probe whenever
possible to allow for movement.

Older Adults
1. Use of vasoconstrictive medications, poor circulation, or thickened nails may make
finger or toe sensors inaccurate.

SELF-STUDY GUIDE QUESTIONS

1. Define the clinical level of consciousness.
2. Discuss the Glasgow coma scale.
3. Compute your BMI and interpret based on BMI Chart.
4. Enumerate the factors affecting temperature, pulse rate, respiration, blood pressure,
and oxygen saturation.
5. What are the different types of fever?
6. Make a simple illustration on the different pulse location.
7. Discuss on how to assess orthostatic hypotension.

MENTAL STATUS
According to Bickley & Szilagyi (2017), the assessment of mental status is
challenging and complex. Changes in mental status warrant careful evaluation for
underlying pathologic and pharmacologic causes. The patient’s personality,
psychodynamics, family and life experiences, and cultural background all come into play.
Amplify your findings from the history and physical examination.
As clinicians, we are uniquely poised to detect clues to mental illness and harmful
behavior through empathic listening and close observation.
As you interact with the patient, you will quickly observe the patient’s level of
alertness and orientation, and mood, attention, and memory. While the history unfolds, you

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will learn about the patient’s insight and judgment, as well as any recurring or unusual
thoughts or perceptions.

Mental Status Examination

The Mental Status Examination consists of five components:
1. Appearance and behavior
2. Speech and language
3. Mood
4. Thoughts and perceptions
5. Cognitive function
Cognitive function includes:
a) Orientation
b) Attention
c) Memory
d) Attention
e) Higher cognitive
Higher cognitive functions such as:
a) Information and vocabulary
b) Calculations
c) Abstract thinking
d) Constructional ability

Prepare the patient for formal testing and explain your rationale. The format that
follows should help structure your observations, but is not intended as a step-by-step guide.
Be flexible, but thorough. In some situations, however, sequence is important. If the
patient’s consciousness, attention, comprehension of words, and ability to speak are
impaired, assess these deficits promptly. If the patient cannot give a reliable history, testing
most of the other mental functions will be difficult and merits an evaluation for acute
causes.

Appearance and Behavior

Integrate the observations you have made throughout the history and physical
examination, including the following:
1. Level of Consciousness.
a) Is the patient awake and alert?
b) Does the patient understand your questions and respond appropriately and
reasonably quickly, or tend to lose track of the topic, grow silent, or even fall
asleep?
c) If the patient does not respond to your questions, escalate the stimulus in
steps:
1. Speak to the patient by name and in a loud voice.
2. Shake the patient gently, like wakening a sleeper.
If there is no response to these stimuli, promptly assess the patient
for stupor or coma—severe reductions in level of consciousness.
2. Posture and Motor Behavior.
a) Does the patient sit or lie quietly or prefer to walk around?
b) Observe the patient’s posture and ability to relax.
c) Note the pace, range, and type of movement.
d) Are movements voluntary and spontaneous?
e) Are any limbs immobile?
f) Are posture and motor activity affected by topics under discussion, type of
activity, or who is in the room?
3. Dress, Grooming, and Personal Hygiene.
a) How is the patient dressed?
b) Is the clothing clean and presentable?
c) Is it appropriate for the patient’s age and social group?
d) Note the grooming of the patient’s hair, nails, teeth, skin, and, if present,
beard.
e) How do the grooming and hygiene compare with peers of comparable age,
lifestyle, and socioeconomic group?
f) Compare one side of the body with the other.

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 4. Facial Expression.
a) Observe the face both at rest and during conversation.
b) Watch for changes in expression.
c) Are they appropriate for the topics being discussed?
d) Or is the face relatively immobile throughout?
5. Manner, Affect, and Relationship to People and Things.
a) Assess the patient’s affect, or external expression of the inner emotional
state.
b) Is it appropriate to the topics being discussed?
c) Or is the affect labile, blunted, or flat?
d) Does it seem exaggerated at certain points? If so, how?
e) Observe the patient’s openness, approachability, and reactions to others and
the surroundings.
f) Does the patient hear or see things not present, or converse with someone
who is not there?

Speech and Language

Throughout the interview, note the following characteristics of the patient’s speech.
1. Quantity
a) Is the patient talkative or unusually silent?
b) Are comments spontaneous, or limited to direct questions?
2. Rate
a) Is speech fast or slow?
3. Volume
a) Is speech loud or soft?
4. Articulation of Words
a) Are the words clear and distinct?
b) Does the speech have a nasal quality?
5. Fluency
Fluency reflects the rate, flow, and melody of speech and the content and use of
words. Watch for abnormalities of spontaneous speech such as:
a) Hesitancies and gaps in the flow and rhythm of words
b) Disturbed inflections, such as a monotone
c) Circumlocutions, in which phrases or sentences are substituted for a word
the person cannot think of, such as “what you write with” for “pen”
d) Paraphasias, in which words are malformed (“I write with a den”), wrong (“I
write with a bar”), or invented (“I write with a dar”).

If the patient’s speech lacks meaning or fluency, proceed with further testing. A
person who can write a correct sentence does not have aphasia.

Testing for Aphasia

1. Word Comprehension
a) Ask the patient to follow a one-stage command, such as “Point to
your nose.”
b) Try a two-stage command: “Point to your mouth, then your knee.”
2. Repetition
a) Ask the patient to repeat a phrase of one-syllable words (the most
difficult repetition task): “No ifs, ands, or buts.”
3. Naming
a) Ask the patient to name the parts of a watch.
4. Reading Comprehension
1. Ask the patient to read a paragraph aloud. Writing Ask the patient to
write a sentence.

Mood
Ask the patient to describe his or her mood, including usual mood level and
fluctuations related to life events. “How did you feel about that?” for example, or, more
generally, “How is your overall mood?” The reports from family and friends may be of value.

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 Has the mood been intense and unchanging, or labile? How long has it lasted? Is it
appropriate to the patient’s situation? If depression, have there been episodes of an
elevated mood, suggesting a bipolar disorder?
If you suspect depression, assess its severity and any risk of suicide. Ask the
following questions:
1. Do you feel discouraged or depressed?
2. How low do you feel?
3. What do you see for yourself in the future?
4. Do you ever feel that life isn’t worth living? Or that you want to be dead?
5. Have you ever thought of killing yourself?
6. How did (do) you think you would do it? Do you have a plan?
7. What do you think would happen after you were dead?

It is your responsibility to ask directly about suicidal thoughts. This may be the only
way to uncover suicidal ideation and plans that launch immediate intervention and
treatment.

Thought and Perceptions

1. Thought Processes
a) Assess the logic, relevance, organization, and coherence of the patient’s
thought processes throughout the interview.
b) Does speech progress logically toward a goal?
c) Listen for patterns of speech that suggest disorders of thought processes.
Variations and Abnormalities in Thought Processes
a) Circumstantiality. The mildest thought disorder, consisting of speech with
unnecessary detail, indirection, and delay in reaching the point. Some topics
may have a meaningful connection. Many people without mental disorders
have circumstantial speech.
b) Derailment (loosening of associations). “Tangential” speech with shifting
topics that are loosely connected or unrelated. The patient is unaware of the
lack of association.
c) Flight of Ideas. An almost continuous flow of accelerated speech with abrupt
changes from one topic to the next. Changes are based on understandable
associations, plays on words, or distracting stimuli, but ideas are not well
connected.
d) Neologisms. Invented or distorted words, or words with new and highly
idiosyncratic meanings.
e) Incoherence. Speech that is incomprehensible and illogical, with lack of
meaningful connections, abrupt changes in topic, or disordered grammar or
word use. Flight of ideas, when severe, may produce incoherence.
f) Blocking. Sudden interruption of speech in midsentence or before the idea is
completed, attributed to “losing the thought.” Blocking occurs in normal
people.
g) Confabulation. Fabrication of facts or events in response to questions, to fill
in the gaps from impaired memory.
h) Perseveration. Persistent repetition of words or ideas.
i) Echolalia. Repetition of the words and phrases of others.
j) Clanging. Speech with choice of words based on sound, rather than meaning,
as in rhyming and punning. For example, “Look at my eyes and nose, wise
eyes and rosy nose. Two to one, the ayes have it!”
2. Thought Content
To assess thought content, follow the patient’s leads and cues rather than
asking direct questions. For example, “You mentioned that a neighbor caused your
entire illness. Can you tell me more about that?” Or, in another situation, “What do
you think about at times like these?”
For more focused inquiries, be tactful and accepting. “When people are upset
like this, sometimes they can’t keep certain thoughts out of their minds,” or “ . . .
things seem unreal. Have you experienced anything like this?”
Abnormalities of Thought Content
a) Compulsions. Repetitive behaviors that the person feels driven to perform in
response to an obsession, aimed at preventing or reducing anxiety or a

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 dreaded event or situation; these behaviors are excessive and unrealistically
connected to the provoking stimulus.
b) Obsessions. Recurrent persistent thoughts, images, or urges experienced as
intrusive and unwanted that the person tries to ignore, suppress, or
neutralize with other thoughts or actions (for example, performing a
compulsive behavior)
c) Phobias. Persistent irrational fears, accompanied by a compelling desire to
avoid the provoking stimulus.
d) Anxieties. Apprehensive anticipation of future danger or misfortune
accompanied by feelings of worry, distress, and/or somatic symptoms of
tension
e) Feelings of Unreality. A sense that the environment is strange, unreal, or
remote.
f) Feelings of Depersonalization. A sense that one’s self or identity is different,
changed, unreal; lost; or detached from one’s mind or body.
g) Delusions. False fixed personal beliefs that are not amenable to change in
light of conflicting evidence
Types of delusions include:
a) Persecutory
b) Grandiose
c) Jealous
d) Erotomanic—the belief than another person is in love with the
individual
e) Somatic—involves bodily functions or sensations.
f) Unspecified—includes delusions of reference without a prominent
persecutory or grandiose component, or the belief that external
events, objects, or people have a particular and unusual personal
significance (for example, commands from the radio or television).
3. Perceptions
Pursue false perceptions. For example, “When you heard the voice speaking
to you, what did it say? How did it make you feel?” Or, “After you’ve been drinking a
lot, do you ever see things that aren’t really there?” Or, “Sometimes after major
surgery like yours, people hear peculiar or frightening things. Has anything like this
happened to you?” In these ways, find out about the following abnormal
perceptions.
Abnormalities of Perception
a) Illusions. Misinterpretations of real external stimuli, such as mistaking
rustling leaves for the sound of voices.
b) Hallucinations. Perception-like experiences that seem real but, unlike
illusions, lack actual external stimulation. The person may or may not
recognize the experiences as false. Hallucinations may be auditory, visual,
olfactory, gustatory, tactile, or somatic. False perceptions associated with
dreaming, falling asleep, and awakening are not classified as hallucinations.
4. Insight
Some of your first questions to the patient often yield important information
about insight: “What brings you to the hospital?” “What seems to be the trouble?”
“What do you think is wrong?” Note whether the patient is aware that a particular
mood, thought, or perception is abnormal or part of an illness.
5. Judgment
Assess judgment by noting the patient’s responses to family situations, jobs,
use of money, and interpersonal conflicts. “How do you plan to get help after leaving
the hospital?” “How are you going to manage if you lose your job?” “If your husband
starts to abuse you again, what will you do?” “Who will take care of your financial
affairs while you are in the nursing home?”
Note whether decisions and actions are based on reality or impulse, wish
fulfillment, or disordered thought content. What insights and values seem to
underlie the patient’s decisions and behavior? Allowing for cultural variations, how
do these compare with a comparable mature adult? Because judgment reflects
maturity, it may be variable and unpredictable during adolescence.

Cognitive Functions

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 1. Orientation. You can usually assess orientation during the interview. For example,
you can ask quite naturally for clarification about specific dates and times, the
patient’s address and telephone number, the names of family members, or the route
to the hospital. At times, direct questions will be needed: “Can you tell me the time
now . . . and what day it is?”
Assess orientation to:
a) Person—the patient’s name, and names of relatives and professional
personnel
b) Time—the time of day, day of the week, month, season, date and year,
duration of hospitalization
c) Place—the patient’s residence, the names of the hospital, city, and state
2. Attention. The following tests of attention are commonly used.
a) Digit Span. Explain that you would like to test the patient’s ability to
concentrate, perhaps adding that this can be difficult if the patient is in pain
or ill. Recite a series of digits, starting with two at a time and speaking each
number clearly at a rate of about one per second. Ask the patient to repeat
the numbers back to you. If this repetition is accurate, try a series of three
numbers, then four, and so on as long as the patient responds correctly. Jot
down the numbers as you say them to ensure your own accuracy. If the
patient makes a mistake, try once more with another series of the same
length. Stop after a second failure in a single series. When choosing digits,
use street numbers, zip codes, telephone numbers, and other numerical
sequences that are familiar to you, but avoid consecutive numbers, easily
recognized dates, and sequences that are familiar to the patient. Now,
starting again with a series of two, ask the patient to repeat the numbers to
you backward. Normally, a person should be able to repeat correctly at least
five digits forward and four backward.
b) Serial 7s. Instruct the patient, “Starting from a hundred, subtract 7, and keep
subtracting 7 . . . . ” Note the effort required and the speed and accuracy of
the responses. Writing down the answers helps you keep up with the
arithmetic. Normally, a person can complete serial 7s in 1½ minutes, with
fewer than four errors. If the patient cannot do serial 7s, try 3s or counting
backward.
c) Spelling Backward. This can substitute for serial 7s. Say a five-letter word,
spell it, for example, W-O-R-L-D, and ask the patient to spell it backward.
3. Remote Memory. Inquire about birthdays, anniversaries, social security number,
names of schools attended, jobs held, or past historical events such as wars relevant
to the patient’s past.
4. Recent Memory. This can involve the events of the day. Ask questions with answers
you can check against other sources to see if the patient is confabulating, or making
up facts to compensate for a defective memory. These might include the day’s
weather or appointment time, current medications, or laboratory tests taken during
the day.
5. New Learning Ability. Give the patient three or four words such as “83, Water Street,
and blue,” or “table, flower, green, and hamburger.” Ask the patient to repeat them
so that you know that the information has been heard and registered. This step, like
digit span, tests registration and immediate recall. Then proceed to other parts of
the examination. After 3 to 5 minutes, ask the patient to repeat the words. Note the
accuracy of the response, awareness of whether it is correct, and any tendency to
confabulate. Normally, a person should be able to remember the words.

Higher Cognitive Functions

1. Information and Vocabulary. If observed clinically in the context of cultural and
educational background, information and vocabulary provide a rough estimate of
the patient’s baseline abilities. Begin assessing fund of knowledge and vocabulary
during the interview. Ask about work, hobbies, reading, favorite television
programs, or current events. Start with simple questions, then move to more
difficult questions. Note the person’s grasp of information, complexity of the ideas,
and choice of vocabulary More directly, you can ask about specific facts such as:
a) The name of the president, vice president, or governor
b) The names of the last four or five presidents

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 c) The names of five large cities in the country
2. Calculating Ability. Test the patient’s ability to do arithmetical calculations, starting
with simple addition (“What is 4 + 3? . . . 8 + 7?”) and multiplication (“What is 5 × 6? .
. . 9 × 7?”). Proceed to more difficult tasks using two-digit numbers (“15 + 12” or “25
× 6”) or longer, written examples. Alternatively, pose practical functionally
important questions, like: “If something costs 78 cents and you give the clerk one
dollar, how much should you get back?”
3. Abstract Thinking. Test the capacity to think abstractly in two ways.
a) Proverbs. Ask the patient what the following proverbs mean: A stitch in time
saves nine. Don’t count your chickens before they’re hatched. The proof of
the pudding is in the eating. A rolling stone gathers no moss. The squeaky
wheel gets the grease. Note the relevance of the answers and their degree of
concreteness or abstractness. For example, “You should sew a rip before it
gets bigger” is concrete, whereas “Prompt attention to a problem prevents
trouble” is abstract. Average patients should give abstract or semiabstract
responses.
b) Similarities. Ask the patient to tell you how the following are alike: An
orange and an apple. A church and a theater. A cat and a mouse. A piano and
a violin. A child and a dwarf. Wood and coal. Note the accuracy and
relevance of the answers and their degree of concreteness or abstractness.
For example, “A cat and a mouse are both animals” is abstract, “They both
have tails” is concrete, and “A cat chases a mouse” is not relevant.
4. Constructional Ability. The task here is to copy figures of increasing complexity onto
a piece of blank unlined paper.

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 PSYCHOSOCIAL DEVELOPMENT
According to Cherry (2020), Erikson believed that personality developed in a series
of stages. Erikson's stage theory characterizes an individual advancing through the eight life
stages as a function of negotiating their biological and sociocultural forces. Each stage is
characterized by a psychosocial crisis of two conflicting forces.

Figure 3.11 Erik Erikson's Stages of Psychosocial Development

Illustration by Verywell / Joshua Seong

Table 3.8 Erik Erikson's Stages of Psychosocial Development

Approximate Psychosocial Significant
Virtues Major Question Events
Age crisis relationship
Infancy Trust vs. Can I trust the Feeding,
Hope Mother
Under 2 years Mistrust people around me? abandonment
"Can I do things Toilet
Toddlerhood Autonomy vs. myself or am I training,
Will Parents
2–4 years Shame/Doubt reliant on the help clothing
of others?" themselves
Exploring,
Early
Initiative vs. play using
childhood Purpose Family “Am I good or bad?”
Guilt tools or
5–8 years
making art
Middle “Can I make it?”
Industry vs. Neighbors,
Childhood Confidence "How can I be School, sports
Inferiority School
9–12 years good?"
Identity vs.
Adolescence Peers, Role Who am I? Who can Social
Fidelity Role
13–19 years Model I be? relationships
Confusion
Early
Intimacy vs. Friends, "Will I be loved or Romantic
adulthood Love
Isolation Partners will I be alone?" relationships
20–39 years
Middle "How can I
Generativity Household, Work,
Adulthood Care contribute to the
vs. Stagnation Workmates parenthood
40–59 years world?"
Late
Ego Integrity Mankind, My "Did I live a Reflection on
Adulthood Wisdom
vs. Despair kind meaningful life?" life
60 and above

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 COGNITIVE DEVELOPMENT
Cognitive development is how a person perceives, thinks, and gains understanding
of their world through the relations of genetic and learning factors. There are four stages to
cognitive information development. They are, reasoning, intelligence, language, and
memory. These stages start when the baby is about 18 months old, they play with toys,
listen to their parents speak, they watch tv, anything that catches their attention helps build
their cognitive development (Cherry, The 4 Stages of Cognitive Development, 2020).
Jean Piaget was a major force establishing this field, forming his "theory of cognitive
development". Piaget proposed four stages of cognitive development: the sensorimotor,
preoperational, concrete operational, and formal operational period.

Table 3.9 Jean Piaget’s Stages of Cognitive Development

Stage Age Major Characteristics and Developmental Illustration
Changes
Sensorimotor Birth to  The infant knows the world through their
2 Years movements and sensations
 Children learn about the world through basic
actions such as sucking, grasping, looking,
and listening
 Infants learn that things continue to exist
even though they cannot be seen (object
permanence)
 They are separate beings from the people and
objects around them
 They realize that their actions can cause
things to happen in the world around them
Preoperational 2 to 7  Children begin to think symbolically and
Years learn to use words and pictures to represent
objects.
 Children at this stage tend to be egocentric
and struggle to see things from the
perspective of others.
 While they are getting better with language
and thinking, they still tend to think about
things in very concrete terms.
Concrete 7 to 11  During this stage, children begin to thinking
Operational Years logically about concrete events
 They begin to understand the concept of
conservation; that the amount of liquid in a
short, wide cup is equal to that in a tall,
skinny glass, for example
 Their thinking becomes more logical and
organized, but still very concrete
 Children begin using inductive logic, or
reasoning from specific information to a
general principle
Formal 12 and  At this stage, the adolescent or young adult
Operational Up begins to think abstractly and reason about
hypothetical problems
 Abstract thought emerges
 Teens begin to think more about moral,
philosophical, ethical, social, and political
issues that require theoretical and abstract
reasoning
 Begin to use deductive logic, or reasoning
from a general principle to specific
information

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 PAIN
Pain is an unpleasant and highly personal experience that may be imperceptible to
others, while consuming all parts of the person’s life.
This definition certainly portrays how subjective pain is. Another widely agreed-on
definition of pain is “an unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such damage” (Kumar &
Elavarasi, 2016)

Three aspects of these definitions have important implications for nurses.

1. Pain is a physical and emotional experience, not all in the body or all in the mind.
2. It is in response to actual or potential tissue damage, so there may not be abnormal
lab or radiographic reports despite real pain.
3. Pain is described in terms of such damage.

Given that some clients are reluctant to disclose the presence of pain unless prompted,
nurses will be unaware of the client’s pain until they assess for it. Additionally, it is clear
that even nonverbal clients (e.g., preverbal children, intubated clients, or clients with
cognitive impairments) experience pain that demands nursing assessment and treatment
even if clients are unable to “describe in terms” the nature of their discomfort.
Pain interferes with functional abilities and quality of life. Severe or persistent pain
affects all body systems, causing potentially serious health problems while increasing the
risk of complications, delays in healing, and an accelerated progression of fatal illnesses
(Tabloski, 2010).

Nursing Management of Pain

Accurate pain assessment is essential for effective pain management. Many health
facilities make pain assessment the fifth vital sign. This strategy of linking pain assessment
to routine vital sign assessment and documentation represents a push to make pain
assessment a routine aspect of care for all clients. Given the highly subjective and
individually unique nature of pain, a comprehensive assessment of the pain experience
(physiological, psychological, behavioral, emotional, and sociocultural) provides the
necessary foundation for optimal pain control.
For clients experiencing acute, severe pain, the nurse may focus only on location,
quality, and severity, and provide interventions to control the pain before conducting a
more detailed evaluation. Clients with less severe or chronic pain can usually provide a
more detailed description of the experience. As the fifth vital sign, pain should be screened
for every time vital signs are evaluated. A simple screening question such as “Are you
experiencing any discomfort right now?” will usually suffice.
For example, in the initial postoperative period, vital signs are taken as frequently as
every 15 minutes. Screening for pain this frequently is justifiable because there is a high
incidence of pain in the perioperative period. Local, regional, or general anesthesia may be
wearing off, or if severe pain is reported, the medication administered postoperatively is
frequently administered via the intravenous (IV) route and has a peak effect noted within
15 minutes.
Given that many clients will not voice their pain unless asked about it, pain
assessments must be initiated by the nurse. Because the words pain or complain may have
emotional or sociocultural meaning attached, it is better to ask “Do you have any
discomforts to report?” rather than “Do you have any complaints of pain?” It is also essential
that nurses listen to and believe the client’s statements of pain. Believing the client’s
statement is crucial in establishing the sense of trust needed to develop a therapeutic
relationship.

Pain assessments consist of two major components:

1. a pain history to obtain facts from the client and
2. direct observation of behaviors, physical signs of tissue damage, and
secondary physiological responses of the client.

The goal of assessment is to gain an objective understanding of a subjective

experience.

Pain History

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 While taking a pain history, the nurse must provide an opportunity for clients to
express in their own words how they view the pain and the situation. This will help the
nurse understand what the pain means to the client and how the client is coping with it.
Remember that each person’s pain experience is unique and that the client is the best
interpreter of the pain experience. This history should be geared to the specific client. For
example, questions asked of a car crash victim would be different from those asked of a
postoperative client or someone suffering from chronic pain.
The initial pain assessment for someone in severe acute pain may consist of only a
few questions before intervention occurs. The nurse should focus on the previous pain
treatment and effectiveness, when and what analgesics were last taken, other medications
being taken and allergies to medications.
For the person with chronic pain, the nurse may focus on the client’s coping
mechanisms, effectiveness of current pain management, and ways in which the pain has
affected the client’s body, thoughts and feelings, activities, and relationships.

Data on Pain History

Data that should be obtained in a comprehensive pain history include pain location,
intensity, quality, patterns, precipitating factors, alleviating factors, associated symptoms,
effect on ADLs, past pain experiences, meaning of the pain to the person, coping resources,
and affective responses.
1. Location
To ascertain the specific location of the pain, ask the client to point to the site of the
discomfort. A chart consisting of drawings of the body can assist in identifying pain
locations. The client marks the location of pain on the chart. This tool can be
especially effective with clients who have more than one source of pain. A client who
has multiple pain sites of different character can use symbols to draw the
distribution of different pain types (e.g., circle aching areas, mark areas where
shock-like pain is felt with an X).
When assessing the location of a child’s pain, the nurse needs to understand the
child’s vocabulary. For example, “tummy” might refer either to the abdomen or to
part of the chest. Asking the child to point to the pain helps clarify the child’s word
usage to identify location. The use of figure drawings can assist in identifying pain
locations. Parents can also be helpful in interpreting the meaning of a child’s words.
When documenting pain location the nurse may use various body landmarks.
Further clarification is possible with the use of terms such as proximal, distal,
medial, lateral, and diffuse.

2. Pain Intensity or Rating Scales

The single most important indicator of the existence and intensity of pain is the
client’s report of pain. In practice, nurses tend to use less reliable measures for pain
assessment such as changes in vital signs and observation of client behaviors that
they interpret as drug seeking. Pain assessment that is not done accurately or
completely leads to under treatment of pain.
When noting pain intensity it is important to determine any related factors that may
be affecting the pain. When the intensity changes, the nurse needs to consider the
possible cause. For example, the abrupt cessation of acute abdominal pain may
indicate a ruptured appendix.
Several factors affect the perception of intensity:
a) the amount of distraction, or the client’s concentration on another event
b) the client’s state of consciousness
c) the level of activity
d) the client’s expectations

Pain Rating Scale

The use of pain intensity scales is an easy and reliable method of determining
the client’s pain intensity. Such scales provide consistency for nurses to
communicate with the client (adults and children over the age of 7) and other health
care providers. The following are the pain rating scale:
a) Numerical pain rating scale or the 11-point pain intensity scale
This scale uses a 0 to 10 range with 0 indicating “no pain” and 10 indicating
the “worst pain possible”. The inclusion of word modifiers on the scale can

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 assist some clients who find it difficult to apply a number level to their pain.
After ruling out “0” and “10”, a nurse can ask the client if it is mild, mild to
moderate, moderate to severe, or severe.

Figure 3.12 An 11-point pain intensity scale with word modifiers

b)
Wong-Baker FACES Rating Scale
Not all clients understand or relate to numerical pain intensity scales. These
include preverbal children, older adults with impairments in cognition or
communication, and people who do not speak English. This scale may be
easier to use. The FACES scale includes a number scale in relation to each
illustrated facial expression so that the pain intensity can be documented.
When using the FACES rating scale, it is important to remember that the
client’s facial expression does not need to match the picture. The pictures
represent how much pain the client is experiencing.

Figure 3.13 The Wong-Baker FACES Rating Scale

c) Brief Pain Inventory (BPI)

The Brief Pain Inventory - Short Form (BPI-sf) is a 9 item self-administered
questionnaire used to evaluate the severity of a patient's pain and the
impact of this pain on the patient's daily functioning. The patient is asked to
rate their worst, least, average, and current pain intensity, list current
treatments and their perceived effectiveness, and rate the degree that pain
interferes with general activity, mood, walking ability, normal work,
relations with other persons, sleep, and enjoyment of life on a 10 point scale.

Figure 3.14 Brief Pain Inventory - Short Form

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 d) Short Form McGill Pain Questionnaire (SF-MPQ)
The SF-MPQ has been developed for adults with chronic pain. The words or
items are rated on an intensity scale as 0 = none, 1 = mild, 2 = moderate and
3 = severe. There’s also one item for present pain intensity and one item for
a 10 cm visual analogue scale (VAS) for average pain.

Figure 3.15 Short Form McGill Pain Questionnaire

e) FLACC scale
The FLACC scale has been validated in children 2 months to 7 years old and
rates pain behaviors as manifested by Facial expressions, Leg movement,
Activity, Cry, and Consolability measures that yield a 0 to 10 score.
f) CRIES scale
Another scale specifically designed for neonates is CRIES. This scale uses
physiological indicators to assess behaviors that indicate pain. The key
elements are Crying, Requires oxygen, Increased vital signs, Expression, and
Sleeplessness.
g) PAINAD scale
A scale specifically designed for older adults with advanced dementia is
PAINAD. This scale looks at five specific indicators: breathing, vocalization,
facial expression, body language, and consolability (Hargas & Miller, 2008).

The use of a pain rating scale together with a pain flow sheet has been
shown to be effective in improving pain management. Documentation can be
completed by the nurse, the client, or a caregiver. A rating scale can be used in acute,
outpatient, and home care settings.

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 Figure 3.16 Sample of Pain Management Flow Sheet

3. Pain Quality
Descriptive adjectives help people communicate the quality of pain. A
headache may be described as “unbearable” or an abdominal pain as “piercing like a
knife.” The astute clinician can glean subtle clinical clues from the quality of the pain
described; thus it is important to record the description verbatim.
Note that the term “unbearable” is listed as an affective term and “piercing”
is a sensory term. Both pains are real physical conditions signaling an underlying
condition, but the affective description “unbearable” suggests that there is a
coexisting emotional distress that needs to be addressed as well.
Pain described as burning or shock-like tends to be neuropathic in origin and may
be responsive to anticonvulsants (e.g., gabapentin or pregabalin), with or without an
opioid (e.g., morphine, fentanyl, hydromorphone).

4. Pattern
The pattern of pain includes time of onset, duration, and recurrence or
intervals without pain. The nurse therefore determines when the pain began; how
long the pain lasts; whether it recurs and, if so, the length of the interval without
pain; and when the pain last occurred. Attention to the pattern of pain helps the

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 nurse anticipate and meet the needs of the client, as well as recognize patterns of
grave concern (e.g., chest pain only on exertion).

5. Precipitating Factors
Certain activities sometimes precede pain. For example, physical exertion
may precede chest pain, or abdominal pain may occur after eating. These
observations can help prevent pain and determine its cause. Environmental factors
such as extreme cold or heat and extremes of humidity can affect some types of pain.
For example, people with rheumatic conditions have worse pain on cold, damp days
or just before a large storm. Physical and emotional stressors can also precipitate
pain. Strong emotions can trigger a migraine headache or an episode of chest pain.
Extreme physical exertion can trigger muscle spasms in the neck, shoulders, or back.

6. Alleviating Factors
Nurses must ask clients to describe anything that they have done to alleviate
the pain (e.g., home remedies such as herbal teas, medications, rest, applications of
heat or cold, prayer, or distractions like TV). It is important to explore the effect any
of these measures had on the pain, whether or not relief was obtained, or whether
the pain became worse. It is helpful to recommend a diary be kept to gather this
information.

7. Associated Symptoms
Also included in the clinical appraisal of pain are associated symptoms such
as nausea, vomiting, dizziness, and diarrhea. These symptoms may relate to the
onset of the pain or they may result from the presence of the pain.

8. Effect on Activities of Daily Living

Knowing how ADLs are affected by pain helps the nurse understand the
client’s perspective on the pain’s severity. A rating scale of none, a little, or a great
deal, or another range can be used to determine the degree of alteration in ADLs.
The nurse should ask the client to describe how the pain has affected the following
aspects of life:
 Sleep
 Appetite
 Concentration
 Work/school
 Interpersonal relationships
 Marital relations/sex
 Home activities
 Driving/walking
 Leisure activities
 Emotional status (mood, irritability, depression, anxiety).

Assessment Interview for Pain

 Location: Where is your discomfort?
 Quality: Tell me what your discomfort feels like.
 Intensity: On a scale of 0 to 10, with “0” representing no pain and “10” representing
the worst possible pain.
 Pattern
a) Time of onset: When did or does the pain start?
b) Duration: How long have you had it, or how long does it usually last?
c) Constancy: Do you have pain-free periods? When? And for how long?
 Precipitating factors: What triggers the pain or makes it worse?
 Alleviating factors: What measures or methods have you found helpful in lessening
or relieving the pain? What pain medications do you use?
 Associated symptoms: Do you have any other symptoms (e.g., nausea, dizziness,
blurred vision, shortness of breath) before, during, or after your pain?
 Effects on ADLs: How does the pain affect your daily life (e.g., eating, working,
sleeping, and social and recreational activities)?
 Past pain experiences: Tell me about past pain experiences you have had and what
was done to relieve the pain.

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  Meaning of pain: What does having this pain mean to you? Does it signal something
about the future or past? What worries or scares you the most about your pain?
 Coping resources: What do you usually do to help you deal with pain?
 Affective response: How does the pain make you feel? Anxious? Depressed?
Frightened? Tired? Burdensome?

Non-Pharmacologic Pain Management

Non-pharmacologic pain management consists of a variety of physical, cognitive-
behavioral, and lifestyle pain management strategies that target the body, mind, spirit, and
social interactions.

Table 3.10 Non-pharmacologic Interventions for Pain Control

Target Domain Intervention
of Pain Control
Body  Reducing pain triggers, promoting comfort
 Massage
 Applying heat or ice
 Electric stimulation (TENS) Positioning, bracing (selective immobilization)
 Acupressure
 Diet, nutritional supplements
 Exercise, pacing activities
 Invasive interventions (e.g., blocks)
 Sleep hygiene
Mind  Relaxation, imagery, self-hypnosis
 Pain diary, journal writing
 Distracting attention
 Repatterning thinking
 Attitude adjustment
 Reducing fear, anxiety, stress, sadness, helplessness
 Information about pain
 Music therapy
Spirit  Prayer, meditation
 Self-reflection regarding life and pain
 Meaningful rituals
 Energy work (e.g., therapeutic touch, Reiki)
 Spiritual healing
Social  Functional restoration
interactions  Improved communication
 Pet therapy
 Family therapy
 Problem solving
 Vocational training
 Volunteering Support groups

Lifespan Considerations Pain Management

Infants
1. Giving an infant, particularly a very-low-birth-weight infant, a water and sucrose
solution administered through a pacifier provides some evidence of pain reduction
during procedures that may be painful, but should not be a substitute for anesthetic
or analgesic medications.
Children
1. Distract the child with toys, books, or pictures.
2. Hold the child (or ask the parent to hold) to console and promote comfort.
3. Explore misconceptions about pain and correct in understandable “concrete” terms.
Be aware of how your explanations may be misunderstood. For example, telling a
child they won’t hurt during surgery because they will be “put to sleep” will be very
upsetting to a child who knows of an animal that was “put to sleep.”
4. Children can use their imagination during guided imagery. Ask the child to imagine a
“pain switch” (even give it a color) and to visualize turning the switch off in the area
where there is pain. A “magic glove” or “magic blanket” is an imaginary object that

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 the child applies on areas of the body (e.g., hand, thigh, back, hip) to lessen
discomfort.
Older Adults
1. Promote clients’ use of pain control measures that have worked in the past for them.
2. Spend time with clients and listen carefully.
3. Clarify misconceptions. Encourage independence whenever possible.
4. Carefully review the treatment plan to avoid drug–drug, food–drug, or disease–drug
interactions.

VIOLENCE
As stated by Bickley & Szilagyi (2017), intimate partner violence is the leading cause
of serious injury and the second leading cause of death among U.S. women of reproductive
age. The American Medical Association and the American College of Obstetricians and
Gynecologist recommend routine screening of all women for intimate partner violence.
Elders are also highly vulnerable to neglect and abuse. Sensitive interviewing is
essential, since even with skilled inquiry only 25% of patients disclose their abuse
experience.
The type of questioning is important. Experts recommend beginning with
normalizing statements such as “Because abuse is common in many women’s lives, I’ve
begun to ask about it routinely.”
Disclosure is more likely when probing questions lead and then in-depth direct
questions follow. “Are you in a relationship where you have been hit or threatened?” with a
pause to encourage the patient to respond. If the patient says no, continue with “Has anyone
ever treated you badly or made you do things you don’t want to?” or “Is there anyone you
are afraid of?” or “Have you ever been hit, kicked, punched, or hurt by someone you know?”
Following disclosure, empathic validating and nonjudgmental responses are critical but
currently occur less than half the time.

Clues to Physical and Sexual Abuse

Be alert to the unspoken clues to abuse, observe the following:
1. Injuries that are unexplained, seem inconsistent with the patient’s story, are
concealed by the patient, or cause embarrassment.
2. Delay in getting treatment for trauma.
3. History of repeated injuries or “accidents”.
4. Presence of alcohol or drug abuse in patient or partner.
5. Partner tries to dominate the visit, will not leave the room, or seems unusually
anxious or solicitous.
6. Pregnancy at a young age; multiple partners.
7. Repeated vaginal infections and STIs.
8. Difficulty walking or sitting due to genital/anal pain.
9. Vaginal lacerations or bruises.
10. Fear of the pelvic examination or physical contact.
11. Fear of leaving the examination room.

When you suspect abuse, it is important to spend part of the encounter alone with
the patient. You can use the transition to the physical examination as a reason to ask others
to leave the room. If the patient is also resistant, you should not force the situation.

NUTRITIONAL STATUS
The 2015–2020 Dietary Guidelines for Americans (2015), is designed for
professionals to help all individuals ages 2 years and older and their families consume a
healthy, nutritionally adequate diet.
The 2015-2020 Dietary Guidelines provides five overarching guidelines that
encourage healthy eating patterns, recognize that individuals will need to make shifts in
their food and beverage choices to achieve a healthy pattern, and acknowledge that all
segments of our society have a role to play in supporting healthy choices. These Guidelines
also embody the idea that a healthy eating pattern is not a rigid prescription, but rather, an
adaptable framework in which individuals can enjoy foods that meet their personal,
cultural, and traditional preferences and fit within their budget. Several examples of healthy
eating patterns that translate and integrate the recommendations in overall healthy ways to
eat are provided.

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 1. Follow a healthy eating pattern across the lifespan. All food and beverage choices
matter. Choose a healthy eating pattern at an appropriate calorie level to help
achieve and maintain a healthy body weight, support nutrient adequacy, and reduce
the risk of chronic disease.
2. Focus on variety, nutrient density, and amount. To meet nutrient needs within
calorie limits, choose a variety of nutrient-dense foods across and within all food
groups in recommended amounts.
3. Limit calories from added sugars and saturated fats and reduce sodium
intake. Consume an eating pattern low in added sugars, saturated fats, and sodium.
Cut back on foods and beverages higher in these components to amounts that fit
within healthy eating patterns.
4. Shift to healthier food and beverage choices. Choose nutrient-dense foods and
beverages across and within all food groups in place of less healthy choices.
Consider cultural and personal preferences to make these shifts easier to
accomplish and maintain.
5. Support healthy eating patterns for all. Everyone has a role in helping to create and
support healthy eating patterns in multiple settings nationwide, from home to
school to work to communities.

The Dietary Guidelines’ Key Recommendations

The Dietary Guidelines’ Key Recommendations for healthy eating patterns should be
applied in their entirety, given the interconnected relationship that each dietary component
can have with others. Consume a healthy eating pattern that accounts for all foods and
beverages within an appropriate calorie level.

A healthy eating pattern includes:

 A variety of vegetables from all of the subgroups—dark green, red and orange,
legumes (beans and peas), starchy, and other
 Fruits, especially whole fruits
 Grains, at least half of which are whole grains
 Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy
beverages
 A variety of protein foods, including seafood, lean meats and poultry, eggs,
legumes (beans and peas), and nuts, seeds, and soy products
 Oils
A healthy eating pattern limits:
 saturated fats and trans fats
 added sugars
 sodium time to help support a he and re

Figure 3.17 Dietary Guidelines’ Key Recommendations

Key Recommendations that are quantitative are provided for several components of
the diet that should be limited. These components are of particular public health concern in
the United States, and the specified limits can help individuals achieve healthy eating
patterns within calorie limits:

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  Consume less than 10 percent of calories per day from added sugars
 Consume less than 10 percent of calories per day from saturated fats
 Consume less than 2,300 milligrams (mg) per day of sodium
 If alcohol is consumed, it should be consumed in moderation—up to one drink per
day for women and up to two drinks per day for men—and only by adults of legal
drinking age.

Four Steps to Promote Optimal Weight and Nutrition

A healthy weight, defined as a BMI between 18.5 and 24.9 kg/m 2. To promote
optimal patient weight and nutrition, adopt the following steps:
1. Measure BMI and waist circumference.
Adults with a BMI ≥25 kg/m 2, men with waist circumferences >40 inches,
and women with waist circumferences >35 inches are at increased risk for heart
disease and obesity-related diseases. Measuring the waist-to-hip ratio (waist
circumference divided by hip circumference) may be a better risk predictor for
individuals older than 75 years. Ratios >0.95 in men and >0.85 in women are
considered elevated. Determine additional risk factors for cardiovascular diseases,
including smoking, high blood pressure, high cholesterol, physical inactivity, and
family history. Classify the BMI according to the national guidelines in the table
below.
If the BMI is above 25 kg/m 2, assess the patient for additional risk factors for
heart disease and other obesity-related diseases: hypertension, high low-density
lipoprotein (LDL) cholesterol, low high-density lipoprotein (HDL) cholesterol, high
triglycerides, high blood glucose, family history of premature heart disease, physical
inactivity, and cigarette smoking.
Patients with a BMI over 25 kg/m2 and two or more risk factors should
pursue weight loss—especially if the waist circumference is elevated.

2. Assess dietary intake.

Take a diet history and assess the patient’s eating patterns. Select a brief
screening tool and be sensitive to the impact of income and cultural preferences on
what the patient chooses to eat.
3. Assess the patient’s motivation to change.
Once you have assessed BMI, risk factors, and dietary intake, address the
patient’s motivation to make lifestyle changes that promote weight loss. The
Prochaska model (Axelrod, 2016) helps tailor interventions to the patient’s level of
motivation to adopt new eating behaviors.

Figure 3.18 Prochaska Model Stages of Change

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 Illustration by psychcentral.com
4. Provide counseling about nutrition and exercise.
You should be well informed about diet and nutrition as you counsel
overweight patients, especially in light of the many and often contradictory diet
options in the popular press.
The U.S. Department of Agriculture released new dietary guidelines in 2015-
2020 to help clinicians and patients address the obesity epidemic more effectively.
A key element of effective counseling is working with the patient to set
reasonable goals. Experts note that patients often have a “dream weight” as much as
30% below initial body weight. However, a 5% to 10% weight loss is more realistic
and still proven to reduce risk of diabetes and other obesity-associated health
problems.
Educate your patients about common roadblocks to sustained weight loss:
hitting a plateau due to feedback physiologic systems that maintain body
homeostasis; poor adherence to diet due to increasing hunger over time as weight
declines; and inhibition of leptin, a protein cytokine secreted and stored in fat cells
that modulates hunger.
Use a full array of strategies to promote weight loss. A safe goal for weight
loss is 0.5 to 2 lbs per week.

Strategies That Promote Weight Loss

1. The most effective diets combine realistic weight loss goals with exercise and
behavioral reinforcements.
2. Encourage patients to walk 30 to 60 minutes 5 or more days a week, or a total of at
least 150 minutes a week. Pedometers help patients match distance in steps with
calories burned.
3. The total calorie deficit goal, usually 500 to 1,000 kilocalories a day, is more
important than the type of diet. Since many types of diets have been studied and
appear to confer similar results, support the patient’s preferences as long as they
are reasonable. Consider low-fat diets for those with dyslipidemias.
4. Encourage proven behavioral habits such as portion-controlled meals, meal
planning, food diaries, and activity records.
5. Follow professional guidelines for pharmacologic therapies in patients having high
weights and morbidities who do not respond to conventional treatment.

If the BMI falls below 18.5 kg/m 2, investigate possible anorexia, bulimia, or other
serious medical conditions.

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 Table 3.11 Obesity-Related Health Conditions
System Health Related Conditions
Cardiovascular  Hypertension
 Coronary artery disease
 Atrial fibrillation
 Heart failure
 Cor pulmonale
 Varicose veins
Endocrine  Metabolic syndrome
 Type 2 diabetes
 Dyslipidemia
 Polycystic ovarian syndrome/androgenicity
 Amenorrhea/infertility/menstrual disorders
Gastrointestinal  Gastroesophageal reflux disease (GERD)
 Nonalcoholic fatty liver disease (NAFLD)
 Cholelithiasis
 Hernias
 Cancer: colon, pancreas, esophagus, liver
Genitourinary  Urinary stress incontinence
 Obesity-related glomerulopathy
 Hypogonadism (male)
 Cancer: breast, cervical, ovarian, uterine
 Pregnancy complications
 Nephrolithiasis, chronic renal disease
Integument  Striae distensae (stretch marks)
 Status pigmentation of legs
 Lymphedema
 Cellulitis
 Intertrigo, carbuncles
 Acanthosis nigricans/skin tags
Musculoskeletal  Hyperuricemia and gout
 Immobility
 Osteoarthritis (knees, hips)
 Low back pain
Neurologic  Stroke
 Idiopathic intracranial hypertension
 Meralgia paresthetica
Psychological  Depression/low self-esteem
 Body image disturbance
 Social stigmatization
Respiratory  Dyspnea
 Obstructive sleep apnea
 Hypoventilation syndrome/Pickwickian syndrome
 Pulmonary embolism
 Asthma

SELF-STUDY GUIDE QUESTIONS

1. Discuss the assessment of mental status.
2. Cite an example on how to develop the virtues on the stages of psychosocial
development by Erik Erikson.
3. Cite an example on the different stages of Jean Piaget’s cognitive development.
4. Discuss the components in assessing pain history.
5. Explain the key recommendations for healthy eating patterns.

HEALTH ASSESSMENT (NCM 101)

 UNIT 4. PHYSICAL ASSESSMENT
Overview
In the previous unit, you learned about the collection of subjective data, objective
data, and the assessment of general status and vital signs. You can apply the knowledge
you’ve learned in those topics in assessing the different systems and parts of the body.

Learning Outcomes
1. Know how to assess the skin, hair and nails; head; eyes; ears; nose and sinuses;
mouth, throat, and neck; thorax and lungs; breast and axillae; heart and central
vessels; peripheral vascular system; assessing the abdomen; musculoskeletal
system; neurologic system; male genitalia; female genitalia and anus.

The following discussion is based from (Berman & Snyder, Kozier & Erb’s
Fundamentals of Nursing, 2012).
SKIN
The skin is the heaviest single organ of the body, accounting for approximately 16%
of body weight and covering an area of roughly 1.2 to 2.3 meters squared. It contains three
layers: the epidermis, the dermis, and the subcutaneous tissues.
Assessment of the skin involves inspection and palpation. The nurse may also use
the olfactory sense to detect unusual skin odors; these are usually most evident in the
skinfolds or in the axillae. Strong body odor is frequently related to poor hygiene,
hyperhidrosis (excessive perspiration), or bromhidrosis (foul-smelling perspiration).
Pallor is the result of inadequate circulating blood or hemoglobin and subsequent
reduction in tissue oxygenation. In clients with dark skin, it is usually characterized by the
absence of underlying red tones in the skin and may be most readily seen in the buccal
mucosa. In brown-skinned clients, pallor may appear as a yellowish brown tinge; in black-
skinned clients, the skin may appear ashen gray. Pallor in all people is usually most evident
in areas with the least pigmentation such as the conjunctiva, oral mucous membranes, nail
beds, palms of the hand, and soles of the feet.
Cyanosis (a bluish tinge) is most evident in the nail beds, lips, and buccal mucosa. In
dark-skinned clients, close inspection of the palpebral conjunctiva (the lining of the
eyelids) and palms and soles may also show evidence of cyanosis.
Jaundice (a yellowish tinge) may first be evident in the sclera of the eyes and then
in the mucous membranes and the skin. Nurses should take care not to confuse jaundice
with the normal yellow pigmentation in the sclera of a dark- skinned client. If jaundice is
suspected, the posterior part of the hard palate should also be inspected for a yellowish
color tone.
Erythema is skin redness associated with a variety of rashes and other conditions.
Dark-skinned clients have areas of lighter pigmentation, such as the palms, lips, and nail
beds. Localized areas of hyperpigmentation (increased pigmentation) and
hypopigmentation (decreased pigmentation) may also occur as a result of changes in the
distribution of melanin (the dark pigment) or in the function of the melanocytes in the
epidermis. An example of hyperpigmentation in a defined area is a birthmark; an example of
hypopigmentation is vitiligo. Vitiligo, seen as patches of hypopigmented skin, is caused by
the destruction of melanocytes in the area. Albinism is the complete or partial lack of
melanin in the skin, hair, and eyes. Other localized color changes may indicate a problem
such as edema or a localized infection.
Edema is the presence of excess interstitial fluid. An area of edema appears swollen,
shiny, and taut and tends to blanch the skin color or, if accompanied by inflammation, may
redden the skin. Generalized edema is most often an indication of impaired venous
circulation and in some cases reflects cardiac dysfunction or venous abnormalities.
Assess edema, if present that is the location, color, temperature, shape, and the
degree to which the skin remains indented or pitted when pressed by a finger. Measuring
the circumference of the extremity with a millimeter tape may be useful for future
comparison.

Figure 4.1 Scale for Grading Edema

HEALTH ASSESSMENT (NCM 101)

 A skin lesion is an alteration in a client’s normal skin appearance. Primary skin
lesions are those that appear initially in response to some change in the external or internal
environment of the skin.
Table 4.1 Primary Skin Lesions
Skin Lesions Definition Examples
Macule  Patch Flat, unelevated change freckles, measles, petechiae,
in color. flat moles,
 Macules are 1 mm to 1 cm (0.04 port wine birthmark, vitiligo
to 0.4 in.) in size and may have (white patches), rubella
an irregular shape.

Papule  Circumscribed, solid warts, acne, pimples,

(popular drug eruption) elevation of skin. elevated moles
Papules are less than
1 cm (0.4 in.).

Plaque  Plaques are larger than 1 cm psoriasis, rubeola

(0.4 in.)

Nodule, Tumor  Elevated, solid, hard mass squamous cell carcinoma,

that extends deeper into the fibroma
dermis than a papule. malignant melanoma,
 Nodules: have a hemangioma
circumscribed border and are
0.5 to 2 cm (0.2 to 0.8 in.)
 Tumors: are larger than 2 cm
(0.8 in.) and may have an
irregular border.
Pustule  Vesicle or bulla filled with pus acne vulgaris, impetigo

Vesicle, Bulla  A circumscribed, Vesicles: herpes simplex,

round or oval, thin early chicken pox, small burn
translucent mass blister.
filled with serous
fluid or blood. Bullae: large blister, second
 Vesicles are less than 0.5 cm degree burn, herpes simplex
(0.2 in.)
 Bullae are larger than 0.5 cm
(0.2 in.).
Cyst  A 1-cm (0.4 in.) or larger, sebaceous and epidermoid
elevated, encapsulated, fluid cysts, chalazion of the eyelid
filled or semisolid mass arising
from the subcutaneous tissue
or dermis.

HEALTH ASSESSMENT (NCM 101)

 Wheal  A reddened, hives, mosquito bites
localized collection
of edema fluid;
irregular in shape.
Size varies.

Secondary skin lesions are those that do not appear initially but result from
modifications such as chronicity, trauma, or infection of the primary lesion. For example, a
vesicle or blister (primary lesion) may rupture and cause an erosion (secondary lesion).
Nurses are responsible for describing skin lesions accurately in terms of location (e.g., face),
distribution (i.e., body regions involved), and configuration (the arrangement or position of
several lesions) as well as color, shape, size, firmness, texture, and characteristics of
individual lesions. The figure below shows the secondary skin lesions.
Figure 4.2 Secondary Skin Lesions

Equipment in Assessing the Skin

1. Millimeter ruler
2. Clean gloves
3. Magnifying glass

HEALTH ASSESSMENT (NCM 101)

Assessing the Skin
1. Inquire if the client has any history of the following: pain or itching; presence and
spread of lesions, bruises, abrasions, pigmented spots; previous experience with
skin problems; associated clinical signs; family history; presence of problems in
other family members; related systemic conditions; use of medications, lotions,
home remedies; excessively dry or moist feel to the skin; tendency to bruise easily;
association of the problem to season of year, stress, occupation, medications, recent
travel, housing, and so on; recent contact with allergens (e.g., metal paint).
2. Inspect skin color (best assessed under natural light and on areas not exposed to the
sun). Normally, skin color varies from light to deep brown; from ruddy pink to light
pink; from yellow overtones to olive. Abnormal skin colors are pallor, cyanosis,
jaundice, erythema
3. Inspect uniformity of skin color. Generally skin color is uniform except in areas
exposed to the sun; areas of lighter pigmentation (palms, lips, nail beds) in dark-
skinned people
4. Assess edema, if present (i.e., location, color, temperature, shape, and the degree to
which the skin remains indented or pitted when pressed by a finger). Measuring the
circumference of the extremity with a millimeter tape may be useful for future
comparison. See Figure 4.1 Scale for Grading Edema.
5. Inspect, palpate, and describe skin lesions. Apply gloves if lesions are open or
draining. Palpate lesions to determine shape and texture. Describe lesions according
to location, distribution, color, configuration, size, shape, type, or structure. Use the
millimeter ruler to measure lesions. If gloves were applied, remove and discard
gloves. Perform hand hygiene.
Describing Skin Lesions
 Type or structure. Skin lesions are classified as primary (those that appear
initially in response to some change in the external or internal environment of
the skin) and secondary (those that do not appear initially but result from
modifications such as chronicity, trauma, or infection of the primary lesion).
For example, a vesicle (primary lesion) may rupture and cause an erosion
(secondary lesion).
 Size, shape, and texture. Note size in millimeters and whether the lesion is
circumscribed or irregular; round or oval shaped; flat, elevated, or depressed;
solid, soft, or hard; rough or thickened; fluid filled or has flakes.
 Color. There may be no discoloration, one discrete color (e.g., red, brown, or
black), several colors, as with ecchymosis (a bruise), in which an initial dark
red or blue color fades to a yellow color. When color changes are limited to the
edges of a lesion, they are described as circumscribed; when spread over a
large area, they are described as diffuse.
 Distribution. Distribution is described according to the location of the lesions
on the body and symmetry or asymmetry of findings in comparable body
areas.
 Configuration. Configuration refers to the arrangement of lesions in relation to
each other. Configurations of lesions may be annular (arranged in a circle),
may be clustered together (grouped), may be linear (arranged in a line), may
be arc or bow shaped, may be merged together (indiscrete), may follow the
course of cutaneous nerves, or may be meshed in the form of a network.
6. Observe and palpate skin moisture. Moisture in skin folds and the axillae (varies
with environmental temperature and humidity, body temperature, and activity).
7. Palpate skin temperature. Compare the two feet and the two hands, using the backs
of your fingers.
8. Note skin turgor (fullness or elasticity) by lifting and pinching the skin on an
extremity or on the sternum. When pinched, skin springs back to previous state (is
elastic); may be slower in older adults. Skin stays pinched or tented or moves back
slowly (e.g., in dehydration). Count in seconds how long the skin remains tented.
9. Document findings in the client record using forms or checklists supplemented by
narrative notes when appropriate. Draw location of skin lesions on body surface
diagrams.
Figure 4.3 Diagram for charting skin lesions

HEALTH ASSESSMENT (NCM 101)

 .

Life Considerations in Assessing the Skin

Infants
1. Physiological jaundice may appear in newborns 2 to 3 days after birth and usually
lasts about 1 week. Pathologic jaundice, or that which indicates a disease, appears
within 24 hours of birth and may last more than 8 days.
2. Newborns may have milia (whiteheads), small white nodules over the nose and face,
and vernix caseosa (white cheesy, greasy material on the skin).
3. Premature infants may have lanugo, a fine downy haircovering their shoulders and
back.
4. In dark-skinned infants, areas of hyperpigmentation may be found on the back,
especially in the sacral area.
5. Diaper dermatitis may be seen in infants.
6. If a rash is present, inquire in detail about immunization history.
7. Assess skin turgor by pinching the skin on the abdomen.

Children
1. Children normally have minor skin lesions (e.g., bruising or abrasions) on arms and
legs due to their high activity level. Lesions on other parts of the body may be signs
of disease or abuse, and a thorough history should be taken.
2. Secondary skin lesions may occur frequently as children scratch or expose a
primary lesion to microbes.
3. With puberty, oil glands become more productive, and children may develop acne.
Most persons’ ages 12 to 24 have some acne.
4. In dark-skinned children, areas of hyperpigmentation may be found on the back,
especially in the sacral area.
5. If a rash is present, inquire in detail about immunization history.

Older Adults
1. Changes in white skin occur at an earlier age than in black skin.
2. The skin loses its elasticity and wrinkles. Wrinkles first appear on the skin of the
face and neck, which are abundant in collagen and elastic fibers.
3. The skin appears thin and translucent because of loss of dermis and subcutaneous
fat.
4. The skin is dry and flaky because sebaceous and sweat glands are less active. Dry
skin is more prominent over the extremities.
5. The skin takes longer to return to its natural shape after being tented between the
thumb and finger.
6. Due to the normal loss of peripheral skin turgor in older adults, assess for hydration
by checking skin turgor over the sternum or clavicle.
7. Flat tan to brown-colored macules, referred to as senile lentigines or melanotic
freckles, are normally apparent on the back of the hand and other skin areas that are
exposed to the sun. These macules may be as large as 1 to 2 cm (0.4 to 0.8 in.).
8. Warty lesions (seborrheic keratosis) with irregularly shaped borders and a scaly
surface often occur on the face, shoulders, and trunk. These benign lesions begin as
yellowish to tan and progress to a dark brown or black.
9. Vitiligo tends to increase with age and is thought to result from an autoimmune
response.
10. Cutaneous tags (acrochordons) are most commonly seen in the neck and axillary
regions. These skin lesions vary in size and are soft, often flesh colored, and
pedicled.
11. Visible, bright red, fine dilated blood vessels (telangiectasias) commonly occur as a
result of the thinning of the dermis and the loss of support for the blood vessel
walls.

HEALTH ASSESSMENT (NCM 101)

 12. Pink to slightly red lesions with indistinct borders (actinic keratoses) may appear at
about age 50, often on the face, ears, backs of the hands, and arms. They may
become malignant if untreated.

SELF-STUDY GUIDE QUESTIONS

1. Enumerate the primary and secondary skin lesions and give examples.
2. Discuss how to assess the skin turgor.
3. Situation: Michael, 21 year old, Food Panda driver had an accident on the way to his
destination of food delivery. He suffered abrasions on his both knees, right hands
and left elbow. Mark the site of abrasions using the diagram for charting skin
lesions.

HAIR
Adults have two types of hair: vellus hair, which is short, fine, inconspicuous, and
relatively unpigmented; and terminal hair, which is coarser, thicker, more conspicuous, and
usually pigmented. Scalp hair and eyebrows are examples of terminal hair.
Assessing a client’s hair includes inspecting the hair, considering developmental
changes and ethnic differences, and determining the individual’s hair care practices and
factors influencing them. Much of the information about hair can be obtained by
questioning the client. Normal hair is resilient and evenly distributed. In people with severe
protein deficiency (Kwashiorkor), the hair color is faded and appears reddish or bleached,
and the texture is coarse and dry.
Inspect and palpate the hair. Note its quantity, distribution, and texture. Alopecia
refers to hair loss—diffuse, patchy, or total. Sparse hair is seen in hypothyroidism; fine, silky
hair in hyperthyroidism.

Different Kinds of Hair Loss

1. Alopecia Areata. Clearly demarcated round or oval patches of hair loss, usually
affecting young adults and children. There is no visible scaling or inflammation.

2. Trichotillomania (Trichotillosis). Hair loss from pulling, plucking, or twisting hair.

Hair shafts are broken and of varying lengths. More common in children, often in
settings of family or psychosocial stress.

3. Tinea Capitis (“Ringworm”). Round scaling patches of alopecia. Hairs are broken off
close to the surface of the scalp. Usually caused by fungal infection from Trichophyton
tonsurans from humans, less commonly from microsporum canis from dogs or cats.
Mimics seborrheic dermatitis.

HEALTH ASSESSMENT (NCM 101)

Equipment in Assessing the Hair
1. Clean gloves

Assessing the Hair

1. Inquire if the client has any history of the following: recent use of hair dyes, rinses,
or curling or straightening preparations; recent chemotherapy (if alopecia is
present); presence of disease, such as hypothyroidism, which can be associated with
dry, brittle hair.
2. Inspect the evenness of growth over the scalp like patches of hair loss (i.e., alopecia)
3. Inspect hair thickness or thinness. Very thin hair may indicate hypothyroidism.
4. Inspect hair texture and oiliness. Brittle hair may indicate hypothyroidism.
5. Note presence of infections or infestations by parting the hair in several areas,
checking behind the ears and along the hairline at the neck. Check for flaking, sores,
lice, nits (lice eggs), and ringworm.
6. Inspect amount of body hair. Check for hirsutism or abnormal hairiness in women.

Life Considerations in Assessing the Hair

Infants
1. It is normal for infants to have either very little or a great deal of body and scalp
hair.

Children
1. As puberty approaches, axillary and pubic hair will appear. Assess the Five Stages of
Pubic Hair Development in Males and Females.

Older Adults
1. There may be loss of scalp, pubic, and axillary hair.
2. Hairs of the eyebrows, ears, and nostrils become bristle-like and coarse.

SELF-STUDY GUIDE QUESTION

1. What may be the presenting signs on hair if the client was diagnose with
hypothyroidism?

NAILS
Nails are inspected for nail plate shape, angle between the fingernail and the nail
bed, nail texture, nail bed color, and the intactness of the tissues around the nails. The nail
plate is normally colorless and has a convex curve. The angle between the fingernail and the
nail bed is normally 160 degrees. Nail texture is normally smooth. Excessively thick nails
can appear in older adults, in the presence of poor circulation, or in relation to a chronic
fungal infection. Excessively thin nails or the presence of grooves or furrows can reflect
prolonged iron deficiency anemia.
The tissue surrounding the nails is normally intact epidermis. Paronychia is an
inflammation of the tissues surrounding a nail (often referred to as an “ingrown nail”). The
tissues appear inflamed and swollen, and tenderness is usually present.
A blanch test can be carried out to test the capillary refill, that is, peripheral
circulation. Normal nail bed capillaries blanch when pressed but quickly turn pink or their
usual color when pressure is released. A slow rate of capillary refill may indicate circulatory
problems.
Table 4.2 Problems In or Near the Nails
Problems Definition
Paronychia A superficial infection of the proximal and

HEALTH ASSESSMENT (NCM 101)

 lateral nail folds adjacent to the nail plate. The
nail folds are often red, swollen, and tender.
Represents the most common infection of the
hand, usually from Staphylococcus aureus or
Streptococcus species, and may spread until it
completely surrounds the nail plate. Creates a
felon if it extends into the pulp space of the
finger. Arises from local trauma due to nail
biting, manicuring, or frequent hand immersion
in water.
Clubbing of the Fingers Clinically a bulbous swelling of the soft tissue at
the nail base, with loss of the normal angle
between the nail and the proximal nail fold. The
angle increases to 180° or more, and the nail
bed feels spongy or floating. Seen in congenital
heart disease, interstitial lung disease and lung
cancer, inflammatory bowel diseases, and
malignancies.

HEALTH ASSESSMENT (NCM 101)

 Onycholysis A painless separation of the whitened opaque
nail plate from the pinker translucent nail bed.
Starts distally and progresses proximally,
enlarging the free edge of the nail. Local causes
include trauma from excess manicuring,
psoriasis, fungal infection, and allergic reactions
to nail cosmetics. Systemic causes include
diabetes, anemia, photosensitive drug reactions,
hyperthyroidism, peripheral ischemia,
bronchiectasis, and syphilis.
Terry’s Nails Nail plate turns white with a ground-glass
appearance, a distal band of reddish brown, and
obliteration of the lunula. Commonly affects all
fingers, although may appear in only one finger.
Seen in liver disease, usually cirrhosis, heart
failure, and diabetes. May arise from decreased
vascularity and increased connective tissue in
nail bed.
White Spots (Leukonychia) Trauma to the nails is commonly followed by
nonuniform white spots that grow slowly out
with the nail. Spots in the pattern illustrated are
typical of overly vigorous and repeated
manicuring. The curves in this example
resemble the curve of the cuticle and proximal
nail fold.
Transverse White Bands (Mees’ Curving transverse white bands that cross the
Lines) nail parallel to the lunula. Arising from the
disrupted matrix of the proximal nail, they vary
in width and move distally as the nail grows out.
Seen in arsenic poisoning, heart failure,
Hodgkin’s disease, chemotherapy, carbon
monoxide poisoning, and leprosy.
Transverse Linear Depressions Transverse depressions of the nail plates,
(Beau’s Lines) usually bilateral, resulting from temporary
disruption of proximal nail growth from
systemic illness. As with Mees’ lines, timing of
the illness may be estimated by measuring the
distance from the line to the nail bed (nails grow
approximately 1 mm every 6 to 10 days). Seen
in severe illness, trauma, and cold exposure if
Raynaud’s disease is present.
Pitting Punctate depressions of the nail plate caused by
defective layering of the superficial nail plate by
the proximal nail matrix. Usually associated with
psoriasis but also seen in Reiter’s syndrome,
sarcoidosis, alopecia areata, and localized atopic
or chemical dermatitis.
Koilonychias The spoon shape, in which the nail curves
upward from the nail bed, which may be seen in
clients with iron deficiency anemia.

HEALTH ASSESSMENT (NCM 101)

Assessing the Nails
1. Inquire if the client has any history of the following: presence of diabetes mellitus,
peripheral circulatory disease, previous injury, or severe illness.
2. Inspect fingernail plate shape to determine its curvature and angle. Normally, nails
has a convex curvature with an angle of nail plate about 160°.
3. Inspect fingernail and toenail texture. Check for excessive thickness or thinness or
presence of grooves or furrows; Beau’s lines; discolored or detached nail.
4. Inspect fingernail and toenail bed color. Normally, nail bed color is highly vascular
and pink in light-skinned clients; dark-skinned clients may have brown or black
pigmentation in longitudinal streaks. Check for bluish or purplish tint that may
reflect cyanosis; pallor that may reflect poor arterial circulation.
5. Inspect tissues surrounding nails. Check hangnails; paronychia or inflammation.
6. Perform blanch test of capillary refill. Press the nails between your thumb and index
finger; look for blanching and return of pink color to nail bed. Perform on at least
one nail on each hand and foot. Prompt return of pink or usual color is generally less
than 2 seconds. Delayed return of pink or usual color may indicate circulatory
impairment.

Life Considerations in Assessing the Nails

Infants
1. Newborns nails grow very quickly, are extremely thin, and tear easily.

Children
1. Bent, bruised, or ingrown toenails may indicate shoes that are too tight.
2. Nail biting should be discussed with an adult family member because it may be a
symptom of stress.

Older Adults
1. The nails grow more slowly and thicken.
2. Longitudinal bands commonly develop, and the nails tend to split.
3. Bands across the nails may indicate protein deficiency; white spots, zinc deficiency;
and spoon-shaped nails, iron deficiency.
4. Toenail fungus is more common and difficult to eliminate (although not dangerous
to health).

SELF-STUDY GUIDE QUESTION

1. Discuss the problems on nails.

HEAD
During assessment of the head, the nurse inspects and palpates simultaneously and
also auscultates. The nurse examines the skull, face, eyes, ears, nose, sinuses, mouth, and
pharynx.

Skull and Face

There is a large range of normal shapes of skulls. A normal head size is referred to as
normocephalic. If head size appears to be outside of the normal range, the circumference
can be compared to standard size tables. Measurements more than two standard deviations
from the norm for the age, sex, and race of the client are abnormal and should be reported
to the primary care provider.
Names of areas of the head are derived from names of the underlying bones: frontal,
parietal, occipital, mastoid process, mandible, maxilla, and zygomatic.
Many disorders cause a change in facial shape or condition. Kidney or cardiac
disease can cause edema of the eyelids. Hyperthyroidism can cause exophthalmos, a
protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or
staring expression. Hypothyroidism, or myxedema, can cause a dry, puffy face with dry skin
and coarse features and thinning of scalp hair and eyebrows. Increased adrenal hormone
production or administration of steroids can cause a round face with reddened cheeks,
referred to as moon face, and excessive hair growth on the upper lips, chin, and sideburn
areas. Prolonged illness, starvation, and dehydration can result in sunken eyes, cheeks, and
temples.

HEALTH ASSESSMENT (NCM 101)

Assessing the Head
1. Inquire if the client has any history of the following: past problems with lumps or
bumps, itching, scaling, or dandruff; history of loss of consciousness, dizziness,
seizures, headache, facial pain, or injury; when and how any lumps occurred; length
of time any other problem existed; any known cause of problem; associated
symptoms, treatment, and recurrences.
2. Inspect the skull for size, shape, and symmetry. Normally, head is rounded,
normocephalic and symmetric, with frontal, parietal, and occipital prominences and
smooth skull contour.
3. Inspect the facial features (e.g., symmetry of structures and of the distribution of
hair).
4. Inspect the eyes for edema and hollowness.
5. Note symmetry of facial movements. Ask the client to elevate the eyebrows, frown,
or lower the eyebrows, close the eyes tightly, puff the cheeks, and smile and show
the teeth.

Lifespan Considerations in Assessing the Head

Infants
1. Newborns delivered vaginally can have elongated, molded heads, which take on
more rounded shapes after a week or two. Infants born by cesarean section tend to
have smooth, rounded heads.
2. The posterior fontanel (soft spot) is about 1 cm (0.4 in.) in size and usually closes by
8 weeks. The anterior fontanel is larger, about 2 to 3 cm (0.8 to 1.2 in.) in size. It
closes by 18 months.
3. Newborns can lift their heads slightly and turn them from side to side. Voluntary
head control is well established by 4 to 6 months.

SELF-STUDY GUIDE QUESTION

1. Explain the lifespan considerations in assessing the head.

EYES AND VISION

To maintain optimum vision, people need to have their eyes examined regularly
throughout life. It is recommended that people under age 40 have their eyes tested every 3
to 5 years, or more frequently if there is a family history of diabetes, hypertension, blood
dyscrasia, or eye disease (e.g., glaucoma). After age 40, an eye examination is recommended
every 2 years.
An eye assessment should be carried out as part of the client’s initial physical
examination; periodic reassessments need to be made for clients in long-term care.
Examination of the eyes includes assessment of the external structures, visual acuity (the
degree of detail the eye can discern in an image), ocular movement, and visual fields (the
area an individual can see when looking straight ahead). Most eye assessment procedures
involve inspection. Consideration is also given to developmental changes and to individual
hygienic practices, if the client wears contact lenses or has an artificial eye.
Many people wear eyeglasses or contact lenses to correct common refractive errors
of the lens of the eye. These errors include myopia (nearsightedness), hyperopia
(farsightedness), and presbyopia (loss of elasticity of the lens and thus loss of ability to see
close objects). Presbyopia begins at about 45 years of age. People notice that they have
difficulty reading newsprint. When both far and near vision require correction, two lenses
(bifocals) are required.
Astigmatism, an uneven curvature of the cornea that prevents horizontal and
vertical rays from focusing on the retina, is a common problem that may occur in
conjunction with myopia and hyperopia. Astigmatism may be corrected with glasses or
surgery.

Common Inflammatory Visual Problems

Common inflammatory visual problems that nurses may encounter in clients include
conjunctivitis, dacryocystitis, hordeolum, iritis, and contusions or hematomas of the eyelids
and surrounding structures.

HEALTH ASSESSMENT (NCM 101)

 a) Conjunctivitis (inflammation of the bulbar and palpebral conjunctiva) may result
from foreign bodies, chemicals, allergenic agents, bacteria, or viruses. Redness,
itching, tearing, and mucopurulent discharge occur. During sleep, the eyelids may
become encrusted and matted together.
b) Dacryocystitis (inflammation of the lacrimal sac) is manifested by tearing and a
discharge from the nasolacrimal duct.
c) Hordeolum (sty) is a redness, swelling, and tenderness of the hair follicle and glands
that empty at the edge of the eyelids.
d) Iritis (inflammation of the iris) may be caused by local or systemic infections and
results in pain, tearing, and photophobia (sensitivity to light).
e) Contusions or hematomas are “black eyes” resulting from injury.
Cataracts tend to occur in persons over 65 years old although they may be present at
any age. This opacity of the lens or its capsule, which blocks light rays, is frequently
removed and replaced by a lens implant. Cataracts may also occur in infants due to a
malformation of the lens if the mother contracted rubella in the first trimester of pregnancy.
Glaucoma (a disturbance in the circulation of aqueous fluid, which causes an increase
in intraocular pressure) is the most frequent cause of blindness in people over age 40
although it can occur at younger ages. It can be controlled if diagnosed early. Danger signs
of glaucoma include:
a) blurred or foggy vision
b) loss of peripheral vision
c) difficulty focusing on close objects
d) difficulty adjusting to dark rooms
e) seeing rainbow colored rings around lights.

Upper eyelids that lie at or below the pupil margin are referred to as ptosis and are
usually associated with aging, edema from drug allergy or systemic disease (e.g., kidney
disease), congenital lid muscle dysfunction, neuromuscular disease (e.g., myasthenia
gravis), and third cranial nerve impairment.
Eversion, an outturning of the eyelid, is called ectropion; inversion, an inturning of the
lid, is called entropion. These abnormalities are often associated with scarring injuries or
the aging process.
Pupils are normally black, are equal in size (about 3 to 7 mm in diameter), and have
round, smooth borders. Cloudy pupils are often indicative of cataracts. Mydriasis (enlarged
pupils) may indicate injury or glaucoma, or result from certain drugs (e.g., atropine, cocaine,
amphetamines). Miosis (constricted pupils) may indicate an inflammation of the iris or
result from such drugs as morphine/heroin and other narcotics, barbiturates, or
pilocarpine. It is also an age-related change in older adults. Anisocoria (unequal pupils) may
result from a central nervous system disorder; however, slight variations may be normal.
The iris is normally flat and round. A bulging toward the cornea can indicate
increased intraocular pressure.

Equipment in Assessing the Eye and Vision

1. Millimeter ruler
2. Penlight
3. Snellen or E chart
4. Opaque card

Assessing the Eye and Vision

1. Inquire if the client has any history of the following: family history of diabetes,
hypertension, blood dyscrasia, or eye disease, injury, or surgery; client’s last visit to
an ophthalmologist; current use of eye medications; use of contact lenses or
eyeglasses; hygienic practices for corrective lenses; current symptoms of eye
problems (e.g., changes in visual acuity, blurring of vision, tearing, spots,
photophobia, itching, or pain).
External Eye Structures
2. Inspect the eyebrows for hair distribution and alignment and skin quality and
movement (ask client to raise and lower the eyebrows). Normally, eyebrows are
symmetrically aligned.
3. Inspect the eyelashes for evenness of distribution and direction of curl. Normally,
equally distributed; curled slightly outward.

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 4. Inspect the eyelids for surface characteristics (e.g., skin quality and texture),
position in relation to the cornea, ability to blink, and frequency of blinking. Inspect
the lower eyelids while the client’s eyes are closed. Normally, skin is intact, no
discharges, no discoloration. Eyelids close symmetrically. Approximately 15 to 20
involuntary blinks per minute and bilateral blinking. When lids open, no visible
sclera above corneas, and upper and lower borders of cornea are slightly covered.
External Eye Structures
5. Inspect the bulbar conjunctiva (that lying over the sclera) for color, texture, and the
presence of lesions. Conjunctiva is transparent and capillaries are sometimes
evident, sclera appears white (darker or yellowish and with small brown macules in
dark-skinned clients). Abnormal findings are jaundiced sclera (e.g., in liver disease);
excessively pale sclera (e.g., in anemia); reddened sclera (marijuana use,
rheumatoid disease); lesions or nodules (may indicate damage by mechanical,
chemical, allergenic, or bacterial agents).
6. Inspect the cornea for clarity and texture. Ask the client to look straight ahead. Hold
a penlight at an oblique angle to the eye, and move the light slowly across the
corneal surface. Normally, cornea is transparent, shiny, and smooth and the details
of the iris are visible. In older people, a thin, grayish white ring around the margin,
called arcus senilis, may be evident. Abnormal findings on the cornea are opaque;
surface not smooth may be the result of trauma or abrasion.
7. Inspect the pupils for color, shape, and symmetry of size. Normally, pupils are black
in color, equal in size, 3 to 7 mm in diameter, round, smooth border, the iris is flat
and round.
8. Assess each pupil’s direct and consensual reaction to light to determine the function
of the third (oculomotor) and fourth (trochlear) cranial nerves. Normally,
illuminated pupil constricts (direct response).
 Partially darken the room.
 Ask the client to look straight ahead.
 Using a penlight and approaching from the side, shine a light on the pupil.
 Observe the response of the illuminated pupil. It should constrict (direct
response).
 Shine the light on the pupil again, and observe the response of the other pupil.
It should also constrict (consensual response).
9. Assess each pupil’s reaction to accommodation.
 Hold an object (a penlight or pencil) about 10 cm (4 in.) from the bridge of the
client’s nose.
 Ask the client to look first at the top of the object and then at a distant object
(e.g., the far wall) behind the penlight. Alternate the gaze from the near to the
far object. Observe the pupil response.
Pupils constrict when looking at near object; pupils dilate when looking at far object.
 Next, ask the client to look at the near object and then move the penlight or
pencil toward the client’s nose. Normally, pupils converge when near object is
moved toward nose. To record normal assessment of the pupils, use the
abbreviation PERRLA (pupils equally round and react to light and
accommodation).
Visual Fields
10. Assess peripheral visual fields to determine function of the retina and neuronal
visual pathways to the brain and second (optic) cranial nerve.
 Have the client sit directly facing you at a distance of 60 to 90 cm (2 to 3 ft.).
 Ask the client to cover the right eye with a card and look directly at your nose.
 Cover or close your eye directly opposite the client’s covered eye (i.e., your left
eye), and look directly at the client’s nose. Normally, temporally, peripheral
objects can be seen at right angles (90 degrees) to the central point of vision.
 Hold an object (e.g., a penlight or pencil) in your fingers, extend your arm, and
move the object into the visual field from various points in the periphery. The
object should be at an equal distance from the client and yourself. Ask the client
to tell you when the moving object is first spotted.
a) To test the temporal field of the left eye, extend and move your right arm in
from the client’s right periphery.
b) To test the upward field of the left eye, extend and move the right arm
down from the upward periphery.

HEALTH ASSESSMENT (NCM 101)

 c) To test the downward field of the left eye, extend and move the right arm
up from the lower periphery.
d) To test the nasal field of the left eye, extend and move your left arm in from
the periphery.
 Repeat the above steps for the right eye, reversing the process.
11. Normally, temporally, peripheral objects can be seen at right angles (90 degrees) to
the central point of vision. The upward field of vision is normally 50°, because the
orbital ridge is in the way. The downward field of vision is normally 70°, because the
cheekbone is in the way. The nasal field of vision is normally 50°, away from the
central point of vision because the nose is in the way.

Figure 4.4 Assessing the client’s left peripheral visual field.

Extraocular Muscle Tests

12. Assess six ocular movements to determine eye alignment and coordination.
 Stand directly in front of the client and hold the penlight at a comfortable
distance, such as 30 cm (1 ft) in front of the client’s eyes.
 Ask the client to hold the head in a fixed position facing you and to follow the
movements of the penlight with the eyes only.
 Move the penlight in a slow, orderly manner through the six cardinal fields of
gaze, that is, from the center of the eye along the lines of the arrows and back to
the center. See the figure below.
 Stop the movement of the penlight periodically so that nystagmus can be
detected.
13. Abnormal findings, eye movements not coordinated or parallel; one or both eyes fail
to follow a penlight in specific directions, e.g., strabismus (cross-eye) Nystagmus
(rapid involuntary rhythmic eye movement) other than at end point may indicate
neurologic impairment.

Figure 4.5 Six Cardinal Fields of Gaze.

14.
Assess for

location of light reflex by shining penlight on the corneal surface (Hirschberg test).
Normally, light falls symmetrically (e.g., at “6 o’clock” on both pupils).
15. Have client fixate on a near or far object. Cover one eye and observe for movement
in the uncovered eye (cover test). Normally, uncovered eye does not move.
Visual Acuity

HEALTH ASSESSMENT (NCM 101)

 16. If the client can read, assess near vision by providing adequate lighting and asking
the client to read from a magazine or newspaper held at a distance of 36 cm (14 in.).
If the client normally wears corrective lenses, the glasses or lenses should be worn
during the test. The document must be in a language the client can read.

CLINICAL ALERT. A Rosenbaum eye chart may be used to test near vision. It consists of
paragraphs of text or characters in different sizes on a 3.5- x 6.5-inch card. Be sure the client
has a literacy level appropriate for the text used.
17. Assess distance vision by asking the client to wear corrective lenses, unless they are
used for reading only (i.e., for distances of only 36 cm [14 in.]).
 Ask the client to stand or sit 6 m (20 ft) from a Snellen or character chart, cover
the eye not being tested, and identify the letters or characters on the chart.

Figure 4.6 Cover the eye not being tested.

 Take three readings: right eye, left eye, both eyes.

 Record the readings of each eye and both eyes (i.e., the smallest line from which
the person is able to read one-half or more of the letters). At the end of each line
of the chart are standardized numbers (fractions). The top line is 20/200. The
numerator (top number) is always 20, the distance the person stands from the
chart. The denominator (bottom number) is the distance from which the normal
eye can read the chart. Therefore, a person who has 20/40 vision can see at 20
feet from the chart what a normal-sighted person can see at 40 feet from the
chart. Visual acuity is recorded as “s––c” (without correction), or “c––c” (with
correction). You can also indicate how many letters were misread in the line,
e.g., “visual acuity 20/40 – 2 c––c” indicates that two letters were misread in the
20/40 line by a client wearing corrective lenses.

Normal finding is 20/20 vision on Snellen-type chart. Abnormal finding is when the
denominator of 40 or more on Snellen type chart with corrective lenses.
Three types of eye charts are available to test visual acuity. The preschool children’s
chart (left); the Snellen standard chart (center); Snellen E chart for clients unable to read
(right).

Figure 4.7 Types of Eye Charts.

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 18. If the client is unable to see even the top line (20/200) of the Snellen-type chart,
perform functional vision tests.

Performing Functional Vision Tests

 Light Perception (LP). Shine a penlight into the client’s eye from a lateral
position, and then turn the light off. Ask the client to tell you when the light is
on or off. If the client knows when the light is on or off, the client has light
perception, and the vision is recorded as “LP.”
 Hand Movements (H/M). Hold your hand 30 cm (1 ft) from the client’s face and
move it slowly back and forth, stopping it periodically. Ask the client to tell you
when your hand stops moving. If the client knows when your hand stops
moving, record the vision as “H/M 1 ft.”
 Counting Fingers (C/F). Hold up some of your fingers 30 cm (1 ft) from the
client’s face, and ask the client to count your fingers. If the client can do so, note
on the vision record “C/F 1 ft.”

Lifespan Considerations in Assessing the Eyes and Vision

Infants
1. Infants 4 weeks of age should gaze at and follow objects.
2. Ability to focus with both eyes should be present by 6 months of age.
3. Infants do not have tears until about 3 months of age.
4. Visual acuity is about 20/300 at 4 months and progressively improves.

Children
1. Epicanthal folds, common in persons of Asian cultures, may cover the medial canthus
and cause eyes to appear misaligned. Epicanthal folds may also be seen in young
children of any race before the bridge of the nose begins to elevate.
2. Preschool children’s acuity can be checked with picture cards or the Snellen E chart.
Acuity should approach 20/20 by 6 years of age.
3. A cover test and the corneal light reflex (Hirschberg) test should be conducted on
young children to detect misalignment early and prevent amblyopia.
4. Always perform the acuity test with glasses on if a child has prescription lenses.
5. Children should be tested for color vision deficit. From 8% to 10% of Caucasian males
and from 0.5% to 1% of Caucasian females have this deficit; it is much less common in
non-Caucasian children. The Ishihara or Hardy-Rand-Rittler test can be used.

Older Adults
Visual Acuity
1. Visual acuity decreases as the lens of the eye ages and becomes more opaque and
loses elasticity.
2. The ability of the iris to accommodate to darkness and dim light diminishes.
3. Peripheral vision diminishes.
4. The adaptation to light (glare) and dark decreases.

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 5. Accommodation to far objects often improve, but accommodation to near objects
decreases.
6. Color vision declines; older people are less able to perceive purple colors and to
discriminate pastel colors.
7. Many older adults wear corrective lenses; they are most likely to have hyperopia.
Visual changes are due to loss of elasticity (presbyopia) and transparency of the
lens.

External Eye Structures

1. The skin around the orbit of the eye may darken.
2. The eyeball may appear sunken because of the decrease in orbital fat.
3. Skin folds of the upper lids may seem more prominent, and the lower lids may sag.
4. The eyes may appear dry and lusterless because of the decrease in tear production
from the lacrimal glands.
5. A thin, grayish white arc or ring (arcus senilis) appears around part or all of the
cornea. It results from an accumulation of a lipid substance on the cornea. The
cornea tends to cloud with age.
6. The iris may appear pale with brown discolorations as a result of pigment
degeneration.
7. The conjunctiva of the eye may appear paler than that of younger adults and may
take on a slightly yellow appearance because of the deposition of fat.
8. Pupil reaction to light and accommodation is normally symmetrically equal but may
be less brisk.
9. The pupils can appear smaller in size, unequal, and irregular in shape because of
sclerotic changes in the iris.

SELF-STUDY GUIDE QUESTION

1. Explain how to assess the visual acuity of preschool and clients who are unable to
read.

EARS AND HEARING

Assessment of the ear includes direct inspection and palpation of the external ear,
inspection of the internal parts of the ear by an otoscope (instrument for examining the
interior of the ear, especially the eardrum, consisting essentially of a magnifying lens and a
light), and determination of auditory acuity.
The ear is usually assessed during an initial physical examination; periodic
reassessments may be necessary for long-term clients or those with hearing problems. In
some practice settings, only advanced practice nurses perform otoscopic examinations. The
ear is divided into three parts: external ear, middle ear, and inner ear.
1. The external ear includes the auricle or pinna, the external auditory canal, and the
tympanic membrane or eardrum. Landmarks of the auricle include the lobule
(earlobe), helix (the posterior curve of the auricle’s upper aspect), antihelix (the
anterior curve of the auricle’s upper aspect), tragus (the cartilaginous protrusion at
the entrance to the ear canal), triangular fossa (a depression of the antihelix), and
external auditory meatus (the entrance to the ear canal).
Although not part of the ear, the mastoid, a bony prominence behind the ear,
is another important landmark. The external ear canal is curved, is about 2.5 cm (1
in.) long in the adult, and ends at the tympanic membrane. It is covered with skin
that has many fine hairs, glands, and nerve endings. The glands secrete cerumen
(earwax), which lubricates and protects the canal.
The curvature of the external ear canal differs with age. In the infant and
toddler, the canal has an upward curvature. By age 3, the ear canal assumes the
more downward curvature of adulthood.
2. The middle ear is an air-filled cavity that starts at the tympanic membrane and
contains three ossicles (bones of sound transmission): the malleus (hammer), the
incus (anvil), and the stapes (stirrups). The eustachian tube, another part of the
middle ear, connects the middle ear to the nasopharynx. The tube stabilizes the air
pressure between the external atmosphere and the middle ear, thus preventing
rupture of the tympanic membrane and discomfort produced by marked pressure
differences.

HEALTH ASSESSMENT (NCM 101)

 3. The inner ear contains the cochlea, a seashell-shaped structure essential for sound
transmission and hearing, and the vestibule and semicircular canals, which contain
the organs of equilibrium.

Sound transmission and hearing are complex processes. In brief, sound can be
transmitted by air conduction or bone conduction. Air-conducted transmission occurs by
this process:
1. A sound stimulus enters the external canal and reaches the tympanic membrane.
2. The sound waves vibrate the tympanic membrane and reach the ossicles.
3. The sound waves travel from the ossicles to the opening in the inner ear (oval
window).
4. The cochlea receives the sound vibrations.
5. The stimulus travels to the auditory nerve (the eighth cranial nerve) and the
cerebral cortex.

Bone-conducted sound transmission occurs when skull bones transport the sound
directly to the auditory nerve.
Audiometric evaluations, which measure hearing at various decibels, are
recommended for children and older adults. A common hearing deficit with age is loss of
ability to hear high frequency sounds, such as f, s, sh, and ph. This neurosensory hearing
deficit does not respond well to use of a hearing aid.
Conductive hearing loss is the result of interrupted transmission of sound waves
through the outer and middle ear structures. Possible causes are a tear in the tympanic
membrane or an obstruction, due to swelling or other causes, in the auditory canal.
Sensorineural hearing loss is the result of damage to the inner ear, the auditory nerve, or
the hearing center in the brain. Mixed hearing loss is a combination of conduction and
sensorineural loss.

Equipment in Assessment of Ears and Hearing

 Otoscope with several sizes of ear specula

Assessment of Ears and Hearing

1. Inquire if the client has any history of the following: family history of hearing
problems or loss; presence of ear problems or pain; medication history, especially if
there are complaints of ringing in the ears (tinnitus); hearing difficulty: its onset,
factors contributing to it, and how it interferes with activities of daily living; use of a
corrective hearing device: when and from whom it was obtained.
2. Position the client comfortably, seated if possible.
Auricles
3. Inspect the auricles for color, symmetry of size, and position. To inspect position,
note the level at which the superior aspect of the auricle attaches to the head in
relation to the eye. Normally, auricle is aligned with outer canthus of eye, about 10°,
from vertical. Low-set ears are associated with a congenital abnormality, such as
Down syndrome.

Figure 4.8 Alignment of the Ears

HEALTH ASSESSMENT (NCM 101)

 4. Palpate the auricles for texture, elasticity, and areas of tenderness.
 Gently pull the auricle upward, downward, and backward.
 Fold the pinna forward (it should recoil).
 Push in on the tragus.
 Apply pressure to the mastoid process.
External Ear Canal and Tympanic Membrane
5. Inspect the external ear canal for cerumen, skin lesions, pus, and blood.
6. Visualize the tympanic membrane using an otoscope.
 Attach a speculum to the otoscope. Use the largest diameter that will fit the ear
canal without causing discomfort.
Rationale: This achieves maximum vision of the entire ear canal and tympanic
membrane.
 Tip the client’s head away from you, and straighten the ear canal. For an adult,
straighten the ear canal by pulling the pinna up and back.
Rationale: Straightening the ear canal facilitates vision of the ear canal and the
tympanic membrane.
 Hold the otoscope either (a) right side up, with your fingers between the
otoscope handle and the client’s head or (b) upside down, with your fingers and
the ulnar surface of your hand against the client’s head.
Rationale: This stabilizes the head and protects the eardrum and canal from injury if
a quick head movement occurs.
 Gently insert the tip of the otoscope into the ear canal, avoiding pressure by the
speculum against either side of the ear canal.
Rationale: The inner two thirds of the ear canal is bony; if the speculum is pressed
against either side, the client will experience discomfort.
7. Inspect the tympanic membrane for color and gloss. Normally, it’s pearly gray color,
semitransparent.
Gross Hearing Acuity Tests
8. Assess client’s response to normal voice tones. If client has difficulty hearing the
normal voice, proceed with the following tests.
9. Perform the watch tick test. The ticking of a watch has a higher pitch than the
human voice.
 Have the client occlude one ear. Out of the client’s sight, place a ticking watch 2
to 3 cm (1 in.) from the unoccluded ear.
 Ask what the client can hear.
 Repeat with the other ear.
10. Tuning Fork Tests. Perform Weber’s test to assess bone conduction by examining
the lateralization (sideward transmission) of sounds.
 Hold the tuning fork at its base. Activate it by tapping the fork gently against the
back of your hand near the knuckles or by stroking the fork between your
thumb and index fingers. It should be made to ring softly.
 Place the base of the vibrating fork on top of the client’s head and ask where the
client hears the noise.
 Conduct the Rinne test to compare air conduction to bone conduction.

Normally, the sound is heard in both ears or is localized at the center of the head
(Weber negative). See Figure 4.9.

Figure 4.9 Placing the base of the tuning fork on the client’s skull (Weber’s test).

HEALTH ASSESSMENT (NCM 101)

  Hold the handle of the activated tuning fork on the mastoid process of one ear,
until the client states that the vibration can no longer be heard. See Figure 4.10.

Figure 4.10 Rinne test tuning fork placement, base of the tuning fork
on the mastoid process

 Immediately hold the still vibrating fork prongs in front of the client’s ear canal.
Push aside the client’s hair if necessary. Ask whether the client now hears the
sound. Sound conducted by air is heard more readily than sound conducted by
bone. The tuning fork vibrations conducted by air are normally heard longer.
See Figure 4.11.

Figure 4.11 Tuning fork prongs placed in front of client’s ears.

Lifespan Considerations in Assessing the Ears and Hearing

Infants
1. To assess gross hearing, ring a bell from behind the infant or have the parent call the
child’s name to check for a response. Newborns will quiet to the sound and may
open their eyes wider. By 3 to 4 months of age, the child will turn head and eyes
toward the sound. All newborns should be assessed for hearing using auditory brain
response testing prior to discharge from the hospital.

Children
1. To inspect the external canal and tympanic membrane in children less than 3 years
old, pull the pinna down and back. Insert the speculum only 0.6 to 1.25 cm (0.25 to
0.5 in.).
2. Perform routine hearing checks and follow up on abnormal results. In addition to
congenital or infection-related causes of hearing loss, noise-induced hearing loss is

HEALTH ASSESSMENT (NCM 101)

 becoming more common in adolescents and young adults as a result of exposure to
loud music and prolonged use of headsets at loud volumes (Daniel, 2007). Teach
that music loud enough to prevent hearing a normal conversation can damage
hearing.

Older Adults
1. The skin of the ear may appear dry and be less resilient because of the loss of
connective tissue.
2. Increased coarse and wirelike hair growth occurs along the helix, antihelix, and
tragus.
3. The pinna increases in both width and length, and the earlobe elongates.
4. Earwax is drier.
5. The tympanic membrane is more translucent and less flexible. The intensity of the
light reflex may diminish slightly.
6. Sensorineural hearing loss occurs.
7. Generalized hearing loss (presbycusis) occurs in all frequencies, although the first
symptom is the loss of high frequency sounds: the f, s, sh, and ph sounds. To such
persons, conversation can be distorted and result in what appears to be
inappropriate or confused behavior.

SELF-STUDY GUIDE QUESTION

1. Discuss the lifespan considerations in assessing the ears and hearing.

NOSE AND SINUSES

A nurse can inspect the nasal passages very simply with a flashlight. However, a
nasal speculum and a penlight or an otoscope with a nasal attachment facilitates
examination of the nasal cavity.
Assessment of the nose includes inspection and palpation of the external nose (the
upper third of the nose is bone; the remainder is cartilage); patency of the nasal cavities;
and inspection of the nasal cavities. If the client reports difficulty or abnormality in smell,
the nurse may test the client’s olfactory sense by asking the client to identify common odors
such as coffee or mint. This is done by asking the client to close the eyes and placing vials
containing the scent under the client’s nose. The nurse also inspects and palpates the facial
sinuses.

Equipment in Assessing the Nose and Sinuses

1. Nasal speculum
2. Flashlight/penlight

Assessing the Nose and Sinuses

Nose
1. Inquire if the client has any history of the following: allergies, difficulty breathing
through the nose, sinus infections, injuries to nose or face, nosebleeds; medications
taken; changes in sense of smell.
2. Position the client comfortably, seated if possible.
3. Inspect the external nose for any deviations in shape, size, or color and flaring or
discharge from the nares.
4. Lightly palpate the external nose to determine any areas of tenderness, masses, and
displacements of bone and cartilage.
5. Determine patency of both nasal cavities. Ask the client to close the mouth, exert
pressure on one naris, and breathe through the opposite naris. Repeat the
procedure to assess patency of the opposite naris.
6. Inspect the nasal cavities using a flashlight or a nasal speculum.
 Hold the speculum in your right hand to inspect the client’s left nostril and your
left hand to inspect the client’s right nostril.
 Tip the client’s head back.
 Facing the client, insert the tip of the closed nasal speculum (blades together)
about 1 cm (0.4 in.) or up to the point at which the blade widens. Care must be
taken to avoid pressure on the sensitive nasal septum. See Figure 4.12.

Figure 4.12 Using a nasal speculum to inspect the nasal passages.

HEALTH ASSESSMENT (NCM 101)

  Stabilize the speculum with your index finger against the side of the nose. Use
the other hand to position the head and then to hold the light.
 Open the speculum as much as possible and inspect the floor of the nose
(vestibule), the anterior portion of the septum, the middle meatus, and the
middle turbinates. The posterior turbinate is rarely visualized because of its
position.
 Inspect the lining of the nares and the integrity and the position of the nasal
septum.
7. Observe for the presence of redness, swelling, growths, and discharge.
8. Inspect the nasal septum between the nasal chambers.
Facial Sinuses
9. Palpate the maxillary and frontal sinuses for tenderness. See the figure above for
facial sinuses.

Lifespan Considerations in Assessing the Nose and Sinuses

Infants
1. A speculum is usually not necessary to examine the septum, turbinates, and
vestibule. Instead, push the tip of the nose upward with the thumb and shine a light
into the nares.
2. Ethmoid and maxillary sinuses are present at birth; frontal sinuses begin to develop
by 1 to 2 years of age; and sphenoid sinuses develop later in childhood. Infants and
young children have fewer sinus problems than older children and adolescents.

Children
1. A speculum is usually not necessary to examine the septum, turbinates, and
vestibule. It might cause the child to be apprehensive. Instead, push the tip of the
nose upward with the thumb and shine a light into the nares.
2. Ethmoid sinuses develop by age 6. Sinus problems in children under this age are
rare.
3. Cough and runny nose are the most common signs of sinusitis in preadolescent
children.
4. Adolescents may have headaches, facial tenderness, and swelling, similar to the
signs seen in adults.

Older Adults
1. The sense of smell markedly diminishes because of a decrease in the number of
olfactory nerve fibers and atrophy of the remaining fibers. Older adults are less able
to identify and discriminate odors.
2. Nosebleeds may result from hypertensive disease or other arterial vessel changes.

SELF-STUDY GUIDE QUESTION

1. Discuss the lifespan considerations in assessing the nose and sinuses.

MOUTH AND OROPHARYNX

The mouth and oropharynx are composed of a number of structures: lips, oral
mucosa, the tongue and floor of the mouth, teeth and gums, hard and soft palate, uvula,
salivary glands, tonsillar pillars, and tonsils. By age 25, most people have all their
permanent teeth.

HEALTH ASSESSMENT (NCM 101)

 Normally, three pairs of salivary glands empty into the oral cavity: the parotid,
submandibular, and sublingual glands. The parotid gland is the largest and empties through
the Stensen’s duct opposite the second molar. The submandibular gland empties through
Wharton’s duct, which is situated on either side of the frenulum on the floor of the mouth.
The sublingual salivary gland lies in the floor of the mouth and has numerous openings.
Dental caries (cavities) and periodontal disease (pyorrhea) are the two problems
that most frequently affect the teeth. Both problems are commonly associated with plaque
and tartar deposits. Plaque is an invisible soft film that adheres to the enamel surface of
teeth; it consists of bacteria, molecules of saliva, and remnants of epithelial cells and
leukocytes. When plaque is unchecked, tartar (dental calculus) forms.
Tartar is a visible, hard deposit of plaque and dead bacteria that forms at the gum
lines. Tartar buildup can alter the fibers that attach the teeth to the gum and eventually
disrupt bone tissue. Periodontal disease is characterized by gingivitis (red, swollen gingiva,
i.e., gum), bleeding, receding gum lines, and the formation of pockets between the teeth and
gums. In advanced periodontal disease, the teeth are loose and pus is evident when the
gums are pressed.
Other problems nurses may see are glossitis (inflammation of the tongue),
stomatitis (inflammation of the oral mucosa), and parotitis (inflammation of the parotid
salivary gland). The accumulation of foul matter (food, microorganisms, and epithelial
elements) on the teeth and gums is referred to as sordes.

Equipment in Assessing the Mouth and Oropharynx

1. Clean gloves
2. Tongue depressor
3. 2x2 gauze pads
4. Penlight

Assessing the Mouth and Oropharynx

1. Inquire if the client has any history of the following: routine pattern of dental care,
last visit to dentist; length of time ulcers or other lesions have been present; denture
discomfort; medications client is receiving.

Lips and Buccal Mucosa

2. Inspect the outer lips for symmetry of contour, color, and texture. Ask the client to
purse the lips as if to whistle.
3. Inspect and palpate the inner lips and buccal mucosa for color, moisture, texture,
and the presence of lesions.
 Apply clean gloves.
 Ask the client to relax the mouth, and, for better visualization, pull the lip
outward and away from the teeth.
 Grasp the lip on each side between the thumb and index finger.
Teeth and Gums
4. Inspect the teeth and gums while examining the inner lips and buccal mucosa. In
adult, there are 32 teeth. It should be smooth, white, shiny tooth enamel.
 Ask the client to open the mouth. Using a tongue depressor, retract the cheek. See
Figure 4.13. View the surface buccal mucosa from top to bottom and back to
front. A flashlight or penlight will help illuminate the surface. Repeat the
procedure for the other side.

Figure 4.13 Inspecting the Buccal Mucosa Using A Tongue Depressor

HEALTH ASSESSMENT (NCM 101)

  Examine the back teeth. For proper vision of the molars, use the index fingers of
both hands to retract the cheek. See Figure 4.14. Ask the client to relax the lips
and first close, then open, the jaw.
Rationale: Closing the jaw assists in observation of tooth alignment and loss of
teeth; opening the jaw assists in observation of dental fillings and caries.

Figure 4.14 Inspecting the Back Teeth

 Observe the number of teeth, tooth color, the state of fillings, dental caries, and
tartar along the base of the teeth. Note the presence and fit of partial or complete
dentures.
 Inspect the gums around the molars. Observe for bleeding, color, retraction
(pulling away from the teeth), edema, and lesions.
Tongue/Floor of the Mouth
5. Inspect the surface of the tongue for position, color, and texture. Ask the client to
protrude the tongue. Normally, pink color (some brown pigmentation on tongue
borders in dark-skinned clients); moist; slightly rough; thin whitish coating Smooth,
lateral margins; no lesions Raised papillae (taste buds). Tongue deviated from
center (may indicate damage to hypoglossal [12th cranial] nerve); excessive
trembling. Smooth red tongue (may indicate iron, vitamin B12, or vitamin B3
deficiency). Dry, furry tongue (associated with fluid deficit), white coating (may be
oral yeast infection). Nodes, ulcerations, discolorations (white or red areas); areas
of tenderness.
6. Inspect tongue movement. Ask the client to roll the tongue upward and move it from
side to side.
7. Inspect the base of the tongue, the mouth floor, and the frenulum. Ask the client to
place the tip of the tongue against the roof of the mouth.
Palates and Uvula
8. Inspect the hard and soft palate for color, shape, texture, and the presence of bony
prominences.
9. Ask the client to open the mouth wide and tilt the head backward. Then, depress
tongue with a tongue depressor as necessary, and use a penlight for appropriate
visualization.
10. Inspect the uvula for position and mobility while examining the palates. To observe
the uvula, ask the client to say “ah” so that the soft palate rises. Deviation to one side
from tumor or trauma; immobility (may indicate damage to trigeminal [5th cranial]
nerve or vagus [10th cranial] nerve).
Oropharynx and Tonsils
11. Inspect the oropharynx for color and texture. Inspect one side at a time to avoid
eliciting the gag reflex. To expose one side of the oropharynx, press a tongue
depressor against the tongue on the same side about halfway back while the client
tilts the head back and opens the mouth wide. Use a penlight for illumination, if
needed.
12. Inspect the tonsils (behind the fauces) for color, discharge, and size.
Tonsil size:
 Grade 1 (normal): The tonsils are behind the tonsillar pillars (the soft
structures supporting the soft palate).
 Grade 2: The tonsils are between the pillars and the uvula.
 Grade 3: The tonsils touch the uvula.
 Grade 4: One or both tonsils extend to the midline of the oropharynx.

Lifespan Considerations in Assessing the Mouth and Oropharynx

HEALTH ASSESSMENT (NCM 101)

Infants
1. Inspect the palate and uvula for a cleft. A bifid (forked) uvula may indicate an
unsuspected cleft palate (i.e., a cleft in the cartilage that is covered by skin).
2. Newborns may have a pearly white nodule on their gums, which resolves without
treatment.
3. The first teeth erupt at about 6 to 7 months of age. Assess for dental hygiene;
parents should cleanse the infant’s teeth daily with a soft cloth or soft toothbrush.
4. Fluoride supplements should be given by 6 months if the child’s drinking water
contains less than 0.3 parts per million (ppm) fluoride.
5. Children should see a dentist by 1 year of age.

Children
1. Tooth development should be appropriate for age.
2. White spots on the teeth may indicate excessive fluoride ingestion.
3. Drooling is common up to 2 years of age.
4. The tonsils are normally larger in children than in adults and commonly extend
beyond the palatine arch until the age of 11 or 12 years.

Older Adults
1. The oral mucosa may be drier than that of younger persons because of decreased
salivary gland activity. Decreased salivation occurs in older people taking
prescribed medications such as antidepressants, antihistamines, decongestants,
diuretics, antihypertensives, tranquilizers, antispasmodics, and antineoplastics.
Extreme dryness is associated with dehydration.
2. Some receding of the gums occurs, giving an appearance of increased toothiness.
3. Taste sensations diminish. Sweet and salty tastes are lost first. Older persons may
add more salt and sugar to food than they did when they were younger. Diminished
taste sensation is due to atrophy of the taste buds and a decreased sense of smell. It
indicates diminished function of the fifth and seventh cranial nerves.
4. Tiny purple or bluish black swollen areas (varicosities) under the tongue, known as
caviar spots, are not uncommon.
5. The teeth may show signs of staining, erosion, chipping, and abrasions due to loss of
dentin.
6. Tooth loss occurs as a result of dental disease but is preventable with good dental
hygiene.
7. The gag reflex may be slightly sluggish.
8. Older adults who are homebound or are in long-term care facilities often have teeth
or dentures in need of repair, due to the difficulty of obtaining dental care in these
situations. Do a thorough assessment of missing teeth and those in need of repair,
whether they are natural teeth or dentures.

SELF-STUDY GUIDE QUESTION

1. Discuss the lifespan considerations in assessing the mouth and oropharynx.

NECK
Examination of the neck includes the muscles, lymph nodes, trachea, thyroid gland,
carotid arteries, and jugular veins. Areas of the neck are defined by the sternocleidomastoid
muscles, which divide each side of the neck into two triangles: the anterior and posterior.
The trachea, thyroid gland, anterior cervical nodes, and carotid artery lie within the
anterior triangle; the carotid artery runs parallel and anterior to the sternocleidomastoid
muscle. The posterior lymph nodes lie within the posterior triangle.
Each sternocleidomastoid muscle extends from the upper sternum and the medial
third of the clavicle to the mastoid process of the temporal bone behind the ear. These
muscles turn and laterally flex the head. Each trapezius muscle extends from the occipital
bone of the skull to the lateral third of the clavicle. These muscles draw the head to the side
and back, elevate the chin, and elevate the shoulders to shrug them. Lymph nodes in the
neck that collect lymph from the head and neck structures are grouped serially and referred
to as chains.

Assessing the Neck

HEALTH ASSESSMENT (NCM 101)

 1. Inquire if the client has any history of the following: problems with neck lumps;
neck pain or stiffness; when and how any lumps occurred; previous diagnoses of
thyroid problems; and other treatments provided (e.g., surgery, radiation).
Neck Muscles
2. Inspect the neck muscles (sternocleidomastoid and trapezius) for abnormal
swellings or masses. Ask the client to hold the head erect.
3. Observe head movement. Ask client to:
 Move the chin to the chest. Head flexes 45°.
Rationale: This determines function of the sternocleidomastoid muscle.
Check for abnormal findings limited range of motion; painful movements;
involuntary movements (e.g., up-and-down nodding movements associated with
Parkinson’s disease).
 Move the head back so that the chin points upward. Head hyperextends 60°.
Rationale: This determines function of the trapezius muscle.
 Move the head so that the ear is moved toward the shoulder on each side. Head
laterally flexes 40°.
Rationale: This determines function of the sternocleidomastoid muscle.
 Turn the head to the right and to the left. Head laterally rotates 70°.
Rationale: This determines function of the sternocleidomastoid muscle.
4. Assess muscle strength.
 Ask the client to turn the head to one side against the resistance of your hand.
Repeat with the other side.
Rationale: This determines the strength of the sternocleidomastoid muscle.
 Ask the client to shrug the shoulders against the resistance of your hands.
Rationale: This determines the strength of the trapezius muscles.
Lymph Nodes
5. Palpate the entire neck for enlarged lymph nodes.
 Face the client, and bend the client’s head forward slightly or toward the side
being examined.
Rationale: This relaxes the soft tissue and muscles.
 Palpate the nodes using the pads of the fingers. Move the fingertips in a gentle
rotating motion.
 When examining the submental and submandibular nodes, place the fingertips
under the mandible on the side nearest the palpating hand, and pull the skin and
subcutaneous tissue laterally over the mandibular surface so that the tissue rolls
over the nodes.
 When palpating the supraclavicular nodes, have the client bend the head
forward to relax the tissues of the anterior neck and to relax the shoulders so
that the clavicles drop. Use your hand nearest the side to be examined when
facing the client (i.e., your left hand for the client’s right nodes). Use your free
hand to flex the client’s head forward if necessary. Hook your index and third
fingers over the clavicle lateral to the sternocleidomastoid muscle. See Figure
4.15.

Figure 4.15 Palpating the supraclavicular lymph nodes.

 When palpating the anterior cervical nodes and posterior cervical nodes, move
your fingertips slowly in a forward circular motion against the
sternocleidomastoid and trapezius muscles, respectively.

HEALTH ASSESSMENT (NCM 101)

  To palpate the deep cervical nodes, bend or hook your fingers around the
sternocleidomastoid muscle.
Trachea
6. Palpate the trachea for lateral deviation. Place your fingertip or thumb on the
trachea in the suprasternal notch (see the figure earlier, Structures of the neck), and
then move your finger laterally to the left and the right in spaces bordered by the
clavicle, the anterior aspect of the sternocleidomastoid muscle, and the trachea.
Thyroid Gland
7. Inspect the thyroid gland.
 Stand in front of the client.
 Observe the lower half of the neck overlying the thyroid gland for symmetry and
visible masses.
 Ask the client to extend the head and swallow. If necessary, offer a glass of water
to make it easier for the client to swallow.
Rationale: This action determines how the thyroid and cricoid cartilages move and
whether swallowing causes a bulging of the gland.

Lifespan Considerations in Assessing the Neck

Infants and Children
1. Examine the neck while the infant or child is lying supine. Lift the head and turn it
from side to side to determine neck mobility.
2. An infant’s neck is normally short, lengthening by about age 3 years. This makes
palpation of the trachea difficult.

THORAX AND LUNGS

Assessing the thorax and lungs is frequently critical to assessing the client’s
oxygenation status. Changes in the respiratory system can occur slowly or quickly. In clients
with chronic obstructive pulmonary disease (COPD), such as chronic bronchitis,
emphysema, and asthma, changes are frequently gradual. The onset of conditions such as
pneumonia or pulmonary embolus is generally more acute or sudden.

Chest Landmarks
Before beginning the assessment, the nurse must be familiar with a series of
imaginary lines on the chest wall and be able to locate the position of each rib and some
spinous processes. These landmarks help the nurse to identify the position of underlying
organs (e.g., lobes of the lung) and to record abnormal assessment findings.
The midsternal line is a vertical line running through the center of the sternum. The
midclavicular lines (right and left) are vertical lines from the midpoints of the clavicles. The
anterior axillary lines (right and left) are vertical lines from the anterior axillary folds. The
posterior axillary line is a vertical line from the posterior axillary fold. The midaxillary line
is a vertical line from the apex of the axilla.
The vertebral line is a vertical line along the spinous processes. The scapular lines
(right and left) are vertical lines from the inferior angles of the scapulae. Locating the
position of each rib and certain spinous processes is essential for identifying underlying
lobes of the lung.
Each lung is first divided into the upper and lower lobes by an oblique fissure that
runs from the level of the spinous process of the third thoracic vertebra (T3) to the level of
the sixth rib at the midclavicular line.
The right upper lobe is abbreviated RUL; the right lower lobe, RLL. Similarly, the left
upper lobe is abbreviated LUL; the left lower lobe, LLL. The right lung is further divided by a
minor fissure into the right upper lobe and right middle lobe (RML). This fissure runs
anteriorly from the right midaxillary line at the level of the fifth rib to the level of the fourth
rib.
The nurse can identify the manubrium by first palpating the clavicle and following
its course to its attachment at the manubrium. The nurse then palpates and counts distal
ribs and intercostal spaces (ICSs) from the second rib. It is important to note that an ICS is
numbered according to the number of the rib immediately above the space. When palpating
for rib identification, the nurse should palpate along the midclavicular line rather than the
sternal border because the rib cartilages are very close at the sternum. Only the first seven
ribs attach directly to the sternum. The counting of ribs is more difficult on the posterior
than on the anterior thorax.

HEALTH ASSESSMENT (NCM 101)

 For identifying underlying lung lobes, the pertinent landmark is T3. The starting
point for locating T3 is the spinous process of the seventh cervical vertebra (C7).
When the client flexes the neck anteriorly, a prominent process can be observed and
palpated. This is the spinous process of the seventh cervical vertebra. If two spinous
processes are observed, the superior one is C7, and the inferior one is the spinous process
of the first thoracic vertebra (T1). The nurse then palpates and counts the spinous
processes from C7 to T3.
Each spinous process up to T4 is adjacent to the corresponding rib number; for
example, T3 is adjacent to the third rib. After T4, however, the spinous processes project
obliquely, causing the spinous process of the vertebra to lie, not over its correspondingly
numbered rib, but over the rib below. Thus, the spinous process of T5 lies over the body of
T6 and is adjacent to the sixth rib.

Chest Shape and Size

In adults, the thorax is oval. The overall shape of the thorax is elliptical; that is, its
diameter is smaller at the top than at the base. In older adults, kyphosis and osteoporosis
alter the size of the chest cavity as the ribs move downward and forward.

Deformities of the Chest

There are several deformities of the chest:
1. Pigeon chest (pectus carinatum), a permanent deformity, may be caused by rickets
(abnormal bone formation due to lack of dietary calcium). A narrow transverse
diameter, an increased anteroposterior diameter, and a protruding sternum
characterize pigeon chest.
2. A funnel chest (pectus excavatum), a congenital defect, is the opposite of pigeon
chest in that the sternum is depressed, narrowing the anteroposterior diameter.
Because the sternum points posteriorly in clients with a funnel chest, abnormal
pressure on the heart may result in altered function.
3. A barrel chest, in which the ratio of the anteroposterior to transverse diameter is 1
to 1, is seen in clients with thoracic kyphosis (excessive convex curvature of the
thoracic spine) and emphysema (chronic pulmonary condition in which the air sacs,
or alveoli, are dilated and distended).
4. Scoliosis is a lateral deviation of the spine.

Breath Sounds
Abnormal breath sounds, called adventitious breath sounds, occur when air passes
through narrowed airways or airways filled with fluid or mucus, or when pleural linings are
inflamed. Adventitious sounds are often superimposed over normal sounds. Absence of
breath sounds over some lung areas is also a significant finding that is associated with
collapsed and surgically removed lobes or severe pneumonia. Assessment of the lungs and
thorax includes all methods of examination: inspection, palpation, percussion, and
auscultation.

Equipment in Assessing the Thorax and Lungs

1. Stethoscope
Assessing the Thorax and Lungs
1. Inquire if the client has any history of the following: family history of illness,
including cancer, allergies, tuberculosis; lifestyle habits such as smoking and
occupational hazards (e.g., inhaling fumes); medications being taken; current
problems (e.g., swellings, coughs, wheezing, pain).
Posterior Thorax
2. Inspect the shape and symmetry of the thorax from posterior and lateral views.
Compare the anteroposterior diameter to the transverse diameter.
3. Inspect the spinal alignment for deformities. Have the client stand. From a lateral
position, observe the three normal curvatures: cervical, thoracic, and lumbar. Check
for exaggerated spinal curvatures like kyphosis and lordosis.
 To assess for lateral deviation of spine (scoliosis), observe the standing client
from the rear. Have the client bend forward at the waist and observe from
behind. Normal spinal column is straight, right and left shoulders and hips are at
same height. Abnormal findings are when spinal column deviates to one side,
often accentuated when bending over and shoulders or hips not even.

HEALTH ASSESSMENT (NCM 101)

4. Palpate the posterior thorax.
 For clients who have no respiratory complaints, rapidly assess the temperature
and integrity of all chest skin.
 For clients who do have respiratory complaints, palpate all thorax areas for
bulges, tenderness, or abnormal movements. Avoid deep palpation for painful
areas, especially if a fractured rib is suspected. In such a case, deep palpation
could lead to displacement of the bone fragment against the lungs.
5. Palpate the posterior thorax for respiratory excursion (thoracic expansion). Place
the palms of both your hands over the lower thorax with your thumbs adjacent to
the spine and your fingers stretched laterally. See Figure 4. 16. Ask the client to take
a deep breath while you observe the movement of your hands and any lag in
movement. Normally, full and symmetric thorax expansion (i.e., when the client
takes a deep breath, your thumbs should move apart an equal distance and at the
same time; normally the thumbs separate 3 to 5 cm [1.2 to 2 in.] during deep
inspiration).

Figure 4.16 Position of the nurse’s hands when assessing respiratory excursion on the
posterior thorax.

6. Palpate the thorax for vocal (tactile) fremitus, the faintly perceptible vibration felt
through the chest wall when the client speaks. Normal thorax is bilateral symmetry
of vocal fremitus. Fremitus is heard most clearly at the apex of the lungs. Abnormal
findings show that decreased or absent fremitus is associated with pneumothorax
and increased fremitus is associated with consolidated lung tissue, as in pneumonia.
 Place the palmar surfaces of your fingertips or the ulnar aspect of your hand or
closed fist on the posterior thorax, starting near the apex of the lungs. Position A
in the figure below. Low-pitched voices of males are more readily palpated than
higher pitched voices of females.
 Ask the client to repeat such words as “blue moon” or “one, two, three.”
 Repeat the two steps, moving your hands sequentially to the base of the lungs,
through positions B–E in the figure below.
 Compare the fremitus on both lungs and between the apex and the base of each
lung, using either one hand and moving it from one side of the client to the
corresponding area on the other side or using two hands that are placed
simultaneously on the corresponding areas of each side of the thorax.

Figure 4.17 Areas and sequence for palpating tactile fremitus on the posterior thorax

7. Percuss the thorax. Percussion of the thorax is performed to determine whether

underlying lung tissue is filled with air, liquid, or solid material and to determine the
positions and boundaries of certain organs. Because percussion penetrates to a

HEALTH ASSESSMENT (NCM 101)

 depth of 5 to 7 cm (2 to 3 in.), it detects superficial rather than deep lesions. During
percussion, normal thorax notes resonate, except over scapula. Lowest point of
resonance is at the diaphragm (i.e., at the level of the 8th to 10th rib posteriorly).
Note: Percussion on a rib normally elicits dullness. Areas of dullness or flatness over
lung tissue is associated with consolidation of lung tissue or a mass.

Figure 4.18 Normal percussion sounds on the posterior thorax.

 Ask the client to bend the head and fold the arms forward across the chest.
Rationale: This separates the scapula and exposes more lung tissue to
percussion.
 Percuss in the intercostal spaces at about 5-cm (2-in.) intervals in a
systematic sequence. See Figure 4.19.
 Compare one side of the lung with the other.
 Percuss the lateral thorax every few inches, starting at the axilla and
working down to the eighth rib.

Figure 4.19 Sequence for posterior thorax percussion.

8. Auscultate the thorax using the flatdisk diaphragm of the stethoscope.

Rationale: The diaphragm of the stethoscope is best for transmitting the high-pitched
breath sounds.
 Use the systematic zigzag procedure used in percussion.
 Ask the client to take slow, deep breaths through the mouth. Listen at each point
to the breath sounds during a complete inspiration and expiration.
 Compare findings at each point with the corresponding point on the opposite
side of the thorax.

Table 4.3 Normal Breath Sounds

Type Description Location Characteristics
Vesicular Soft-intensity, low- Over peripheral Best heard on
pitched, “gentle sighing” lung; best heard at inspiration, which is

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 sounds created by air base of lungs about 2.5 times
moving through smaller longer than the
airways (bronchioles and expiratory phase
alveoli)
Broncho- Moderate-intensity and Between the Equal inspiratory and
vesicular moderatepitched scapulae and lateral expiratory phases
“blowing” sounds created to the sternum at
by air moving through the first and second
larger airway (bronchi) intercostal spaces
Bronchial High-pitched, loud, Anteriorly over the Louder than vesicular
(tubular) “harsh” sounds created by trachea; not sounds; have a short
air moving through the normally heard inspiratory phase
trachea over lung tissue and long expiratory
phase

HEALTH ASSESSMENT (NCM 101)

 Table 4.4 Adventitious Breath Sounds
Name Description Cause Location
Crackles (rales) Fine, short, interrupted Air passing through Most commonly
crackling sounds; alveolar fluid or mucus in heard in the bases of
rales are high pitched. any air passage the lower lung lobes
Sound can be simulated
by rolling a lock of hair
near the ear. Best heard
on inspiration but can be
heard on both inspiration
and expiration. May not
be cleared by coughing.
Gurgles Continuous, low-pitched, Air passing through Loud sounds can be
(rhonchi) coarse, gurgling, harsh, narrowed air heard over most lung
louder sounds with a passages as a result areas but
moaning or snoring of secretions, predominate over the
quality. Best heard on swelling, tumors trachea and bronchi
expiration but can be
heard on both inspiration
and expiration. May be
altered by coughing.
Friction rub Superficial grating or Rubbing together of Heard most often in
creaking sounds heard inflamed pleural areas of greatest
during inspiration and surfaces thoracic expansion
expiration. Not relieved (e.g., lower anterior
by coughing. and lateral chest)
Wheeze Continuous, high-pitched, Air passing through Heard over all lung
squeaky musical sounds. a constricted fields
Best heard on expiration. bronchus as a result
Not usually altered by of secretions,
coughing. swelling, tumors

Anterior Thorax
9. Inspect breathing patterns (e.g., respiratory rate and rhythm). Normal breathing is
quiet, rhythmic, and effortless respirations.

Table 4.5 Abnormal Breathing Patterns

Rate  Tachypnea—quick, shallow breaths
 Bradypnea—abnormally slow breathing
 Apnea—cessation of breathing
Volume  Hyperventilation—overexpansion of the lungs
characterized by rapid and deep breaths
 Hypoventilation—underexpansion of the lungs,
characterized by shallow respirations
Rhythm  Cheyne-Stokes breathing—rhythmic waxing and
waning of respirations, from very deep to very shallow
breathing and temporary apnea
Ease or Effort  Dyspnea—difficult and labored breathing during which
the individual has a persistent, unsatisfied need for air
and feels distressed
 Orthopnea—ability to breathe only in upright sitting or
standing positions

HEALTH ASSESSMENT (NCM 101)

 Table 4.6 Abnormal Breathing Sounds
Audible without  Stridor—a shrill, harsh sound heard during inspiration
Amplification with laryngeal obstruction
 Stertor—snoring or sonorous respiration, usually due
to a partial obstruction of the upper airway
 Wheeze—continuous, high-pitched musical squeak or
whistling sound occurring on expiration and sometimes
on inspiration when air moves through a narrowed or
partially obstructed airway
 Bubbling—gurgling sounds heard as air passes through
moist secretions in the respiratory tract
Chest Movements  Intercostal retraction—indrawing between the ribs
 Substernal retraction—indrawing beneath the
breastbone
 Suprasternal retraction—indrawing above the clavicles
Secretions and  Hemoptysis—the presence of blood in the sputum
Coughing  Productive cough—a cough accompanied by
expectorated secretions
 Nonproductive cough—a dry, harsh cough without
secretions

10. Inspect the costal angle (angle formed by the intersection of the costal margins) and
the angle at which the ribs enter the spine. Normal costal angle is less than 90°, and
the ribs insert into the spine at approximately a 45° angle and widened costal angle
is associated with chronic obstructive pulmonary disease.
11. Palpate the anterior thorax (see posterior thorax palpation).
12. Palpate the anterior thorax for respiratory excursion. Position your thumbs 3 to 5
cm (1.2 to 2 in.). See figure below.
 Place the palms of both your hands on the lower thorax, with your fingers
laterally along the lower rib cage and your thumbs along the costal margins.
 Ask the client to take a deep breath while you observe the movement of your
hands.

Figure 4. 20 Position of the nurse’s hands when assessing respiratory excursion on the
anterior thorax.

13. Palpate tactile fremitus in the same manner as for the posterior thorax and using the
sequence shown in the figure below. If the breasts are large and cannot be retracted
adequately for palpation, this part of the examination is usually omitted.

Figure 4.21 Areas and sequence for palpating tactile fremitus on the anterior thorax.

HEALTH ASSESSMENT (NCM 101)

 14. Percuss the anterior thorax systematically.
 Begin above the clavicles in the supraclavicular space, and proceed downward
to the diaphragm.

Figure 4.22 Sequence for anterior thorax percussion.

15. Auscultate the trachea.

 For reference see the bronchial and tubular breath sounds on the above table of
Normal Breath Sounds and Adventitious breath sounds.
16. Auscultate the anterior thorax. Use the sequence used in percussion in the above
Figure 4.22 sequence for anterior thorax percussion, beginning over the bronchi
between the sternum and the clavicles.
 For reference see the bronchial and tubular breath sounds on the above table of
normal breath sounds and adventitious breath sounds.

Lifespan Considerations in Assessing the Thorax and Lungs

Infants
1. The thorax is rounded; that is, the diameter from the front to the back
(anteroposterior) is equal to the transverse diameter. It is also cylindrical, having a
nearly equal diameter at the top and the base. This makes it harder for infants to
expand their thoracic space.
2. To assess tactile fremitus, place the hand over the crying infant’s thorax.
3. Infants tend to breathe using their diaphragm; assess rate and rhythm by watching
the abdomen, rather than the thorax, rise and fall.
4. The right bronchial branch is short and angles down as it leaves the trachea, making
it easy for small objects to be inhaled. Sudden onset of cough or other signs of
respiratory distress may indicate the infant has inhaled a foreign object.

Children
1. By about 6 years of age, the anteroposterior diameter has decreased in proportion
to the transverse diameter, with a 1:2 ratio present.
2. Children tend to breathe more abdominally than thoracically up to age 6.
3. During the rapid growth spurts of adolescence, spinal curvature and rotation
(scoliosis) may appear. Children should be assessed for scoliosis by age 12 and
annually until their growth slows. Curvature greater than 10% should be referred
for further medical evaluation.

Older Adults
1. The thoracic curvature may be accentuated (kyphosis) because of osteoporosis and
changes in cartilage, resulting in collapse of the vertebrae. This can also compromise
and decrease normal respiratory effort.
2. Kyphosis and osteoporosis alter the size of the thorax cavity as the ribs move
downward and forward.
3. The anteroposterior diameter of the thorax widens, giving the person a barrel-
chested appearance. This is due to loss of skeletal muscle strength in the thorax and
diaphragm and constant lung inflation from excessive expiratory pressure on the
alveoli.

HEALTH ASSESSMENT (NCM 101)

 4. Breathing rate and rhythm are unchanged at rest; the rate normally increases with
exercise but may take longer to return to the pre-exercise rate.
5. Inspiratory muscles become less powerful, and the inspiration reserve volume
decreases. A decrease in depth of respiration is therefore apparent.
6. Expiration may require the use of accessory muscles. The expiratory reserve volume
significantly increases because of the increased amount of air remaining in the lungs
at the end of a normal breath.
7. Deflation of the lung is incomplete.
8. Small airways lose their cartilaginous support and elastic recoil; as a result, they
tend to close, particularly in basal or dependent portions of the lung.
9. Elastic tissue of the alveoli loses its stretchability and changes to fibrous tissue.
Exertional capacity decreases.
10. Cilia in the airways decrease in number and are less effective in removing mucus;
older clients are therefore at greater risk for pulmonary infections.

SELF-STUDY GUIDE QUESTIONS

1. Enumerate the different chest deformities and their indication.
2. Illustrate the sequence of palpating anterior and posterior thorax.
3. Illustrate the sequence for anterior and posterior thorax percussion.

HEART AND THE CENTRAL BLOOD VESSELS

The cardiovascular system consists of the heart and the central blood vessels
(primarily the pulmonary, coronary, and neck arteries and veins). The peripheral vascular
system includes those arteries and veins distal to the central vessels, extending all the way
to the brain and to the extremities.

Heart
Nurses assess the heart through inspection, palpation, and auscultation, in that
sequence. Auscultation is more meaningful when other data are obtained first. The heart is
usually assessed during an initial physical assessment; periodic reassessments may be
necessary for long-term or at-risk clients or those with cardiac problems.
In the average adult, most of the heart lies behind and to the left of the sternum. A
small portion (the right atrium) extends to the right of the sternum. The upper portion of
the heart (both atria), referred to as its base, lies toward the back. The lower portion (the
ventricles), referred to as its apex, points anteriorly. The apex of the left ventricle actually
touches the chest wall at or medial to the left midclavicular line (MCL) and at or near the
fifth left intercostal space (LICS), which is slightly below the left nipple. The point where the
apex touches the anterior chest wall and heart movements are most easily observed and
palpated is known as the point of maximal impulse (PMI).
The precordium, the area of the chest overlying the heart, is inspected and palpated
for the presence of abnormal pulsations or lifts or heaves.
The terms lift and heave, often used interchangeably, refer to a rising along the
sternal border with each heartbeat. A lift occurs when cardiac action is very forceful. It
should be confirmed by palpation with the palm of the hand. Enlargement or overactivity of
the left ventricle produces a heave lateral to the apex, whereas enlargement of the right
ventricle produces a heave at or near the sternum.
Heart sounds can be heard by auscultation. The normal first two heart sounds are
produced by closure of the valves of the heart. The first heart sound, S1, occurs when the
atrioventricular (A-V) valves close. These valves close when the ventricles have been
sufficiently filled. Although the A-V valves do not close simultaneously, the closure occurs
closely enough to be heard as one sound.
S1 is a dull, low-pitched sound described as “lub.” After the ventricles empty the
blood into the aorta and pulmonary arteries, the semilunar valves close, producing the
second heart sound, S2, described as “dub.” S2 has a higher pitch than S1 and is shorter in
duration.
These two sounds, S1 and S2 (“lub-dub”), occur within 1 second or less, depending
on the heart rate. The two heart sounds are audible anywhere on the precordial area, but
they are best heard over the aortic, pulmonic, tricuspid, and mitral areas.
Each area is associated with the closure of heart valves: the aortic area with the
aortic valve (inside the aorta as it arises from the left ventricle); the pulmonic area with the
pulmonic valve (inside the pulmonary artery as it arises from the right ventricle); the

HEALTH ASSESSMENT (NCM 101)

tricuspid area with the tricuspid valve (between the right atrium and ventricle); and the
mitral area (sometimes referred to as the apical area) with the mitral valve (between the
left atrium and ventricle).
Associated with these sounds are systole and diastole. Systole is the period in which
the ventricles contract. It begins with S1 and ends at S2. Systole is normally shorter than
diastole. Diastole is the period in which the ventricles relax. It starts with S2 and ends at the
subsequent S1. Normally no sounds are audible during these periods.
The experienced nurse, however, may perceive extra heart sounds (S3 and S4)
during diastole. Both sounds are low in pitch and heard best at the apex, with the bell of the
stethoscope, and with the client lying on the left side. S3 occurs early in diastole right after
S2 and sounds like “lub-dub-ee “(S1, S2, S3) or “Kentucky.” It often disappears when the
client sits up. S3 is normal in children and young adults. In older adults, it may indicate
heart failure.
The S4 sound (ventricular gallop) occurs near the very end of diastole just before S1 and
creates the sound of “dee-lubdub” (S4, S1, S2) or “Ten-nessee.” S4 may be heard in older
clients and can be a sign of hypertension.
The nurse may also hear abnormal heart sounds, such as clicks, rubs, and murmurs.
These are caused by valve disorders or impaired blood flow within the heart and require
advanced training to diagnose.

Central Vessels
The carotid arteries supply oxygenated blood to the head and neck. Because they
are the only source of blood to the brain, prolonged occlusion of these arteries can result in
serious brain damage. The carotid pulses correlate with central aortic pressure, thus
reflecting cardiac function better than the peripheral pulses.
When cardiac output is diminished, the peripheral pulses may be difficult or
impossible to feel, but the carotid pulse should be felt easily. The carotid is also auscultated
for a bruit.
A bruit (a blowing or swishing sound) is created by turbulence of blood flow due
either to a narrowed arterial lumen (a common development in older people) or to a
condition, such as anemia or hyperthyroidism, that elevates cardiac output. If a bruit is
found, the carotid artery is then palpated for a thrill.
A thrill, which frequently accompanies a bruit, is a vibrating sensation like the
purring of a cat or water running through a hose. It, too, indicates turbulent blood flow due
to arterial obstruction. The jugular veins drain blood from the head and neck directly into
the superior vena cava and right side of the heart. The external jugular veins are superficial
and may be visible above the clavicle. The internal jugular veins lie deeper along the carotid
artery and may transmit pulsations onto the skin of the neck. Normally, external neck veins
are distended and visible when a person lies down; they are flat and not as visible when a
person stands up, because gravity encourages venous drainage. By inspecting the jugular
veins for pulsations and distention, the nurse can assess the adequacy of function of the
right side of the heart and venous pressure. Bilateral jugular venous distention (JVD) may
indicate right-sided heart failure.

Equipment in Assessing the Heart and Central Blood Vessels

1. Stethoscope
2. Centimeter ruler

Assessing the Heart and Central Blood Vessels

1. Inquire if the client has any history of the following: family history of incidence and
age of heart disease, high cholesterol levels, high blood pressure, stroke, obesity,
congenital heart disease, arterial disease, hypertension, and rheumatic fever; client’s
past history of rheumatic fever, heart murmur, heart attack, varicosities, or heart
failure; present symptoms indicative of heart disease, e.g., fatigue, dyspnea,
orthopnea, edema, cough, chest pain, palpitations, syncope, hypertension, wheezing,
hemoptysis; presence of diseases that affect heart, e.g., obesity, diabetes, lung
disease, endocrine disorders; lifestyle habits that are risk factors for cardiac disease,
e.g., smoking, alcohol intake, eating and exercise patterns, areas and degree of stress
perceived.
2. Simultaneously inspect and palpate the precordium for the presence of abnormal
pulsations, lifts, or heaves. Locate the valve areas of the heart:

HEALTH ASSESSMENT (NCM 101)

  Locate the angle of Louis. It is felt as a prominence on the sternum.
 Move your fingertips down each side of the angle until you can feel the
second intercostal spaces. The client’s right second intercostal space is the
aortic area, and the left second intercostal space is the pulmonic area. From
the pulmonic area, move your fingertips down three left intercostal spaces
along the side of the sternum. The left fifth intercostal space close to the
sternum is the tricuspid or right ventricular area.
 From the tricuspid area, move your fingertips laterally 5 to 7 cm (2 to 3 in.)
to the left midclavicular line. This is the apical or mitral area, or point of
maximal impulse (PMI). If you have difficulty locating the PMI, have the
client roll onto the left side to move the apex closer to the chest wall.
 Inspect and palpate the aortic and pulmonic areas, observing them at an
angle and to the side, to note the presence or absence of pulsations.
Observing these areas at an angle increases the likelihood of seeing
pulsations.
 Inspect and palpate the tricuspid area for pulsations and heaves or lifts.
 Inspect and palpate the apical area for pulsation, noting its specific location
(it may be displaced laterally or lower) and diameter. If displaced laterally,
record the distance between the apex and the MCL in centimeters. Normally,
pulsations are visible in 50% of adults and palpable in most PMI in fifth LICS
at or medial to MCL and at the diameter of 1 to 2 cm (0.4 to 0.8 in.). If PMI is
displaced laterally or lower it may indicate enlarged heart.
 Inspect and palpate the epigastric area at the base of the sternum for
abdominal aortic pulsations. Check for bounding abdominal pulsations this
may indicate aortic aneurysm.
3. Auscultate the heart in all four anatomic sites: aortic, pulmonic, tricuspid, and apical
(mitral). Auscultation need not be limited to these areas; however, the nurse may
need to move the stethoscope to find the most audible sounds for each client.
Normally, S1 is heard at all sites, usually louder at apical area. S2 is also heard at all
sites, usually louder at base of heart.
Systole: silent interval; slightly shorter duration than diastole at normal heart rate
(60 to 90 beats/min).
 Eliminate all sources of room noise. Rationale: Heart sounds are of low
intensity, and other noise hinders the nurse’s ability to hear them.
 Keep the client in a supine position with head elevated 15 to 45°.
 Use both the diaphragm and the bell to listen to all areas.
 In every area of auscultation, distinguish both S1 and S2 sounds. Normally,
S3 is present in children and young adults.
 When auscultating, concentrate on one particular sound at a time in each
area: the first heart sound, followed by systole, then the second heart sound,
then diastole. Systole and diastole are normally silent intervals.
 Later, reexamine the heart while the client is in the upright sitting position.
Rationale: Certain sounds are more audible in certain positions.
Carotid Arteries
4. Palpate the carotid artery, using extreme caution. Asymmetric volumes may indicate
possible stenosis or thrombosis.
 Palpate only one carotid artery at a time. Rationale: This ensures adequate
blood flow through the other artery to the brain. Decreased pulsations may
indicate impaired left cardiac output.
 Avoid exerting too much pressure and massaging the area. Rationale:
Pressure can occlude the artery, and carotid sinus massage can precipitate
bradycardia. The carotid sinus is a small dilation at the beginning of the
internal carotid artery just above the bifurcation of the common carotid
artery, in the upper third of the neck. Thickening, hard, rigid, beaded,
inelastic walls may indicate arteriosclerosis.
 Ask the client to turn the head slightly toward the side being examined. This
makes the carotid artery more accessible.
5. Auscultate the carotid artery. Presence of bruit in one or both arteries may suggests
occlusive artery disease.
 Turn the client’s head slightly away from the side being examined. Rationale:
This facilitates placement of the stethoscope.

HEALTH ASSESSMENT (NCM 101)

  Auscultate the carotid artery on one side and then the other.
 Listen for the presence of a bruit. If you hear a bruit, gently palpate the
artery to determine the presence of a thrill.
Jugular Veins
6. Inspect the jugular veins for distention while the client is placed in a semi-Fowler’s
position (15° to 45° angle), with the head supported on a small pillow. Normally,
veins that are not visible may indicate that the right side of heart is functioning
normally while, veins that are visibly distended may indicate advanced
cardiopulmonary disease.
7. If jugular distention is present, assess the jugular venous pressure (JVP). Bilateral
measurements above 3 to 4 cm (1.2 to 1.6 in.) are considered elevated and may
indicate right-sided heart failure while unilateral distention may be caused by local
obstruction.
 Locate the highest visible point of distention of the internal jugular vein.
Although either the internal or the external jugular vein can be used, the
internal jugular vein is more reliable. Rationale: The external jugular vein is
more easily affected by obstruction or kinking at the base of the neck.
 Measure the vertical height of this point in centimeters from the sternal
angle, the point at which the clavicles meet. Repeat the preceding steps on
the other side.

Lifespan Considerations in Assessing the Heart and Central Vessels

Infants
1. Physiological splitting of the second heart sound (S2) may be heard when the child
takes a deep breath and the aortic valve closes a split second before the pulmonic
valve. If splitting of S2 is heard during normal respirations, it is abnormal and may
indicate an atrial-septal defect, pulmonary stenosis, or another heart problem.
2. Infants may normally have sinus arrhythmia that is related to respiration. The heart
rate slows during expiration and increases when the child breathes in.
3. Murmurs may be heard in newborns as the structures of fetal circulation, especially
the ductus arteriosus, close.

Children
1. Heart sounds may be louder because of the thinner chest wall.
2. A third heart sound (S3), caused as the ventricles fill, is best heard at the apex, and is
present in about one third of all children.
3. The PMI is higher and more medial in children under 8 years old.

Older Adults
1. If no disease is present, heart size remains the same size throughout life.
2. Cardiac output and strength of contraction decrease, thus lessening the older
person’s activity tolerance.
3. The heart rate returns to its resting rate more slowly after exertion than it did when
the individual was younger.
4. S4 heart sound is considered normal in older adults.
5. Extra systoles commonly occur. Ten or more systoles per minute are considered
abnormal.
6. Sudden emotional and physical stresses may result in cardiac arrhythmias and heart
failure.

PERIPHERAL VASCULAR SYSTEM

Assessing the peripheral vascular system includes measuring the blood pressure,
palpating peripheral pulses, and inspecting the skin and tissues to determine perfusion
(blood supply to an area) to the extremities. Certain aspects of peripheral vascular
assessment are often incorporated into other parts of the assessment procedure. For
example, blood pressure is usually measured at the beginning of the physical examination.

Assessing the Peripheral Vascular System

1. Inquire if the client has any history of the following: past history of heart disorders,
varicosities, arterial disease, and hypertension; lifestyle habits such as exercise
patterns, activity patterns and tolerance, smoking, and use of alcohol.

HEALTH ASSESSMENT (NCM 101)

Peripheral Pulses
2. Palpate the peripheral pulses on both sides of the client’s body individually,
simultaneously (except the carotid pulse), and systematically to determine the
symmetry of pulse volume. If you have difficulty palpating some of the peripheral
pulses, use a Doppler ultrasound probe. Asymmetric volumes may indicate impaired
circulation. Absence of pulsation indicates arterial spasm or occlusion. Decreased,
weak, thready pulsations may indicate impaired cardiac output. Increased pulse
volume may indicate hypertension, high cardiac output, or circulatory overload.
Peripheral Veins
3. Inspect the peripheral veins in the arms and legs for the presence and/or
appearance of superficial veins when limbs are dependent and when limbs are
elevated. In dependent position, presence of distention and nodular bulges at calves.
When limbs elevated, veins collapse (veins may appear tortuous or distended in
older people).
4. Assess the peripheral leg veins for signs of phlebitis. Firmly dorsiflex the client’s foot
while supporting the entire leg in extension (Homans’ test), or have the person
stand or walk.
 Inspect the calves for redness and swelling over vein sites.
 Palpate the calves for firmness or tension of the muscles, the presence of edema
over the dorsum of the foot, and areas of localized warmth. Rationale: Palpation
augments inspection findings, particularly in darker pigmented people in whom
redness may not be visible.
 Push the calves from side to side to test for tenderness.
Peripheral Perfusion
5. Inspect the skin of the hands and feet for color, temperature, edema, and skin
changes. Check for cyanotic skin color that may indicate venous insufficiency, pallor
increases when limb is elevated. Dependent rubor, a dusky red color when limb is
lowered may indicate arterial insufficiency. Brown pigmentation around ankles may
indicate arterial or chronic venous insufficiency. Marked edema indicates venous
insufficiency and mild edema indicates arterial insufficiency. Skin thin and shiny or
thick, waxy, shiny, and fragile, with reduced hair and ulceration indicates venous or
arterial insufficiency.
6. Assess the adequacy of arterial flow if arterial insufficiency is suspected.
Capillary Refill Test
7. Press at least one nail on each hand and foot between your thumb and index finger
sufficiently to cause blanching (about 5 seconds). Check for delayed return of color
this may indicate arterial insufficiency.
8. Release the pressure, and observe how quickly normal color returns (less than 2
seconds).
Other Assessments
9. Inspect the fingernails for changes indicative of circulatory impairment.

Lifespan Considerations in Assessing the Peripheral Vascular System

Infants
1. Screen for coarctation of the aorta by palpating the peripheral pulses and comparing
the strength of the femoral pulses with the radial pulses and apical pulse. If
coarctation is present, femoral pulses will be diminished and radial pulses will be
stronger.

Children
1. Changes in the peripheral vasculature, such as bruising, petechiae, and purpura, can
indicate serious systemic diseases in children (e.g., leukemia, meningococcemia).

Older Adults
1. The overall effectiveness of blood vessels decreases as smooth muscle cells are
replaced by connective tissue. The lower extremities are more likely to show signs
of arterial and venous impairment because of the more distal and dependent
position.

HEALTH ASSESSMENT (NCM 101)

 2. Peripheral vascular assessment should always include upper and lower extremities’
temperature, color, pulses, edema, skin integrity, and sensation. Any differences in
symmetry of these findings should be noted.
3. Proximal arteries become thinner and dilate.
4. Peripheral arteries become thicker and dilate less effectively because of
arteriosclerotic changes in the vessel walls.
5. Blood vessels lengthen and become more tortuous and prominent. Varicosities
occur more frequently.
6. In some instances, arteries may be palpated more easily because of the loss of
supportive surrounding tissues. Often, however, the most distal pulses of the lower
extremities are more difficult to palpate because of decreased arterial perfusion.
7. Systolic and diastolic blood pressures increase, but the increase in the systolic
pressure is greater. As a result, the pulse pressure widens. Any client with a blood
pressure reading above 140/90 should be referred for follow-up assessments.
8. Peripheral edema is frequently observed and is most commonly the result of chronic
venous insufficiency or low protein levels in the blood (hypoproteinemia).

SELF-STUDY GUIDE QUESTIONS

1. Explain the difference of bruit and thrill.
2. Discuss the lifespan considerations in assessing the heart and central vessels.
3. Describe the assessment of capillary refill test.

BREAST AND AXILLAE

The breasts of men and women need to be inspected and palpated. Men have some
glandular tissue beneath each nipple, a potential site for malignancy, whereas mature
women have glandular tissue throughout the breast. In females, the largest portion of
glandular breast tissue is located in the upper outer quadrant of each breast. A projection of
breast tissue from this quadrant extends into the axilla, called the axillary tail of Spence. The
majority of breast tumors are located in this upper outer breast quadrant including the tail
of Spence.
During assessment, the nurse can localize specific findings by using this section of
the breast into quadrants and the axillary tail.

Equipment in Assessing the Breast and Axillae

1. Centimeter ruler

Assessing the Breast and Axillae

1. Inquire if the client has a history of breast masses and what was done about them;
pain or tenderness in the breasts and relation to the woman’s menstrual cycle;
discharge from the nipple; medication history (some medications, e.g., oral
contraceptives, steroids, digitalis, and diuretics, may cause nipple discharge;
estrogen replacement therapy may be associated with the development of cysts or
cancer); risk factors that may be associated with development of breast cancer (e.g.,
mother, sister, aunt with breast cancer; alcohol consumption, high-fat diet, obesity,
use of oral contraceptives, menarche before age 12, menopause after age 55, age 30
or more at first pregnancy). Inquire if the client performs breast self-examination;
technique used and when performed in relation to the menstrual cycle.
2. Inspect the breasts for size, symmetry, and contour or shape while the client is in a
sitting position. Females have rounded shape; slightly unequal in size; generally
symmetric while male breasts are even with the chest wall, if obese, may be similar
in shape to female breasts.
3. Inspect the skin of the breast for localized discolorations or hyperpigmentation,
retraction or dimpling, localized hypervascular areas, swelling or edema. Swelling or
edema appearing as pig skin or orange peel due to exaggeration of the pores
4. Inspect the areola area for size, shape, symmetry, color, surface characteristics, and
any masses or lesions. Color of the areola varies widely, from light pink to dark
brown.
5. Inspect the nipples for size, shape, position, color, discharge, and lesions. Round,
everted, and equal in size, similar in color; soft and smooth, both nipples point in
same direction (out in young women and men, downward in older women). No

HEALTH ASSESSMENT (NCM 101)

 discharge, except from pregnant or breast-feeding females. Inversion of one or both
nipples that is present from puberty.
6. Palpate the axillary, subclavicular, and supraclavicular lymph nodes while the client
sits with the arms abducted and supported on the nurse’s forearm. Use the flat
surfaces of all fingertips to palpate the areas of the axilla.
7. Palpate the breast for masses, tenderness, and any discharge from the nipples.
Palpation of the breast is generally performed while the client is supine.
Rationale: In the supine position, the breasts flatten evenly against the chest wall,
facilitating palpation.

For clients who have a past history of breast masses, who are at high risk for breast
cancer, or who have pendulous breasts, examination in both a supine and a sitting position
is recommended. If the client reports a breast lump, start with the “normal” breast to obtain
baseline data that will serve as a comparison to the reportedly involved breast. To enhance
flattening of the breast, instruct the client to abduct the arm and place her hand behind her
head. Then place a small pillow or rolled towel under the client’s shoulder. For palpation,
use the palmar surface of the middle three fingertips (held together) and make a gentle
rotary motion on the breast. Start at one point for palpation, and move systematically to the
end point to ensure that all breast surfaces are assessed. Pay particular attention to the
upper outer quadrant area and the tail of Spence.

Table 4.7 Three Patterns for Palpation

Hands-of-the-clock or Concentric circles pattern Vertical strips pattern

spokes-on-a-wheel pattern

If you detect a mass, record the following data:

a) Location: the exact location relative to the quadrants and axillary tail, or the
clock and the distance from the nipple in centimeters.
b) Size: the length, width, and thickness of the mass in centimeters. If you are
able to determine the discrete edges, record this fact.
c) Shape: whether the mass is round, oval, lobulated, indistinct, or irregular.
d) Consistency: whether the mass is hard or soft.
e) Mobility: whether the mass is movable or fixed.
f) Skin over the lump: whether it is reddened, dimpled, or retracted.
g) Nipple: whether it is displaced or retracted.
h) Tenderness: whether palpation is painful.
8. Palpate the areolae and the nipples for masses. Compress each nipple to determine
the presence of any discharge. If discharge is present, milk the breast along its
radius to identify the discharge-producing lobe. Assess any discharge for amount,
color, consistency, and odor. Note also any tenderness on palpation.
9. Teach the client the technique of breast self-examination.
Inspection before a Mirror
Look for any change in size or shape; lumps or thickenings; any rashes or
other skin irritations; dimpled or puckered skin; any discharge or change in the
nipples (e.g., position or asymmetry). Inspect the breasts in all of the following
positions:

HEALTH ASSESSMENT (NCM 101)

 a) Stand and face the mirror with your arms relaxed at your sides or hands
resting on the hips; then turn to the right and the left for a side view (look
for any flattening in the side view).
b) Bend forward from the waist with arms raised over the head.
c) Stand straight with the arms raised over the head and move the arms slowly
up and down at the sides. (Look for free movement of the breasts over the
chest wall.)
d) Press your hands firmly together at chin level while the elbows are raised to
shoulder level.
Palpation: Lying Position
a) Place a pillow under your right shoulder and place the right hand behind
your head. This position distributes breast tissue more evenly on the chest.
b) Use the finger pads (tips) of the three middle fingers (held together) on your
left hand to feel for lumps.
c) Press the breast tissue against the chest wall firmly enough to know how
your breast feels. A ridge of firm tissue in the lower curve of each breast is
normal.
d) Use small circular motions systematically all the way around the breast as
many times as necessary until the entire breast is covered. Refer to the table
patterns for palpation that the client may use.
e) Bring your arm down to your side and feel under your armpit, where breast
tissue is also located.
f) Repeat the exam on your left breast, using the finger pads of your right hand.
Palpation: Standing or Sitting
a) Repeat the examination of both breasts while upright with one arm behind
your head. This position makes it easier to check the area where a large
percentage of breast cancers are found, the upper outer part of the breast
and toward the armpit.
b) Optional: Do the upright BSE in the shower. Soapy hands glide more easily
over wet skin. Report any changes to your health care provider promptly.

Lifespan Considerations in Assessing the Breasts and Axillae

Infants
1. Newborns, both boys and girls, up to 2 weeks of age may have breast enlargement
and white discharge from the nipples (witch’s milk).
2. Supernumerary (“extra”) nipples infrequently are present as small dimples along
the mammary chain; these may be associated with renal anomalies.

Children
1. Female breast development begins between 9 and 13 years of age and occurs in five
stages (Tanner stages). One breast may develop more rapidly than the other, but at
the end of development, they are more or less the same size.
Tanner Stage of Breast Development
 Stage 1 Prepubertal with no noticeable change
 Stage 2 Breast bud with elevation of nipple and enlargement of the areola
 Stage 3 Enlargement of the breast and areola with no separation of contour
 Stage 4 Projection of the areola and nipple
 Stage 5 Recession of the areola by about age 14 or 15, leaving only the nipple
projecting
2. Boys may develop breast buds and have slight enlargement of the areola in early
adolescence. Further enlargement of breast tissue (gynecomastia) can occur. This
growth is transient, usually lasting about 2 years, resolving completely by late
puberty.
3. Axillary hair usually appears in Tanner stages 3 or 4 and is related to adrenal rather
than gonadal changes.

Pregnant Females
1. Breast, areola, and nipple size increase.
2. The areolae and nipples darken; nipples may become more erect; areolae contain
small, scattered, elevated Montgomery’s glands.

HEALTH ASSESSMENT (NCM 101)

 3. Superficial veins become more prominent, and jagged linear stretch marks may
develop.
4. A thick yellow fluid (colostrum) may be expressed from the nipples after the first
trimester.

Older Adults
1. In the postmenopausal female, breasts change in shape and often appear pendulous
or flaccid; they lack the firmness they had in younger years.
2. The presence of breast lesions may be detected more readily because of the
decrease in connective tissue.
3. General breast size remains the same. Although glandular tissue atrophies, the
amount of fat in breasts (predominantly in the lower quadrants) increases in most
women.

SELF-STUDY GUIDE QUESTION

1. Describe the technique of breast self-examination.

ABDOMEN
The nurse locates and describes abdominal findings using two common methods of
subdividing the abdomen: quadrants and regions. To divide the abdomen into quadrants,
the nurse imagines two lines: a vertical line from the xiphoid process to the pubic
symphysis, and a horizontal line across the umbilicus. These quadrants are labeled right
upper quadrant, left upper quadrant, right lower quadrant, and left lower quadrant.
Using the second method, division into nine regions, the nurse imagines two vertical
lines that extend superiorly from the midpoints of the inguinal ligaments, and two
horizontal lines, one at the level of the edge of the lower ribs and the other at the level of the
iliac crests. Specific organs or parts of organs lie in each abdominal region.
In addition, practitioners often use certain landmarks to locate abdominal signs and
symptoms. These are the xiphoid process of the sternum, the costal margins, the
anterosuperior iliac spine, the inguinal ligaments, and the superior margin of the pubic
symphysis.
Table 4.8 Organs in the Four Abdominal Quadrants
Left Upper Quadrant Right Upper Quadrant
 Left lobe of liver  Liver
 Stomach  Gallbladder
 Spleen  Duodenum
 Upper lobe of left kidney  Head of pancreas
 Pancreas  Right adrenal gland
 Left adrenal gland  Upper lobe of right kidney
 Splenic flexure of colon  Hepatic flexure of colon
 Section of transverse colon  Section of ascending colon
 Section of descending colon  Section of transverse colon
Left Lower Quadrant Right Lower Quadrant
 Lower lobe of left kidney  Lower lobe of right kidney
 Sigmoid colon  Cecum
 Section of descending colon  Appendix
 Left ovary  Section of ascending colon
 Left fallopian tube  Right ovary
 Left ureter  Right fallopian tube
 Left spermatic cord  Right ureter
 Part of uterus  Right spermatic cord
 Part of uterus

HEALTH ASSESSMENT (NCM 101)

 Table 4.9 Organs in the Nine Abdominal Regions
LEFT HYPOCHONDRIAC EPIGASTRIC RIGHT HYPOCHONDRIAC
 Stomach  Aorta  Right lobe of liver
 Spleen  Pyloric end of stomach  Gallbladder
 Tail of pancreas  Part of duodenum  Part of duodenum
 Splenic flexure of colon  Pancreas  Hepatic flexure of colon
 Upper half of left  Part of liver  Upper half of right
kidney kidney
 Suprarenal gland  Suprarenal gland
LEFT LUMBAR UMBILICAL Omentum RIGHT LUMBAR
 Descending colon  Mesentery  Ascending colon
 Lower half of left  Lower part of  Lower half of right
kidney duodenum kidney
 Part of jejunum and  Part of jejunum and  Part of duodenum and
ileum ileum jejunum
LEFT INGUINAL HYPOGASTRIC (PUBIC) RIGHT INGUINAL
 Sigmoid colon  Ileum  Cecum
 Left ureter Left  Bladder  Appendix
spermatic cord  Uterus  Lower end of ileum
 Left ovary  Right ureter
 Right spermatic cord
 Right ovary

Equipment in Assessing the Abdomen

1. Examining light
2. Tape measure (metal or unstretchable cloth)
3. Skin-marking pen
4. Stethoscope

Assessing the Abdomen

Assessment of the abdomen involves all four methods of examination (inspection,
auscultation, palpation, and percussion). When assessing the abdomen, the nurse performs
inspection first, followed by auscultation, percussion, and/or palpation. Auscultation is
done before palpation and percussion because palpation and percussion cause movement
or stimulation of the bowel, which can increase bowel motility and thus heighten bowel
sounds, creating false results.
1. Inquire about the following: incidence of abdominal pain; its location, onset,
sequence, and chronology; its quality (description); its frequency; associated
symptoms (e.g., nausea, vomiting, diarrhea); incidence of constipation or diarrhea
(have client describe what client means by these terms); change in appetite, food
intolerances, and foods ingested in last 24 hours; specific signs and symptoms (e.g.,
heartburn, flatulence and/or belching, difficulty swallowing, hematemesis [vomiting
blood], blood or mucus in stools, and aggravating and alleviating factors); previous
problems and treatment (e.g., stomach ulcer, gallbladder surgery, history of
jaundice).
2. Assist the client to a supine position, with the arms placed comfortably at the sides.
Place small pillows beneath the knees and the head to reduce tension in the
abdominal muscles. Expose the client’s abdomen only from the chest line to the
pubic area to avoid chilling and shivering, which can tense the abdominal muscles.
Inspection of the Abdomen
3. Inspect the abdomen for skin integrity.
4. Inspect the abdomen for contour and symmetry:
 Observe the abdominal contour (profile line from the rib margin to the pubic
bone) while standing at the client’s side when the client is supine.
 Ask the client to take a deep breath and to hold it. Rationale: This makes an
enlarged liver or spleen more obvious.
 Assess the symmetry of contour while standing at the foot of the bed.

HEALTH ASSESSMENT (NCM 101)

  If distention is present, measure the abdominal girth by placing a tape
around the abdomen at the level of the umbilicus. If girth will be measured
repeatedly, use a skin marking pen to outline the upper and lower margins
of the tape placement for consistency of future measurements.
 Observe abdominal movements associated with respiration, peristalsis, or
aortic pulsations. Visible peristalsis in very lean people is normal but visible
peristalsis in non-lean clients is an indication of possible bowel obstruction.
 Observe the vascular pattern. Visible venous pattern (dilated veins) is
associated with liver disease, ascites, and venocaval obstruction.
Auscultation of the Abdomen
5. Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction
rubs. Warm the hands and the stethoscope diaphragms. Rationale: Cold hands and a
cold stethoscope may cause the client to contract the abdominal muscles, and these
contractions may be heard during auscultation.
For Bowel Sounds
 Use the flat-disk diaphragm. Rationale: Intestinal sounds are relatively high
pitched and best accentuated by the diaphragm. Light pressure with the
stethoscope is adequate.
 Ask when the client last ate. Rationale: Shortly after or long after eating,
bowel sounds may normally increase. They are loudest when a meal is long
overdue. Four to 7 hours after a meal, bowel sounds may be heard
continuously over the ileocecal valve area while the digestive contents from
the small intestine empty through the valve into the large intestine.
 Place diaphragm of the stethoscope in each of the four quadrants of the
abdomen over all of the auscultatory sites.
Figure 4.23 Auscultation site in abdomen

 Listen
for active
bowel
sounds
—

irregular gurgling noises occurring about every 5 to 20 seconds. The

duration of a single sound may range from less than a second to more than
several seconds.
Hypoactive, i.e., extremely soft and infrequent (e.g., one per minute).
Hypoactive sounds indicate decreased motility and are usually associated
with manipulation of the bowel during surgery, inflammation, paralytic
ileus, or late bowel obstruction.
Hyperactive/increased, i.e., high pitched, loud, rushing sounds that
occur frequently (e.g., every 3 seconds) also known as borborygmi.
Hyperactive sounds indicate increased intestinal motility and are usually
associated with diarrhea, an early bowel obstruction, or the use of laxatives.
True absence of sounds (none heard in 3 to 5 minutes) indicates a
cessation of intestinal motility.
For Vascular Sounds
 Use the bell of the stethoscope over the aorta, renal arteries, iliac arteries,
and femoral arteries.
 Listen for bruits. Loud bruit over aortic area indicates possible aneurysm.
Peritoneal Friction Rubs
 Peritoneal friction rubs are rough, grating sounds like two pieces of leather
rubbing together. Friction rubs may be caused by inflammation, infection, or
abnormal growths.

HEALTH ASSESSMENT (NCM 101)

Percussion of the Abdomen
6. Percuss several areas in each of the four quadrants to determine presence of
tympany (gas in stomach and intestines) and dullness (decrease, absence, or
flatness of resonance over solid masses or fluid). Use a systematic pattern: Begin in
the lower right quadrant, proceed to the upper right quadrant, the upper left
quadrant, and the lower left quadrant.
Palpation of the Abdomen
7. Perform light palpation first to detect areas of tenderness and/or muscle guarding.
Systematically explore all four quadrants. Ensure that the client’s position is
appropriate for relaxation of the abdominal muscles, and warm the hands.
Rationale: Cold hands can elicit muscle tension and thus impede palpatory
evaluation.
Palpation of the Bladder
8. Palpate the area above the pubic symphysis if the client’s history indicates possible
urinary retention. Distended and palpable as smooth, round, tense mass indicates
urinary retention.

Lifespan Considerations Assessing the Abdomen

Infants
1. Internal organs of newborns and infants are proportionately larger than those of
older children and adults, so their abdomens are rounded and tend to protrude.
2. The infant’s liver may be palpable 1 to 2 cm (0.4 to 0.8 in.) below the right costal
margin.
3. Umbilical hernias may be present at birth.

Children
1. Toddlers have a characteristic “pot belly” appearance, which can persist until age 3
to 4 years.
2. Late preschool and school-age children are leaner and have a flat abdomen.
3. Peristaltic waves may be more visible than in adults.
4. Children may not be able to pinpoint areas of tenderness; by observing facial
expressions the examiner can determine areas of maximum tenderness.
5. The liver is relatively larger than in adults. It can be palpated 1 to 2 cm (0.4 to 0.8
in.) below the right costal margin.
6. If the child is ticklish, guarding, or fearful, use a task that requires concentration
(such as squeezing the hands together) to distract the child, or have the child place
his or her hands on yours as you palpate the abdomen, “helping” you to do the
exam.

Older Adults
1. The rounded abdomens of older adults are due to an increase in adipose tissue and
a decrease in muscle tone.
2. The abdominal wall is slacker and thinner, making palpation easier and more
accurate than in younger clients. Muscle wasting and loss of fibroconnective tissue
occur.
3. The pain threshold in older adults is often higher; major abdominal problems such
as appendicitis or other acute emergencies may therefore go undetected.
4. Gastrointestinal pain needs to be differentiated from cardiac pain. Gastrointestinal
pain may be located in the chest or abdomen, whereas cardiac pain is usually
located in the chest. Factors aggravating gastrointestinal pain are usually related to
either ingestion or lack of food intake; gastrointestinal pain is usually relieved by
antacids, food, or assuming an upright position. Common factors that can aggravate
cardiac pain are activity or anxiety; rest or nitroglycerin relieves cardiac pain.
5. Stool passes through the intestines at a slower rate in older adults, and the
perception of stimuli that produce the urge to defecate often diminishes.

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 6. Fecal incontinence may occur in adults who are confused or have a neurologic
impairment.
7. Many older adults erroneously believe that the absence of a daily bowel movement
signifies constipation. When assessing for constipation, the nurse must consider the
client’s diet, activity, medications, and characteristics and ease of passage of feces as
well as the frequency of bowel movements.
8. The incidence of colon cancer is higher among older adults than younger adults.
Symptoms include a change in bowel function, rectal bleeding, and weight loss.
Changes in bowel function, however, are associated with many factors, such as diet,
exercise, and medications.
9. Decreased absorption of oral medications often occurs with aging.
10. In the liver, impaired metabolism of some drugs may occur with aging.

SELF-STUDY GUIDE QUESTION

1. Describe the normal sequence of examination technique. Explain the difference of
the sequence in normal examination and abdominal examination.

MUSCULOSKELETAL SYSTEM
The musculoskeletal system encompasses the muscles, bones, and joints. The
completeness of an assessment of this system depends largely on the needs and problems of
the individual client. The nurse usually assesses the musculoskeletal system for muscle
strength, tone, size, and symmetry of muscle development, and for tremors. A tremor is an
involuntary trembling of a limb or body part. Tremors may involve large groups of muscle
fibers or small bundles of muscle fibers. An intention tremor becomes more apparent when
an individual attempts a voluntary movement, such as holding a cup of coffee. A resting
tremor is more apparent when the client is at rest and diminishes with activity. A
fasciculation is an abnormal contraction of a bundle of muscle fibers that appears as a
twitch. Bones are assessed for normal form. Joints are assessed for tenderness, swelling,
thickening, crepitation (a crackling, grating sound), and range of motion. Body posture is
assessed for normal standing and sitting positions. For information about body posture.

Equipment in Assessing the Musculoskeletal System

1. Goniometer
2. Tape measure

Assessing the Musculoskeletal System

1. Inquire if the client has any history of the following: muscle pain: onset, location,
character, associated phenomena (e.g., redness and swelling of joints), and
aggravating and alleviating factors; limitations to movement or inability to perform
activities of daily living; previous sports injuries; loss of function without pain.
Muscles
2. Inspect the muscles for size. Compare the muscles on one side of the body (e.g., of
the arm, thigh, and calf) to the same muscle on the other side. For any discrepancies,
measure the muscles with a tape. Check for atrophy (a decrease in size) or
hypertrophy (an increase in size).
3. Inspect the muscles and tendons for contractures (shortening). Check for
malposition of body part, e.g., foot drop (foot flexed downward).
4. Inspect the muscles for tremors, for example by having the client hold the arms out
in front of the body.
5. Test muscle strength. Compare the right side with the left side.
 Sternocleidomastoid: Client turns the head to one side against the resistance
of your hand. Repeat with the other side.
 Trapezius: Client shrugs the shoulders against the resistance of your hands.
 Deltoid: Client holds arm up and resists while you try to push it down.
 Biceps: Client fully extends each arm and tries to flex it while you attempt to
hold arm in extension.

HEALTH ASSESSMENT (NCM 101)

  Triceps: Client flexes each arm and then tries to extend it against your
attempt to keep arm in flexion.
 Wrist and finger muscles: Client spreads the fingers and resists as you
attempt to push the fingers together.
 Grip strength: Client grasps your index and middle fingers while you try to
pull the fingers out.
 Hip muscles: Client is supine, both legs extended; client raises one leg at a
time while you attempt to hold it down.
 Hip abduction: Client is supine, both legs extended. Place your hands on the
lateral surface of each knee; client spreads the legs apart against your
resistance.
 Hip adduction: Client is in same position as for hip abduction. Place your
hands between the knees; client brings the legs together against your
resistance.
 Hamstrings: Client is supine, both knees bent. Client resists while you
attempt to straighten the legs.
 Quadriceps: Client is supine, knee partially extended; client resists while you
attempt to flex the knee.
 Muscles of the ankles and feet: Client resists while you attempt to dorsiflex
the foot and again resists while you attempt to flex the foot.
Grading Muscle Strength
0: 0% of normal strength; complete paralysis
1: 10% of normal strength; no movement, contraction of muscle is palpable or
visible
2: 25% of normal strength; full muscle movement against gravity, with support
3: 50% of normal strength; normal movement against gravity
4: 75% of normal strength; normal full movement against gravity and against
minimal resistance
5: 100% of normal strength; normal full movement against gravity and against
full resistance
Bones
6. Inspect the skeleton for structure.
7. Palpate the bones to locate any areas of edema or tenderness. Presence of
tenderness or swelling may indicate fracture, neoplasms, or osteoporosis
Joints
8. Inspect the joint for swelling. Palpate each joint for tenderness, smoothness of
movement, swelling, crepitation, and presence of nodules.
9. Assess joint range of motion. Ask the client to move selected body parts. The amount
of joint movement can be measured by a goniometer, a device that measures the
angle of the joint in degrees.
Types of Joint Movements
a) Flexion. Decreasing the angle of the joint (e.g., bending the elbow).
b) Extension. Increasing the angle of the joint (e.g., straightening the arm at the
elbow).
c) Hyperextension. Further extension or straightening of a joint (e.g., bending the
head backward).
d) Abduction. Movement of the bone away from the midline of the body.
e) Adduction. Movement of the bone toward the midline of the body.
f) Rotation. Movement of the bone around its central axis.
g) Circumduction. Movement of the distal part of the bone in a circle while the
proximal end remains fixed.
h) Eversion. Turning the sole of the foot outward by moving the ankle joint.
i) Inversion. Turning the sole of the foot inward by moving the ankle joint.
j) Pronation. Moving the bones of the forearm so that the palm of the hand faces
downward when held in front of the body.
k) Supination. Moving the bones of the forearm so that the palm of the hand faces
upward when held in front of the body.

HEALTH ASSESSMENT (NCM 101)

Lifespan Considerations Assessing the Musculoskeletal System
Infants
1. Palpate the clavicles of newborns. A mass and crepitus may indicate a fracture
experienced during vaginal delivery. The newborn may also have limited movement
of the arm and shoulder on the affected side.
2. When the arms and legs of newborns are pulled to extension and released,
newborns naturally return to the flexed fetal position.
3. Check muscle strength by holding the infant lightly under the arms with feet placed
lightly on a table. Infants should not fall through the hands and should be able to
bear body weight on their legs if normal muscle strength is present.
4. Check infants for developmental dysplasia of the hip (congenital dislocation) by
examining for asymmetric gluteal folds, asymmetric abduction of the legs (Ortolani
and Barlow tests), or apparent shortening of the femur.
5. Infants should be able to sit without support by 8 months of age, crawl by 7 to 10
months, and walk by 12 to 15 months.
6. Observe for symmetry of muscle mass, strength, and function.

Children
1. Pronation and “toeing in” of the feet are common in children between 12 and 30
months of age.
2. Genu varum (bowleg) is normal in children for about 1 year after beginning to walk.
3. Genu valgus (knock-knee) is normal in preschool and early school-age children.
4. Lordosis (swayback) is common in children before age 5.
5. Observe the child in normal activities to determine motor function.
6. During the rapid growth spurts of adolescence, spinal curvature and rotation
(scoliosis) may appear. Children should be assessed for scoliosis by age 12 and
annually until their growth slows. Curvature greater than 10% should be referred
for further medical evaluation. Muscle mass increases in adolescence, especially as
children engage in strenuous physical activity, and requires increased nutritional
intake.
7. Children are at risk for injury related to physical activity and should be assessed for
nutritional status, physical conditioning, and safety precautions in order to prevent
injury.
8. Adolescent girls who participate extensively in strenuous athletic activities are at
risk for delayed menses, osteoporosis, and eating disorders; assessment should
include a history of these factors.

Older Adults
1. Muscle mass decreases progressively with age, but there are wide variations among
different individuals.
2. The decrease in speed, strength, resistance to fatigue, reaction time, and
coordination in the older person is due to a decrease in nerve conduction and
muscle tone.
3. The bones become more fragile and osteoporosis leads to a loss of total bone mass.
As a result, older adults are predisposed to fractures and compressed vertebrae.
4. In older adults, osteoarthritic changes in the joints can be observed.
5. Note any surgical scars from joint replacement surgeries.

SELF-STUDY GUIDE QUESTIONS

1. Explain what goniometer is.
2. Illustrate the joint movement. Use an arrow to illustrate the movement.

NEUROLOGIC SYSTEM
A thorough neurologic examination may take 1 to 3 hours; however, routine
screening tests are usually done first. If the results of these tests raise questions, more

HEALTH ASSESSMENT (NCM 101)

extensive evaluations are made. Three major considerations determine the extent of a
neurologic exam:
(a) the client’s chief complaints;
(b) the client’s physical condition (i.e., level of consciousness and ability to ambulate)
because many parts of the examination require movement and coordination of the
extremities; and
(c) the client’s willingness to participate and cooperate.

Examination of the neurologic system includes assessment of mental status

including level of consciousness, the cranial nerves, reflexes, motor function, and sensory
function.
Parts of the neurologic assessment are performed throughout the health
examination. For example, the nurse performs a large part of the mental status assessment
during the taking of the history and when observing the client’s general appearance. Also,
the nurse assesses the function of cranial nerves. Cranial nerves II, III, IV, V, and VI
(ophthalmic branch) are assessed with the eyes and vision, and cranial nerve VIII (cochlear
branch) is assessed with the ears and hearing.

Mental Status
Assessment of mental status reveals the client’s general cerebral function. These
functions include intellectual (cognitive) as well as emotional (affective) functions. If
problems with use of language, memory, concentration, or thought processes are noted
during the nursing history.
Major areas of mental status assessment include language, orientation, memory, and
attention span and calculation.
1. Language
Any defects in or loss of the power to express oneself by speech, writing, or signs, or
to comprehend spoken or written language due to disease or injury of the cerebral
cortex, is called aphasia.
Aphasias can be categorized as sensory or receptive aphasia, and motor or
expressive aphasia. Sensory or receptive aphasia is the loss of the ability to
comprehend written or spoken words. Two types of sensory aphasia are auditory
(or acoustic) aphasia and visual aphasia. Clients with auditory aphasia have lost the
ability to understand the symbolic content associated with sounds. Clients with
visual aphasia have lost the ability to understand printed or written figures. Motor
or expressive aphasia involves loss of the power to express oneself by writing,
making signs, or speaking. Clients may find that even though they can recall words,
they have lost the ability to combine speech sounds into words.
2. Orientation
This aspect of the assessment determines the client’s ability to recognize other
persons (person), awareness of when and where they presently are (time and
place), and who they, themselves, are (self).
3. Memory
The nurse assesses the client’s recall of information presented seconds previously
(immediate recall), events or information from earlier in the day or examination
(recent memory), and knowledge recalled from months or years ago (remote or
longterm memory).
4. Attention Span and Calculation
This component determines the client’s ability to focus on a mental task that is
expected to be able to be performed by persons of normal intelligence.

Level of Consciousness
Level of consciousness (LOC) can lie anywhere along a continuum from a state of
alertness to coma. A fully alert client responds to questions spontaneously; a comatose
client may not respond to verbal stimuli.
The Glasgow Coma Scale was originally developed to predict recovery from a head
injury; however, it is used by many professionals to assess LOC. It tests in three major areas:
eye response, motor response, and verbal response. An assessment totaling 15 points
indicates the client is alert and completely oriented. A comatose client scores 7 or less.

Cranial Nerves

HEALTH ASSESSMENT (NCM 101)

 The nurse needs to be aware of specific nerve functions and assessment methods for
each cranial nerve to detect abnormalities. In some cases, each nerve is assessed; in other
cases only selected nerve functions are evaluated.

Reflexes
A reflex is an automatic response of the body to a stimulus. It is not voluntarily
learned or conscious. The deep tendon reflex (DTR) is activated when a tendon is
stimulated (tapped) and its associated muscle contracts. The quality of a reflex response
varies among individuals and by age. As a person ages, reflex responses may become less
intense. Reflexes are tested using a percussion hammer. The response is described on a
scale of 0 to 4. Experience is necessary to determine appropriate scoring for an individual.
Generalist nurses do not commonly assess each of the deep tendon reflexes except for the
plantar (Babinski) reflex, indicative of possible spinal cord injury.

Motor Function
Neurologic assessment of the motor system evaluates proprioception and cerebellar
function. Structures involved in proprioception are the proprioceptors, the posterior
columns of the spinal cord, the cerebellum, and the vestibular apparatus (which is
innervated by cranial nerve VIII) in the labyrinth of the internal ear. Proprioceptors are
sensory nerve terminals that occur chiefly in the muscles, tendons, joints, and internal ear.
They give information about movements and the position of the body. Stimuli from the
proprioceptors travel through the posterior columns of the spinal cord. Deficits of function
of the posterior columns of the spinal cord result in impairment of muscle and position
sense. Clients with such impairment often must watch their own arm and leg movements to
ascertain the position of the limbs. The cerebellum (a) helps to control posture, (b) acts
with the cerebral cortex to make body movements smooth and coordinated, and (c)
controls skeletal muscles to maintain equilibrium.

Sensory Function
Sensory functions include touch, pain, temperature, position, and tactile
discrimination. The first three are routinely tested. Generally, the face, arms, legs, hands,
and feet are tested for touch and pain, although all parts of the body can be tested. If the
client complains of numbness, peculiar sensations, or paralysis, the practitioner should
check sensation more carefully over flexor and extensor surfaces of limbs.
This is a lengthy procedure and may be performed by a specialist. Abnormal
responses to touch stimuli include loss of sensation (anesthesia); more than normal
sensation (hyperesthesia); less than normal sensation (hypoesthesia); or an abnormal
sensation such as burning, pain, or an electric shock (paresthesia).
A detailed neurologic examination includes position sense, temperature sense, and
tactile discrimination. Three types of tactile discrimination are generally tested: one- and
two-point discrimination, the ability to sense whether one or two areas of the skin are being
stimulated by pressure; stereognosis, the act of recognizing objects by touching and
manipulating them; and extinction, the failure to perceive touch on one side of the body
when two symmetric areas of the body are touched simultaneously.

Equipment in Assessing the Neurologic System

(Depending on Components of Examination)
1. Percussion hammer
2. Wisps of cotton to assess light-touch sensation
3. Sterile safety pin for tactile discrimination

Assessing the Neurologic System

1. Inquire if the client has any of the following: presence of pain in the head, back, or
extremities, as well as onset and aggravating and alleviating factors; disorientation
to time, place, or person; speech disorder; history of loss of consciousness, fainting,
convulsions, trauma, tingling or numbness, tremors or tics, limping, paralysis,
uncontrolled muscle movements, loss of memory, mood swings, or problems with
smell, vision, taste, touch, or hearing.
Language
2. If the client displays difficulty speaking:

HEALTH ASSESSMENT (NCM 101)

  Point to common objects, and ask the client to name them.
 Ask the client to read some words and to match the printed and written words
with pictures.
 Ask the client to respond to simple verbal and written commands, e.g., “point to
your toes” or “raise your left arm.”
Orientation
3. Determine the client’s orientation to time, place, and person, by tactful questioning.
 Ask the client the time of day, date, day of the week, duration of illness, city
and state of residence, and names of family members.
 Ask the client why he or she is seeing a health care provider. Orientation is
lost gradually, and early disorientation may be very subtle. “Why” questions
may elicit a more accurate clinical picture of the client’s orientation status
than questions directed to time, place, and person. To evaluate the response,
you must know the correct answer.
 More direct questioning may be necessary for some people, e.g., “Where are
you now?” “What day is it today?” Most people readily accept these
questions if initially the nurse asks, “Do you get confused at times?” If the
client cannot answer these questions accurately, also include assessment of
the self by asking the client to state his or her full name.
Memory
4. Listen for lapses in memory. Ask the client about difficulty with memory. If
problems are apparent, three categories of memory are tested: immediate recall,
recent memory, and remote memory.
To assess immediate recall:
 Ask the client to repeat a series of three digits, e.g., 7–4–3, spoken slowly.
 Gradually increase the number of digits, e.g., 7–4–3–5, 7–4–3–5–6, and 7–4–
3–5–6–7–2, until the client fails to repeat the series correctly.
 Start again with a series of three digits, but this time ask the client to repeat
them backward. The average person can repeat a series of five to eight digits
in sequence and four to six digits in reverse order.
To assess recent memory:
 Ask the client to recall the recent events of the day, such as how the client
got to the clinic. This information must be validated, however.
 Ask the client to recall information given early in the interview, e.g., the
name of a doctor.
 Provide the client with three facts to recall, e.g., a color, an object, and an
address; or a three-digit number, and ask the client to repeat all three. Later
in the interview, ask the client to recall all three items.
To assess remote memory:
 Ask the client to describe a previous illness or surgery, e.g., 5 years ago, or a
birthday or anniversary. Generally remote memory will be intact until late in
neurologic pathology. It is least useful to assess for acute neurologic
problems.
Attention Span and Calculation
5. Test the ability to concentrate or maintain attention span by asking the client to
recite the alphabet or to count backward from 100. Test the ability to calculate by
asking the client to subtract 7 or 3 progressively from 100, i.e., 100, 93, 86, 79, or
100, 97, 94, 91 (referred to as serial sevens or serial threes). Normally, an adult can
complete the serial sevens test in about 90 seconds with three or fewer errors.
Because educational level, language, or cultural differences affect calculating ability,
this test may be inappropriate for some people.
Level of Consciousness
6. Apply the Glasgow Coma Scale: eye response, motor response, and verbal response.
An assessment totaling 15 points indicates the client is alert and completely
oriented. A comatose client scores 7 or less.
Cranial Nerves

HEALTH ASSESSMENT (NCM 101)

 7. For the specific functions and assessment methods of each cranial nerve, see Table
4.7. Test each nerve not already evaluated in another component of the health
assessment. A quick way to remember which cranial nerves are assessed in the face
is shown in Figure 4.24.

Figure 4.24 Cranial nerves by the numbers.

Table 4.10 Cranial Nerve Functions and Assessment Methods

Cranial
Name Type Function Assessment Method
Nerve
Ask client to close eyes and identify
different mild aromas, such as coffee,
I Olfactory Sensory Smell
vanilla, peanut butter, orange/lemon,
chocolate.
Vision and visual fields Ask client to read
Snellen-type chart; check visual fields by
II Optic Sensory Vision and visual fields confrontation; and conduct an
ophthalmoscopic examination. See
Assessing the Eyes.
Extraocular eye Assess six ocular movements and pupil
movement(EOM); reaction.
III Oculomotor Motor movement of sphincter
of pupil; movement of
ciliary muscles of lens
EOM; specifically, Assess six ocular movements
moves eyeball
IV Trochlear Motor
downward and
laterally
While client looks upward lightly touch
the lateral sclera of the eye with sterile
gauze to elicit blink reflex. To test light
Trigeminal Sensation of cornea,
sensation, have client close eyes, wipe a
Ophthalmic Sensory skin of face, and nasal
wisp of cotton over client’s forehead and
branch mucosa
paranasal sinuses. To test deep sensation,
use alternating blunt and sharp ends of a
V safety pin over same areas.
Sensation of skin of Assess skin sensation as for ophthalmic
face and anterior oral branch above.
Maxillary branch Sensory
cavity (tongue and
teeth)
Muscles of mastication; Ask client to clench teeth.
Mandibular Motor and
sensation of skin of
branch Sensory
face
EOM; moves eyeball Assess directions of gaze.
VI Abducens Motor
laterally
VII Facial Motor and Facial expression; taste Ask client to smile, raise the eyebrows,
Sensory (anterior two-thirds of frown, puff out cheeks, close eyes tightly.
tongue) Ask client to identify various tastes
placed on tip and sides of tongue: sugar

HEALTH ASSESSMENT (NCM 101)

 (sweet), salt, lemon juice (sour), and
quinine (bitter); identify areas of taste.
Auditory Romberg test
Sensory Equilibrium
Vestibular branch
VIII
Assess client’s ability to hear spoken
Cochlear branch Sensory Hearing
word and vibrations of tuning fork.
Swallowing ability, Apply tastes on posterior tongue for
Motor and tongue movement, identification. Ask client to move tongue
IX Glossopharyngeal
Sensory taste (posterior from side to side and up and down.
tongue)
Sensation of pharynx Assessed with cranial nerve IX; assess
Motor and and larynx; client’s speech for hoarseness.
X Vagus
Sensory swallowing; vocal cord
movement
Ask client to shrug shoulders against
Head movement; resistance from your hands and turn
XI Accessory Motor
shrugging of shoulders head to side against resistance from your
hand (repeat for other side).
Protrusion of tongue; Ask client to protrude tongue at midline,
XII Hypoglossal Motor moves tongue up and then move it side to side.
down and side to side

Reflexes
8. Test reflexes using a percussion hammer, comparing one side of the body with the
other to evaluate the symmetry of response.
0 No reflex response
+1 Minimal activity (hypoactive)
+2 Normal response
+3 More active than normal
+4 Maximal activity (hyperactive)
Plantar (Babinski) Reflex
The plantar, or Babinski, reflex is superficial. It may be absent in adults
without pathology or overridden by voluntary control.
 Use a moderately sharp object, such as the handle of the percussion hammer,
a key, or an applicator stick.
 Stroke the lateral border of the sole of the client’s foot, starting at the heel,
continuing to the ball of the foot, and then proceeding across the ball of the
foot toward the big toe.
 Observe the response. Normally, all five toes bend downward; this reaction
is negative Babinski. In an abnormal (positive) Babinski response the toes
spread outward and the big toe moves upward.

Figure 4.25 Testing the plantar (Babinski) reflex.

Motor Function
9. Gross Motor and Balance Tests
Generally, the Romberg test and one other gross motor function and balance
tests are used.
Walking Gait
 Ask the client to walk across the room and back, and assess the client’s gait.

HEALTH ASSESSMENT (NCM 101)

 Romberg Test
 Ask the client to stand with feet together and arms resting at the sides, first
with eyes open, then closed. Stand close during this test. Rationale: This
prevents the client from falling. Normally, the result of negative Romberg
patient may sway slightly but is able to maintain upright posture and foot
stance while positive Romberg patient cannot maintain foot stance and
moves the feet apart to maintain stance. If client cannot maintain balance
with the eyes shut, client may have sensory ataxia or lack of coordination of
the voluntary muscles. If balance cannot be maintained whether the eyes are
open or shut, client may have cerebellar ataxia.
Standing on One Foot with Eyes Closed
 Ask the client to close the eyes and stand on one foot. Repeat on the other
foot. Stand close to the client during this test. Maintains stance for at least 5
seconds.
Heel-Toe Walking
 Ask the client to walk a straight line, placing the heel of one foot directly in
front of the toes of the other foot.
Toe or Heel Walking
 Ask the client to walk several steps on the toes and then on the heels.
10. Fine Motor Tests for the Upper Extremities
Finger-To-Nose Test
 Ask the client to abduct and extend the arms at shoulder height and then
rapidly touch the nose alternately with one index finger and then the other.
The client repeats the test with the eyes closed if the test is performed easily.
Alternating Supination and Pronation of Hands on Knees
 Ask the client to pat both knees with the palms of both hands and then with
the backs of the hands alternately at an ever increasing rate.
Finger to Nose and to the Nurse’s Finger
 Ask the client to touch the nose and then your index finger, held at a distance
of about 45 cm (18 in.), at a rapid and increasing rate.
Fingers to Fingers
 Ask the client to spread the arms broadly at shoulder height and then bring
the fingers together at the midline, first with the eyes open and then closed,
first slowly and then rapidly.
Fingers to Thumb (Same Hand)
 Ask the client to touch each finger of one hand to the thumb of the same
hand as rapidly as possible.
11. Fine Motor Tests for the Lower Extremities
Ask the client to lie supine and to perform these tests.
Heel Down Opposite Shin
 Ask the client to place the heel of one foot just below the opposite knee and
run the heel down the shin to the foot. Repeat with the other foot. The client
may also use a sitting position for this test.
Toe or Ball of Foot to the Nurse’s Finger
 Ask the client to touch your finger with the large toe of each foot.
12. Light-Touch Sensation
Compare the light-touch sensation of symmetric areas of the body. Rationale:
Sensitivity to touch varies among different skin areas.
 Ask the client to close the eyes and to respond by saying “yes” or “now”
whenever the client feels the cotton wisp touching the skin.
 With a wisp of cotton, lightly touch one specific spot and then the same spot
on the other side of the body.
 Test areas on the forehead, cheek, hand, lower arm, abdomen, foot, and
lower leg. Check a distal area of the limb first (i.e., the hand before the arm
and the foot before the leg). Rationale: The sensory nerve may be assumed to
be intact if sensation is felt at its most distal part.

HEALTH ASSESSMENT (NCM 101)

  If areas of sensory dysfunction are found, determine the boundaries of
sensation by testing responses about every 2.5 cm (1 in.) in the area. Make a
sketch of the sensory loss area for recording purposes.
13. Pain Sensation Assess pain sensation as follows:
 Ask the client to close the eyes and to say “sharp,” “dull,” or “don’t know”
when the sharp or dull end of a safety pin is felt.
 Alternately, use the sharp and dull end to lightly prick designated anatomic
areas at random, e.g., hand, forearm, foot, lower leg, abdomen. The face is not
tested in this manner.
 Allow at least 2 seconds between each test to prevent summation effects of
stimuli, i.e., several successive stimuli perceived as one stimulus.
14. Position or Kinesthetic Sensation
Commonly, the middle fingers and the large toes are tested for the kinesthetic
sensation (sense of position).
 To test the fingers, support the client’s arm and hand with one hand. To test
the toes, place the client’s heels on the examining table.
 Ask the client to close the eyes.
 Grasp a middle finger or a big toe firmly between your thumb and index
finger, and exert the same pressure on both sides of the finger or toe while
moving it.
 Move the finger or toe until it is up, down, or straight out, and ask the client
to identify the position.
 Use a series of brisk up-and-down movements before bringing the finger or
toe suddenly to rest in one of the three positions.

Lifespan Considerations in Assessing the Neurologic System

Infants
1. Reflexes commonly tested in newborns include:
 Rooting: Stroke the side of the face near mouth; infant opens mouth and turns
to the side that is stroked.
 Sucking: Place nipple or finger 3 to 4 cm (1.2 to 1.6 in.) into mouth; infant sucks
vigorously.
 Tonic neck: Place infant supine, turn head to one side; arm on side to which
head is turned extends; on opposite side, arm curls up (fencer’s pose).
 Palmar grasp: Place finger in infant’s palm and press; infant curls fingers
around.
 Stepping: Hold infant as if weight bearing on surface; infant steps along, one
foot at a time.
 Moro: Present loud noise or unexpected movement; infant spreads arms and
legs, extends fingers, then flexes and brings hands together; may cry.
2. Most of these reflexes disappear between 4 and 6 months of age.

Children
1. Present the procedures as games whenever possible.
2. Positive Babinski reflex is abnormal after the child ambulates or at age 2.
3. For children under age 5, the Denver Developmental Screening Test II provides a
comprehensive neurologic evaluation—particularly for motor function.
4. Note the child’s ability to understand and follow directions.
5. Assess immediate recall or recent memory by using names of cartoon characters.
Normal recall in children is one less than age in years.
6. Assess for signs of hyperactivity or abnormally short attention span.
7. Children should be able to walk backward by age 2, balance on one foot for 5
seconds by age 4, heel-toe walk by age 5, and heel-toe walk backward by age 6.
8. The Romberg test is appropriate over age 3.

Older Adults
1. A full neurologic assessment can be lengthy. Conduct in several sessions if indicated,
and cease the tests if the client is noticeably fatigued.

HEALTH ASSESSMENT (NCM 101)

 2. A decline in mental status is not a normal result of aging. Changes are more the
result of physical or psychological disorders (e.g., fever, fluid and electrolyte
imbalances, medications). Acute, abrupt-onset mental status changes are usually
caused by delirium. These changes are often reversible with treatment. Chronic
subtle insidious mental health changes are usually caused by dementia and are
usually irreversible.
3. Intelligence and learning ability are unaltered with age. Many factors, however,
inhibit learning (e.g., anxiety, illness, pain, cultural barrier).
4. Short-term memory is often less efficient. Long-term memory is usually unaltered.
5. Because old age is often associated with loss of support persons, depression is a
common disorder. Mood changes, weight loss, anorexia, constipation, and early
morning awakening may be symptoms of depression.
6. The stress of being in unfamiliar situations can cause confusion in older adults.
7. As a person ages, reflex responses may become less intense.
8. Because older adults tire more easily than younger clients, a total neurologic
assessment is often done at a different time than the other parts of the physical
assessment.
9. Although there is a progressive decrease in the number of functioning neurons in
the central nervous system and in the sense organs, older adults usually function
well because of the abundant reserves in the number of brain cells.
10. Impulse transmission and reaction to stimuli are slower.
11. Many older adults have some impairment of hearing, vision, smell, temperature and
pain sensation, memory, and mental endurance.
12. Coordination changes, including a reduced speed of fine finger movements. Standing
balance remains intact, and Romberg’s test remains negative.
13. Reflex responses may slightly increase or decrease. Many show loss of Achilles
reflex, and the plantar reflex may be difficult to elicit.
14. When testing sensory function, the nurse needs to give older adults time to respond.
Normally, older adults have unaltered perception of light touch and superficial pain,
decreased perception of deep pain, and decreased perception of temperature
stimuli. Many also reveal a decrease or absence of position sense in the large toes.

SELF-STUDY GUIDE QUESTIONS

1. Explain how to assess the cranial nerves.

MALE GENITALS AND INGUINAL AREA

In adult men, a complete examination includes assessment of the external genitals,
the presence of any hernias, and the prostate gland. Nurses in some practice settings
performing routine assessment of clients may assess only the external genitals.
The male reproductive and urinary systems share the urethra, which is the
passageway for both urine and semen. Therefore, in physical assessment of the male these
two systems are frequently assessed together.
Examination of the male genitals by a female practitioner is becoming increasingly
common, although not all agencies permit a female practitioner to examine the male
genitals. Some agencies may require the presence of another person during the examination
so that there is no question of unprofessional behavior. Most male clients accept
examination by a female, especially if she is emotionally comfortable about performing it
and does so in a matter-of-fact and competent manner. If the female nurse does not feel
comfortable about this part of the examination or if the client is reluctant to be examined by
a woman, the nurse should refer this part of the examination to a male practitioner.
Development of secondary sex characteristics that is the pubic hair, the penis, the
testes and scrotum, is assessed in relationship to the client’s age.
All male clients should be screened for the presence of inguinal or femoral hernias.
A hernia is a protrusion of the intestine through the inguinal wall or canal. Cancer of the
prostate gland is the most common cancer in adult men and occurs primarily in men over
age 50.
Examination of the prostate gland is performed with the examination of the rectum
and anus. Testicular cancer is much rarer than prostate cancer and occurs primarily in
young men ages 15 to 35. Testicular cancer is most commonly found on the anterior and

HEALTH ASSESSMENT (NCM 101)

lateral surfaces of the testes. Testicular self-examination should be conducted monthly.
Perform the following steps in examining testicles:
1. Choose one day of each month (e.g., the first or last day of each month) to examine
yourself.
2. Examine yourself when you are taking a warm shower or bath.
3. Support the testicle underneath with one hand. Place the fingers of the other hand
under the testicle and the thumb on top (this may be easier to do if the leg on that
side is raised).
4. Roll each testicle between the thumb and fingers of your hand, feeling for lumps,
thickening, or a hardening in consistency. The testes should feel smooth.

Figure 4.26 Rolling the testicle between the thumb and fingers.

5. Palpate the epididymis, a cordlike structure on the top and back of the testicle. The
epididymis feels soft and not as smooth as a testicle.
6. Locate the spermatic cord, or vas deferens, which extends upward from the scrotum
toward the base of the penis. It should feel firm and smooth.
7. Using a mirror, inspect your testicles for swelling, any enlargement, or lumps in the
skin of the testicle.
8. Report any lumps or other changes to your health care provider promptly.

Equipment in Assessing the Male Genitals and Inguinal Area

1. Clean gloves

Assessing the Male Genitals and Inguinal Area

1. Inquire about the following: usual voiding patterns and changes, bladder control,
urinary incontinence, frequency, urgency, abdominal pain; symptoms of sexually
transmitted infection; swellings that could indicate presence of hernia; family
history of nephritis, malignancy of the prostate, or malignancy of the kidney.
2. Cover the pelvic area with a sheet or drape at all times when not actually being
examined.
Pubic Hair
3. Inspect the distribution, amount, and characteristics of pubic hair. Normally,
triangular distribution, often spreading up the abdomen.
Penis
4. Inspect the penile shaft and glans penis for lesions, nodules, swellings, and
inflammation. Normally, penis appears slightly wrinkled and varies in color as
widely as other body skin. The foreskin is easily retractable from the glans penis and
a small amount of thick white smegma between the glans and foreskin.
5. Inspect the urethral meatus for swelling, inflammation, and discharge. There are
some variation in meatal locations (e.g., hypospadias, on the underside of the penile
shaft, and epispadias, on the upper side of the penile shaft).
Scrotum
6. Inspect the scrotum for appearance, general size, and symmetry. Inspect all skin
surfaces by spreading the rugated surface skin and lifting the scrotum as needed to
observe posterior surfaces. Scrotal skin is darker in color than that of the rest of the
body and is loose. Size varies with temperature changes (the dartos muscles
contract when the area is cold and relax when the area is warm).
Inguinal Area

HEALTH ASSESSMENT (NCM 101)

 7. Inspect both inguinal areas for bulges while the client is standing, if possible. First,
have the client remain at rest. Next, have the client hold his breath and strain or
bear down as though having a bowel movement. Bearing down may make the hernia
more visible.
Lifespan Considerations in Assessing the Male Genitals and Inguinal Area
Infants
1. The foreskin of the uncircumcised infant is normally tight at birth and should not be
retracted. It will gradually loosen as the baby grows and is usually fully retractable
by 2 to 3 years of age. Assess for cleanliness, redness, or irritation.
2. Assess for placement of the urethral meatus.
3. Palpate the scrotum to determine if the testes are descended; in the newborn and
infant, the testes may retract into the inguinal canal, especially with stimulation of
the cremasteric reflex.
4. Assess the inguinal area for swelling or tenderness that may indicate the presence of
an inguinal hernia.

Children
1. Ensure that you have the parent or guardian’s approval to perform the examination
and then tell the child what you are going to do. Preschool children are taught to not
allow others to touch their “private parts.”
2. In young boys, the cremasteric reflex can cause the testes to ascend into the inguinal
canal. If possible have the boy sit crosslegged, which stretches the muscle and
decreases the reflex.

Older Adults
1. The penis decreases in size with age; the size and firmness of the testes decrease.
2. Testosterone is produced in smaller amounts.
3. More time and direct physical stimulation are required for an older man to achieve
an erection, but he can maintain the erection for a longer period before ejaculation
than he could at a younger age.
4. Seminal fluid is reduced in amount and viscosity.
5. Urinary frequency, nocturia, dribbling, and problems with beginning and ending the
stream are usually the result of prostatic enlargement.

SELF-STUDY GUIDE QUESTION

1. Explain how to perform testicular self-examination.

FEMALE GENITALS AND INGUINAL AREA

The examination of the genitals and reproductive tract of women includes
assessment of the inguinal lymph nodes and inspection and palpation of the external
genitals. Completeness of the assessment of the genitals and reproductive tract depends on
the needs and problems of the individual client.
In most practice settings, generalist nurses perform only inspection of the external
genitals and palpation of the inguinal lymph nodes. For sexually active adolescent and adult
women, a Papanicolaou test (Pap test) is used to detect cancer of the cervix. If there is an
increased or abnormal vaginal discharge, specimens should be taken to check for sexually
transmitted disease.
Examination of the genitals usually creates uncertainty and apprehension in
women, and the lithotomy position required for an internal examination can cause
embarrassment. The nurse must explain each part of the examination in advance and
perform the examination in an objective, supportive, and efficient manner.
Not all agencies permit male practitioners to examine the female genitals. Some
agencies may require the presence of another woman during the examination so that there
is no question of unprofessional behavior. If the male nurse does not feel comfortable about
this part of the examination or if the client is reluctant to be examined by a man, the nurse
should refer this part of the examination to a female practitioner.

HEALTH ASSESSMENT (NCM 101)

 Examination of the internal genitals involves (a) palpating Skene’s and Bartholin’s
glands, (b) assessing the pelvic musculature, (c) inserting a vaginal speculum to inspect the
cervix and vagina, and (d) obtaining a Papanicolaou smear.
The nurse’s responsibilities when assisting with an examination of the internal female
genitals include the following:
1. Assembling equipment. These include drapes, gloves, vaginal speculum, warm water
or lubricant, and supplies for cytology and culture studies.
2. Preparing the client. Advise the client not to douche prior to the procedure. Explain
the procedure. It should take only 5 minutes and is normally not painful. Assist the
client to a lithotomy position as needed, and drape her appropriately.
3. Supporting the client during the procedure. This involves explaining the procedure as
needed, and encouraging the client to take deep breaths that will help the pelvic
muscles relax.
4. Monitoring and assisting the client after the procedure. Assist the client from the
lithotomy position and with perineal care as needed.
5. Documenting the procedure. Include the date and time it was performed, the name of
the examiner, and any nursing assessments and interventions.

Equipment in Assessing the Female Genitals and Inguinal Area

1. Clean gloves
2. Drape
3. Supplemental lighting, if needed

Assessing the Female Genitals and Inguinal Area

1. Inquire regarding the following: age of onset of menstruation, last menstrual period
(LMP), regularity of cycle, duration, amount of daily flow, and whether menstruation
is painful; incidence of pain during intercourse; vaginal discharge; number of
pregnancies, number of live births, labor or delivery complications; urgency and
frequency of urination at night; blood in urine, painful urination, incontinence; history
of sexually transmitted infection, past and present.
2. Cover the pelvic area with a sheet or drape at all times when the client is not actually
being examined. Position the client supine.
3. Inspect the distribution, amount, and characteristics of pubic hair. There are wide
variations; generally kinky in the menstruating adult, thinner and straighter after
menopause. Normal pubic hair is distributed in the shape of an inverse triangle. Scant
pubic hair may indicate hormonal problem.
4. Inspect the skin of the pubic area for parasites, inflammation, swelling, and lesions. To
assess pubic skin adequately, separate the labia majora and labia minora.
5. Inspect the clitoris, urethral orifice, and vaginal orifice when separating the labia
minora. Clitoris does not exceed 1 cm (0.4 in.) in width and 2 cm (0.8 in.) in length.
Urethral orifice appears as a small slit and is the same color as surrounding tissues.
6. Palpate the inguinal lymph nodes. Use the pads of the fingers in a rotating motion,
noting any enlargement or tenderness.

Lifespan Considerations Assessing the Female Genitals and Inguinal Lymph Nodes
Infant
1. Infants can be held in a supine position on the parent’s lap with the knees supported
in a flexed position and separated.
2. In newborns, because of maternal estrogen, the labia and clitoris may be edematous
and enlarged, and there may be a small amount of white or bloody vaginal
discharge.
3. Assess the mons and inguinal area for swelling or tenderness that may indicate
presence of an inguinal hernia.

Children

HEALTH ASSESSMENT (NCM 101)

 1. Ensure that you have the parent or guardian’s approval to perform the examination
and then tell the child what you are going to do. Preschool children are taught not to
allow others to touch their “private parts.”
2. Girls should be assessed for Tanner staging of pubertal development.
Five Stages of Pubic Hair Development in Females
Stage 1 Preadolescence. No pubic hair except for fine body hair.
Stage 2 Usually occurs at ages 11 and 12. Sparse, long, slightly pigmented curly hair
develops along the labia.
Stage 3 Usually occurs at ages 12 and 13. Hair becomes darker in color and curlier
and develops over the pubic symphysis.
Stage 4 Usually occurs between ages 13 and 14. Hair assumes the texture and curl
of the adult but is not as thick and does not appear on the thighs.
Stage 5 Sexual maturity. Hair assumes adult appearance and appears on the inner
aspect of the upper thighs
3. Girls should have a Papanicolaou (Pap) test done if sexually active, or by age 18
years.
4. The clitoris is a common site for syphilitic chancres in younger females.

Older Adults
1. Labia are atrophied and flatter.
2. The clitoris is a potential site for cancerous lesions.
3. The vulva atrophies as a result of a reduction in vascularity, elasticity, adipose
tissue, and estrogen levels. Because the vulva is more fragile, it is more easily
irritated.
4. The vaginal environment becomes drier and more alkaline, resulting in an alteration
of the type of flora present and a predisposition to vaginitis. Dyspareunia (difficult
or painful intercourse) is also a common occurrence.
5. The cervix and uterus decrease in size.
6. The fallopian tubes and ovaries atrophy.
7. Ovulation and estrogen production cease.
8. Vaginal bleeding unrelated to estrogen therapy is abnormal in older women.
9. Prolapse of the uterus can occur in older females, especially those who have had
multiple pregnancies.

SELF-STUDY GUIDE QUESTION

1. Summarize the nurse’s responsibilities when assisting with an examination of the
internal female genitals.

ANUS
Anal examination is an essential part of every comprehensive physical examination,
involves only inspection.

Equipment in Assessing the Anus

1. Clean gloves

Assessing the Anus

1. Inquire if the client has any history of the following: bright blood in stools, tarry
black stools, diarrhea, constipation, abdominal pain, excessive gas, hemorrhoids, or
rectal pain; family history of colorectal cancer; when last stool specimen for occult
blood was performed and the results; and for males, if not obtained during the
genitourinary examination, signs or symptoms of prostate enlargement (e.g., slow
urinary stream, hesitance, frequency, dribbling, and nocturia).
2. Position the client. In adults, a left lateral or Sims’ position with the upper leg
acutely flexed is required for the examination. A dorsal recumbent position with
hips externally rotated and knees flexed or a lithotomy position may be used. For
males, a standing position while the client bends over the examining table may also
be used.

HEALTH ASSESSMENT (NCM 101)

HEALTH ASSESSMENT (NCM 101)
 Figure 4.27 Possible Positions in Assessing the Anus

3. Inspect the anus and surrounding tissue for color, integrity, and skin lesions. Then,
ask the client to bear down as though defecating. Bearing down creates slight
pressure on the skin that may accentuate rectal fissures, rectal prolapse, polyps, or
internal hemorrhoids. Describe the location of all abnormal findings in terms of a
clock, with the 12 o’clock position toward the pubic symphysis. Normally, perianal
skin is intact and usually slightly more pigmented than the skin of the buttocks. Anal
skin is typically more pigmented, coarser, and moister than perianal skin and is
usually hairless.

Lifespan Considerations Assessing the Anus

Infants
1. Lightly touching the anus should result in a brief anal contraction (“wink” reflex).

Children
1. Erythema and scratch marks around the anus may indicate a pinworm parasite.
Children with this condition may be disturbed by itching during sleep.

Older Adults
1. Chronic constipation and straining at stool cause an increase in the frequency of
hemorrhoids and rectal prolapse.

SELF-STUDY GUIDE QUESTION

1. Upon assessment you observe that there is an erythema and scratch marks around
the anus of a 7-year old, male client. Identify the indication of your assessment.

HEALTH ASSESSMENT (NCM 101)

 UNIT 5. RELEVANT ETHICO-LEGAL GUIDELINES IN CONDUCTING HEALTH
ASSESSMENT
Overview
Nurses are highly accountable to patient and we are directed by the ethico-legal
guidelines in conducting health assessment.

Learning Objectives
Upon completion of this unit I am able to:
1. know the informed consent;
2. discuss the patient’s rights; and
3. understand the data privacy act.

INFORMED CONSENT
As enacted by the Senate and House of Representatives of the Philippines in
Congress (Revilla, Jr., 2010), the patient has a right to a clear, truthful and substantial
explanation, in a manner and language understandable to the patient, of all proposed
procedures, whether diagnostic, preventive, curative, rehabilitative or therapeutic, wherein
the person who will perform the said procedure shall provide his name and credentials to
the patient, possibilities of any risk of mortality or serious side effects, problems related to
recuperation, and probability of success and reasonable risks involved, provided, that the
patient will not be subjected to any procedure without his written informed consent, except
in the following cases:
1. in emergency cases, when the patient is at imminent risk of physical injury, decline
or death if treatment is withheld or postponed. In such cases, the physician can
perform any diagnostic or treatment procedure as good practice of medicine
dictates without such consent;
2. when the health of the population is dependent on the adoption of a mass health
program to control epidemic;
3. when the law makes it compulsory for everyone to submit to a procedure;
4. when the patient is either a minor, or legally incompetent, in which case, a third
party consent is required;
5. when disclosure of material information to patient will jeopardize the success of
treatment, in which case, third party disclosure and consent shall be in order; and
6. when the patient waives his right in writing.

Informed consent shall be obtained from a patient concerned if he is of legal age and
of sound mind. In case the patient is incapable of giving consent and a third party consent
is required, the following persons, in the order of priority stated hereunder, may give
consent:
a. spouse;
b. son or daughter of legal age;
c. either parent;
d. brother or sister of legal age, or
e. guardian

If a patient is a minor, consent shall be obtained from his parents or Iegal son or
daughter of legal age; brother or sister of legal age, or guardian.
If next of kin, parents or legal guardians refuse to give consent to a medical or
surgical procedure necessary to save the life or 1iC.b of a minor or a patient incapable of
giving consent, courts, upon the petition of the physician or any person interested in the
welfare of the patient, in a summary proceeding, may issue an order giving consent.

Components of Informed Consent

These are the following:
1. You must have the capacity (or ability) to make the decision.
2. The medical provider must disclose information on the treatment, test, or procedure
in question, including the expected benefits and risks, and the likelihood (or
probability) that the benefits and risks will occur.
3. You must comprehend the relevant information.
4. You must voluntarily grant consent, without coercion or duress.

HEALTH ASSESSMENT (NCM 101)

Essential Elements of Informed Consent
These are the following:
1. Confidentiality
2. New information
3. Voluntary participation
4. Person/s to contact for study information
5. Rights of subject, if study related injury
6. Reasons for termination
7. Duration of study
8. Number of subjects
9. Any other pertinent information

PATIENT’S BILL OF RIGHTS

The following are the rights of the patient as stated by Revilla, Jr. (2010):
1. Right to appropriate medical care and humane treatment.
2. Right to informed consent.
3. Right to privacy and confidentiality.
4. Right to information.
5. The right to choose health care provider and facility.
6. Right to self-determination.
7. Right to religious belief
8. Right to medical records.
9. Right to leave.
10. Right to refuse participation in medical research.
11. Right to correspondence and to receive visitors.
12. Right to express grievances.
13. Right to be informed of his rights and obligations as a patient.

DATA PRIVACY ACT 2012

Republic Act No. 10173, otherwise known as the Data Privacy Act (National Privacy
Commission, 2012)  is a law that seeks to protect all forms of information, be it private,
personal, or sensitive. It is meant to cover both natural and juridical persons involved in the
processing of personal information.

Rule I. Preliminary Provisions

Section 1. Title. These rules and regulations shall be known as the Implementing Rules and
Regulations of Republic Act No. 10173 known as the Data Privacy Act of 2012, or
the “Rules.”
Section 2. Policy. These rules and regulations further enforce the Data Privacy Act and
adopts generally accepted international principles and standards for data
protection, safeguarding the fundamental right of every individual to privacy
while supporting the free flow of information for innovation, growth and national
development. The Rules recognize the vital role of information and
communications technology in nation-building and enforce the State’s inherent
obligation to ensure that personal data in information and communications
systems in the government and in the private sector are secured and protected.
Section 3. Definition of Terms.  Whenever used in this Act, the following terms shall have the
respective meanings hereafter set forth:
 Consent of the data subject refers to any freely given, specific, informed indication
of will, whereby the data subject agrees to the collection and processing of
personal information about and/or relating to him or her. Consent shall be
evidenced by written, electronic or recorded means. It may also be given on
behalf of the data subject by an agent specifically authorized by the data subject
to do so.
 Data subject refers to an individual whose personal information is processed.
 Personal information refers to any information whether recorded in a material
form or not, from which the identity of an individual is apparent or can be
reasonably and directly ascertained by the entity holding the information, or
when put together with other information would directly and certainly identify
an individual.

HEALTH ASSESSMENT (NCM 101)

  Personal information controller refers to a person or organization who controls
the collection, holding, processing or use of personal information, including a
person or organization who instructs another person or organization to collect,
hold, process, use, transfer or disclose personal information on his or her behalf.
The term excludes:
(1) A person or organization who performs such functions as instructed by
another person or organization; and
(2) An individual who collects, holds, processes or uses personal information
in connection with the individual’s personal, family or household affairs.
 Personal information processor refers to any natural or juridical person qualified
to act as such under this Act to whom a personal information controller may
outsource the processing of personal data pertaining to a data subject.
 Processing refers to any operation or any set of operations performed upon
personal information including, but not limited to, the collection, recording,
organization, storage, updating or modification, retrieval, consultation, use,
consolidation, blocking, erasure or destruction of data.
 Privileged information refers to any and all forms of data which under the Rules
of Court and other pertinent laws constitute privileged communication.
 Sensitive personal information refers to personal information:
(1) About an individual’s race, ethnic origin, marital status, age, color, and
religious, philosophical or political affiliations;
(2) About an individual’s health, education, genetic or sexual life of a person,
or to any proceeding for any offense committed or alleged to have been
committed by such person, the disposal of such proceedings, or the
sentence of any court in such proceedings;
(3) Issued by government agencies peculiar to an individual which includes,
but not limited to, social security numbers, previous or current health
records, licenses or its denials, suspension or revocation, and tax
returns; and
(4) Specifically established by an executive order or an act of Congress to be
kept classified.
 Scope. – This Act applies to the processing of all types of personal information
and to any natural and juridical person involved in personal information
processing including those personal information controllers and processors who,
although not found or established in the Philippines, use equipment that are
located in the Philippines, or those who maintain an office, branch or agency in
the Philippines subject to the immediately succeeding paragraph: Provided, That
the requirements of Section 5 are complied with.
This Act does not apply to the following:
a) Information about any individual who is or was an officer or employee
of a government institution that relates to the position or functions of
the individual, including:
(1) The fact that the individual is or was an officer or employee of the
government institution;
(2) The title, business address and office telephone number of the
individual;
(3) The classification, salary range and responsibilities of the
position held by the individual; and
(4) The name of the individual on a document prepared by the
individual in the course of employment with the government;
Penalties
Section 25. Unauthorized Processing of Personal Information and Sensitive Personal
Information.
a) The unauthorized processing of personal information shall be penalized by
imprisonment ranging from one (1) year to three (3) years and a fine of not less than
Five hundred thousand pesos (Php500,000.00) but not more than Two million pesos
(Php2,000,000.00) shall be imposed on persons who process personal information
without the consent of the data subject, or without being authorized under this Act
or any existing law.
(b) The unauthorized processing of personal sensitive information shall be penalized by
imprisonment ranging from three (3) years to six (6) years and a fine of not less than

HEALTH ASSESSMENT (NCM 101)

 Five hundred thousand pesos (Php500,000.00) but not more than Four million
pesos (Php4,000,000.00) shall be imposed on persons who process personal
information without the consent of the data subject, or without being authorized
under this Act or any existing law.
Section 26. Accessing Personal Information and Sensitive Personal Information Due to
Negligence. 
(a) Accessing personal information due to negligence shall be penalized by
imprisonment ranging from one (1) year to three (3) years and a fine of not less
than Five hundred thousand pesos (Php500,000.00) but not more than Two
million pesos (Php2,000,000.00) shall be imposed on persons who, due to
negligence, provided access to personal information without being authorized
under this Act or any existing law.
(b) Accessing sensitive personal information due to negligence shall be penalized by
imprisonment ranging from three (3) years to six (6) years and a fine of not less
than Five hundred thousand pesos (Php500,000.00) but not more than Four
million pesos (Php4,000,000.00) shall be imposed on persons who, due to
negligence, provided access to personal information without being authorized
under this Act or any existing law.
Section 27. Improper Disposal of Personal Information and Sensitive Personal Information. –
(a) The improper disposal of personal information shall be penalized by imprisonment
ranging from six (6) months to two (2) years and a fine of not less than One
hundred thousand pesos (Php100,000.00) but not more than Five hundred
thousand pesos (Php500,000.00) shall be imposed on persons who knowingly or
negligently dispose, discard or abandon the personal information of an individual
in an area accessible to the public or has otherwise placed the personal
information of an individual in its container for trash collection.
Section 30. Concealment of Security Breaches Involving Sensitive Personal Information. – The
penalty of imprisonment of one (1) year and six (6) months to five (5) years and a
fine of not less than Five hundred thousand pesos (Php500,000.00) but not more
than One million pesos (Php1,000,000.00) shall be imposed on persons who, after
having knowledge of a security breach and of the obligation to notify the
Commission pursuant to Section 20(f), intentionally or by omission conceals the
fact of such security breach.

SELF-STUDY GUIDE QUESTIONS

1. Discuss the informed consent.
2. Enumerate the patient’s rights and cite an example situation for each right.
3. Summarize the data privacy act.

HEALTH ASSESSMENT (NCM 101)

 UNIT 6. CORE VALUES OF NURSING CONDUCTING HEALTH ASSESSMENT
Overview
Nursing is a caring profession. Caring encompasses empathy for and connection
with people. Caring is best demonstrated by a nurse's ability to embody the core values of
professional nursing.

Learning Objective
Upon completion of this unit I am able to:
1. explain the core values of nursing conducting health assessment.

Based from the CHED Memorandum Order No. 15 series of 2017, (Commission on
Higher Education, 2017) the nurse assumes the caring role in the promotion of health,
prevention of diseases, restoration of health, alleviation of suffering, and, when recovery is
not possible, in assisting patients towards a peaceful death. The nurse collaborates with
other members of the health team like physicians, medical technologists, physical and
occupational therapists, dieticians and nutritionists, etc. and other sectors to achieve quality
healthcare. Moreover, the nurse works with individuals, families, population groups,
communities, and society in ensuring active participation in the delivery of holistic
healthcare.
Within the context of the Philippine society, nursing education with caring as its
foundation subscribes to the following core values which are vital components in the
development of a professional nurse:
1. Love of God
2. Caring as the core of nursing
a. Compassion
b. Competence
c. Confidence
d. Conscience
e. Commitment (commitment to a culture of excellence, discipline, integrity,
and professionalism)
3. Love of People
a. Respect for the dignity of each person regardless of creed, color, gender, and
political affiliation.
4. Love of Country
a. Patriotism (Civic duty, social responsibility, and good governance)
b. Preservation and enrichment of the environment and culture heritage

SELF-STUDY GUIDE QUESTIONS

1. Discuss the core values of nursing as applied to health assessment.

HEALTH ASSESSMENT (NCM 101)

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HEALTH ASSESSMENT (NCM 101)