Fundamentals of Nursing Review Notes

NURSING PROCESS

ASSESSMENT

Description

● It is systematic and continuous collection, validation and communication of client

data as compared to what is standard/norm.

Purpose

To establish a data base (all the information about the client):

● nursing health history

● physical assessment
● the physician’s history & physical examination
● results of laboratory & diagnostic tests material from other health personnel

FOUR Types of Assessment

1. Initial assessment– assessment performed within a specified time on admission

2. Problem-focused assessment– use to determine status of a specific problem
identified in an earlier assessment
3. Emergency assessment– rapid assessment done during any physiologic/physiologic
crisis of the client to identify life threatening problems.
4. Time-lapsed assessment – reassessment of client’s functional health pattern done
several months after initial assessment to compare the client’s current status to
baseline data previously obtained.

Activities during Assessment

1. Collection of data
2. Validation of data
3. Organization of data
4. Analyzing of data
 5. Recording/documentation of data

Collection of data

● gathering of information about the client

● includes physical, psychological, emotion, socio-cultural, spiritual factors that may
affect client’s health status
● includes past health history of client (allergies, past surgeries, chronic diseases, use
of folk healing methods)
● includes current/present problems of client (pain, nausea, sleep pattern, religious
practices, meds or treatment the client is taking now)

Types of Data

1. Subjective data
○ also referred to as Symptom/Covert data
○ Information from the client’s point of view or are described by the person
experiencing it.
○ Information supplied by family members, significant others; other health
professionals are considered subjective data.
○ Example: pain, dizziness, anxiety
2. Objective data
○ also referred to as Sign/Overt data
○ Those that can be detected observed or measured/tested using accepted
standard or norm.
○ Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin

Methods of Data Collection

1. Interview
○ A planned, purposeful conversation/communication with the client to get
information, identify problems, evaluate change, to teach, or to provide
support or counseling.
○ it is used while taking the nursing history of a client
2. Observation
○ Use to gather data by using the 5 senses and instruments.
3. Examination
○ Systematic data collection to detect health problems using unit of
measurements, physical examination techniques (IPPA), interpretation of
laboratory results.
 ○ Should be conducted systematically:
1. Cephalocaudal approach– head-to-toe assessment
2. Body System approach– examine all the body system
3. Review of System approach – examine only particular area affected

Source of data

1. Primary source– data directly gathered from the client using interview and physical
examination.
2. Secondary source – data gathered from client’s family members, significant others,
client’s medical records/chart, other members of health team, and related care
literature/journals.
○ In the Assessment Phase, obtain a Nursing Health History– a structured
interview designed to collect specific data and to obtain a detailed health
record of a client.

Components of a Nursing Health History:

● Biographic data – name, address, age, sex, martial status, occupation, religion and
others
● Reason for visit/Chief complaint – the reason for the visit
● History of present Illness – chronologic story of the present problem
● Past Health History – includes childhood diseases, immunization, allergies, medical
history, accidents and hospitalization
● Family History – reveals risk factors for certain diseases that run in the family
● Review of systems – review of all health problems by body systems
● Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily
living, recreation or hobbies.
● Social data – include family relationships, ethnic and educational background,
economic status, home and neighborhood conditions.
● Psychological data – information about the client’s emotional state.
● Pattern of health care – includes all health care resources: hospitals, clinics, health
centers, family doctors.

Validation of Data
 ● The act of “double-checking” or verifying data to confirm that it is accurate and
complete.

Purposes of data validation

1. ensure that data collection is complete

2. ensure that objective and subjective data agree
3. obtain additional data that may have been overlooked
4. avoid jumping to conclusion
5. differentiate cues and inferences

Organization of Data

Uses a written or computerized format that organizes assessment data systematically.

1. Maslow’s basic needs

2. Body System Model
3. Gordon’s Functional Health Patterns:

Gordon’s Functional Health Patterns

1. Health perception-health management pattern.

2. Nutritional-metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-concept pattern
8. Role-relationship pattern
9. Sexuality-reproductive pattern
10. Coping-stress tolerance pattern
11. Value-belief pattern

Analyze data

● Compare data against standard and identify significant cues. Standard/norm are
generally accepted measurements, model, pattern:
 Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic
values, normal growth and development pattern

Communicate/Record/Document Data

● The nurse records all data collected about the client’s health status
● Data are recorded in a factual manner not as interpreted by the nurse
● Record subjective data in client’s word; restating in other words what client says
might change its original meaning.

DIAGNOSIS

Definition

● Is the 2nd step of the nursing process.

● Identifying the health problem based on the responses of the client to his illness.

Nursing Diagnosis

● Is a statement of a client’s potential or actual health problem resulting from analysis

of data.
● Is a statement of client’s potential or actual alterations/changes in his health status.
● A statement that describes a client’s actual or potential health problems that a nurse
can identify and for which she can order nursing interventions to maintain the health
status, to reduce, eliminate or prevent alterations/changes.

Three Activities in Diagnosing:

1. Data Analysis
2. Problem Identification
3. Formulation of Nursing Diagnosis
Characteristics of Nursing Diagnosis

1. It states a clear and concise health problem.

2. It is derived from existing evidences about the client.
3. It is potentially amenable to nursing therapy.
4. It is the basis for planning and carrying out nursing care.

Components of A nursing diagnosis (PES or PE)

1. Problem statement/diagnostic label/definition = P

2. Etiology/related factors/causes = E
3. Defining characteristics/signs and symptoms = S

*Therefore may be written as 2-Part or a 3-Part statement.

Types of Nursing Diagnosis

1. Actual Nursing Diagnosis– a client problem that is present at the time of the nursing
assessment. It is based on the presence of signs and symptoms.
1. Examples:
1. Imbalanced Nutrition: Less than body requirements r/t decreased
appetite nausea.
2. Disturbed Sleep Pattern r/t cough, fever and pain.
3. Constipation r/t long term use of laxative.
4. Ineffective airway clearance r/t to viscous secretions
2. Potential Nursing diagnosis– one in which evidence about a health problem is
incomplete or unclear therefore requires more data to support or reject it; or
the causative factors are unknown but a problem is only considered possible
to occur.
1. Examples:
1. Possible nutritional deficit
2. Possible low self-esteem r/t loss job
3. Possible altered thought processes r/t unfamiliar surroundings
2. Risk Nursing diagnosis– is a clinical judgment that a problem does not
exist, therefore no S/S are present, but the presence of RISK
FACTORS is indicates that a problem is only is likely to develop unless
nurse intervene or do something about it. No subjective or objective
cues are present therefore the factors that cause the client to be more
vulnerable to the problem are the etiology of a risk nursing diagnosis.
1. Examples:
■ Risk for Impaired skin integrity (left ankle) r/t decrease
peripheral circulation in diabetes.
 ■ Risk for interrupted family processes r/t mother’s illness
& unavailability to provide child care.

Activities during diagnosis:

1. Compare data against standards

2. Cluster or group data
3. Data analysis after comparing with standards
4. Identify gaps and inconsistencies in data
5. Determine the client’s health problems, health risks, strengths
6. Formulate Nursing Diagnosis – prioritize nursing diagnosis based on what problem
endangers the client’s life

PLANNING

Definition

● Involves determining before and the strategies or course of actions to be taken

before implementation of nursing care. To be effective, the client and his family
should be involve in planning.

Purpose

● To determine the goals of care and the course of actions to be undertaken during the
implementation phase.
● To promote continuity of care.
● To focus charting requirements.
● To allow for delegation of specific activities.
1. Establish/Set priorities
● Priority– is something that takes precedence in position, and considered the most
important among several items. It is a decision making process that ranks the order
of nursing diagnosis in terms of importance to the client.

Guideline for setting priorities:

1. Life-threatening situations should be given highest priority.

 2. Use the principle of ABC’s (airway, breathing, circulation)
3. Use Maslow’s hierarchy of needs.
4. Consider something that is very important to the client.
5. Actual problems take precedence over potential concerns.
6. Clients with unstable condition should be given priority over those with stable
conditions. Ex: attend to client with fever before attending to client who is scheduled
for physical therapy in the afternoon.
7. Consider the amount of time, materials, equipment required to care for clients. Ex:
attend to client who requires dressing change for postop wound before attending to
client who requires health teachings & is ready to be discharged late in the
afternoon.
8. Attend to client before equipment. Ex: assess the client before checking IV fluids,
urinary catheter, and drainage tube.
9. Plan nursing interventions/nursing orders to direct activities to be carried out in the
implementation phase.

Nursing interventions

● Any treatment, based upon clinical judgment and knowledge, that a nurse performs
to enhance client outcomes.
● They are used to monitor health status; prevent, resolve or control a problem; assist
with activities of daily living; or promote optimum health and independence.
● They maybe independent, dependent and independent/collaborative activities that
nurses carry out to provide client care.
○ Independent Nursing Intervention– those activities that the nurse is licensed
to initiate as a result of the nurse’s own knowledge and skills.
○ Dependent Nursing Intervention– those activities carried out on the order of a
physician, under a physician’s supervision, or according to specific routines.
○ Interdependent/Collaborative – those activities the nurse carries out in
collaboration or in relation with other members of the health care team.
3. Write a Nursing Care Plan

Nursing Care Plan (NCP)

● A written summary of the care that a client is to receive.

● It is the “blueprint” of the nursing process.
● It is nursing centered in that the nurse remains in the scope of nursing practice
domain in treating human responses to actual or potential health problems.
● It is s step-by-step process as evidence by:
1. Sufficient data are collected to substantiate nursing diagnosis.
2. At least one goal must be stated for each nursing diagnosis.
3. Outcome criteria must be identified for each goal.
 4. Nursing interventions must be specifically designed to meet the identified
goal.
5. Each intervention should be supported by a scientific rationale, which is the
justification or reason for carrying out the intervention.
6. Evaluation must address whether each goal was completely met, partially met
or completely unmet.

IMPLEMENTATION

Definition

● Is putting the nursing care plan into action.

Purpose

● To carry out planned nursing interventions to help the client attain goals and achieve
optimal level of health.

Activities

1. Reassessing – to ensure prompt attention to emerging problems.

2. Set priorities – to determine the order in which nursing interventions are carried out.
3. Perform nursing interventions – these may be independent. Dependent or
collaborative measures.
4. Record actions – to complete nursing interventions, relevant documentation should
be done. Remember: Something that is NOT written is considered as NOT done at
all.

Requirements of Implementation

1. Knowledge – include intellectual skills like problem-solving, decision-making and

teaching.
2. Technical skills – to carry out treatment and procedures.
 3. Communication skills – use of verbal and non-verbal communication to carry out
planned nursing interventions.
4. Therapeutic use of self– is being willing and being able to care.

EVALUATION

● Evaluation, the final step of the nursing process, is crucial to determine whether,
after application of the nursing process, the client’s condition or well-being improves.
The nurse applies all that is known about a client and the client’s condition, as well
as experience with previous clients, to evaluate whether nursing care was effective.
The nurse conducts evaluation measures to determine if expected outcomes are
met, not the nursing interventions.
● The expected outcomes are the standards against which the nurse judges if goals
have been met and thus if care is successful. Providing health care in a timely,
competent, and cost-effective manner is complex and challenging. The evaluation
process will determine the effectiveness of care, make necessary modifications, and
to continuously ensure favorable client outcomes.

HEAD-TO-TOE ASSESSMENT

Physical assessment

● a systematic data collection method that uses the senses of sight, hearing, smell and
touch to detect health problems. There are four techniques used in physical
assessment and these are: Inspection, palpation, percussion and auscultation.
Usually history taking is completed before physical examination

Inspection

● It’s the use of vision to distinguish the normal from the abnormal findings. Body parts
are inspected to identify color, shape, symmetry, movement, pulsation and texture.
Principles of inspection

● Availability of adequate light

● Position and expose body part to view all surfaces
● Inspect each area for size, shape, color, symmetry, Position and abnormalities.
● If possible compare each area inspected with the same area on the opposite side.
● Use additional light to inspect body cavities

Palpation

● It involves use of hands to touch body parts for data collection.

● The nurse uses fingertips and palms to determine the size, shape, and configuration
of underlying body structure and pulsation of blood vessels.
● It help to detect the outline of organs such as thyroid, spleen or liver and mobility of
masses.
● It detects body temperature, moisture, turgor, texture, tenderness, thickness, and
distention.

Principles of palpation

● Help client to relax and be comfortable because muscle tension impairs effective
assessment.
● Advise client to take slow deep breaths during palpation
● Palpate tender areas last and note nonverbal signs of discomfort.
● Rub hands to warm them, have short fingernails and use gentle touch.

Percussion

● It is the technique in which one or both hands are used to strike the body surface to
produce a sound called percussion note that travels through body tissue.
● The character of the sound determines the location, size and density of underlying
structure to verify abnormalities.
● An abnormal sound suggest a mass or substance like air, fluid in an organ or cavity.

Auscultation
 ● It involves listening to sounds and a stethoscope is mostly used.
● Various body systems like cardiovascular, respiratory and gastrointestinal have
characterized sounds.
● Bowel, breath, heart and blood movement sounds are heard using the stethoscope.
● It is important to know the normal sound to distinguish from abnormal.

Preparation for physical exam

● Infection prevention– Follow IP precaution through out procedure

● Environment– P/A requires privacy and away from other destructors throughout
● Equipment– Get all the necessary equipment, other equipment needs to be warmed
before being placed on the body e.g. rubbing diaphragm of the stethoscope briskly
between hands.
● Patient preparation– Prepare the patient physically and make the patient comfortable
throughout the physical assessment for successful exam. Explain to the patient
everything to be done.

General survey

● The assessment of the patient/client begins on the first contact.

● It includes apparent state of health , level of consciousness, and signs of distress.
● The general height, weight, and build can be noted including skin color, dressing,
grooming, personal hygiene, facial expression, gait, odor, posture and motor activity.

NOTE: If there is a sign of acute distress comprehensive health assessment is deferred

until when patient is stable.

Vital signs

● Assessment of vital signs is the first in physical assessment because positioning and
moving the client during examination interferes with obtaining accurate results.
● Specific vital signs can be also obtained during assessment of individual body
system.

Skull, Scalp & Hair

● Observe the size, shape and contour of the skull.

 ● Observe scalp in several areas by separating the hair at various locations; inquire
about any injuries. Note presence of lice, nits, dandruff or lesions.
● Palpate the head by running the pads of the fingers over the entire surface of skull;
inquire about tenderness upon doing so. (wear gloves if necessary)
● Observe and feel the hair condition.

Normal Findings:

Skull

● Generally round, with prominences in the frontal and occipital area. (Normocephalic).
● No tenderness noted upon palpation.

Scalp

● Lighter in color than the complexion.

● Can be moist or oily.
● No scars noted.
● Free from lice, nits and dandruff.
● No lesions should be noted.
● No tenderness or masses on palpation.

Hair

● Can be black, brown or burgundy depending on the race.

● Evenly distributed covers the whole scalp (No evidences of Alopecia)
● Maybe thick or thin, coarse or smooth.
● Neither brittle nor dry.

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Face

● Observe the face for shape.

● Inspect for Symmetry.
○ Inspect for the palpebral fissure (distance between the eye lids); should be
equal in both eyes.
○ Ask the patient to smile, There should be bilateral Nasolabial fold (creases
extending from the angle of the corner of the mouth). Slight asymmetry in the
fold is normal.
○ If both are met, then the Face is symmetrical
○
 ● Test the functioning of Cranial Nerves that innervates the facial structures

CN V (Trigeminal)

1. Sensory Function
● Ask the client to close the eyes.
● Run cotton wisp over the fore head, check and jaw on both sides of the face.
● Ask the client if he/she feel it, and where she feels it.
● Check for corneal reflex using cotton wisp.
● The normal response in blinking.
2. Motor function
● Ask the client to chew or clench the jaw.
● The client should be able to clench or chew with strength and force.

CN VII (Facial)

1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).
● Place a sweet, sour, salty, or bitter substance near the tip of the tongue.
● Normally, the client can identify the taste.
2. Motor function
● Ask the client to smile, frown, raise eye brow, close eye lids, whistle, or puff the
cheeks.

Normal Findings

● Shape maybe oval or rounded.

● Face is symmetrical.
● No involuntary muscle movements.
● Can move facial muscles at will.
● Intact cranial nerve V and VII.

Eyebrows, Eyes and Eyelashes

● All three structures are assessed using the modality of inspection.

Normal findings

Eyebrows

● Symmetrical and in line with each other.

● Maybe black, brown or blond depending on race.
● Evenly distributed.
Eyes

● Evenly placed and inline with each other.

● None protruding.
● Equal palpebral fissure.

Eyelashes

● Color dependent on race.

● Evenly distributed.
● Turned outward.

Eyelids and Lacrimal Apparatus

1. Inspect the eyelids for position and symmetry.

2. Palpate the eyelids for the lacrimal glands.
● To examine the lacrimal gland, the examiner, lightly slide the pad of the index finger
against the client’s upper orbital rim.
● Inquire for any pain or tenderness.
3. Palpate for the nasolacrimal duct to check for obstruction.
● To assess the nasolacrimal duct, the examiner presses with the index finger against
the client’s lower inner orbital rim, at the lacrimal sac, NOT AGAINST THE NOSE.
● In the presence of blockage, this will cause regurgitation of fluid in the puncta

Normal Findings

Eyelids

● Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are
open.
● No PTOSIS noted. (Drooping of upper eyelids).
● Meets completely when eyes are closed.
●

Lacrimal Apparatus

● Lacrimal gland is normally non palpable.

● No tenderness on palpation.
● No regurgitation from the nasolacrimal duct.

Conjunctivae
 ● The bulbar and palpebral conjunctivae are examined by separating the eyelids
widely and having the client look up, down and to each side. When separating the
lids, the examiner should exert NO PRESSURE against the eyeball; rather, the
examiner should hold the lids against the ridges of the bony orbit surrounding the
eye.

In examining the palpebral conjunctiva, everting the upper eyelid in necessary and is done
as follow:

● Ask the client to look down but keep his eyes slightly open. This relaxes the levator
muscles, whereas closing the eyes contracts the orbicularis muscle, preventing lid
eversion.
● Gently grasp the upper eyelashes and pull gently downward. Do not pull the lashes
outward or upward; this, too, causes muscles contraction.
● Place a cotton tip application about I can above the lid margin and push gently
downward with the applicator while still holding the lashes. This everts the lid.
● Hold the lashes of the everted lid against the upper ridge of the bony orbit, just
beneath the eyebrow, never pushing against the eyebrow.
● Examine the lid for swelling, infection, and presence of foreign objects.
● To return the lid to its normal position, move the lid slightly forward and ask the client
to look up and to blink. The lid returns easily to its normal position.

Normal Findings:

● Both conjunctivae are pinkish or red in color.

● With presence of many minutes capillaries.
● Moist
● No ulcers
● No foreign objects

Sclerae

● The sclerae is easily inspected during the assessment of the conjunctivae.

Normal Findings

● Sclerae is white in color (anicteric sclera)

● No yellowish discoloration (icteric sclera).
● Some capillaries maybe visible.
● Some people may have pigmented positions.

Cornea
 ● The cornea is best inspected by directing penlight obliquely from several positions.

Normal findings

● There should be no irregularities on the surface.

● Looks smooth.
● The cornea is clear or transparent. The features of the iris should be fully visible
through the cornea.
● There is a positive corneal reflex.

Anterior Chamber and Iris

● The anterior chamber and the iris are easily inspected in conjunction with the cornea.
The technique of oblique illumination is also useful in assessing the anterior
chamber.

Normal Findings:

● The anterior chamber is transparent.

● No noted any visible materials.
● Color of the iris depends on the person’s race (black, blue, brown or green).
● From the side view, the iris should appear flat and should not be bulging forward.
There should be NO crescent shadow casted on the other side when illuminated
from one side.

Pupils

● Examination of the pupils involves several inspections, including assessment of the

size, shape reaction to light is directed is observed for direct response of
constriction. Simultaneously, the other eye is observed for consensual response of
constriction.

The test for papillary accommodation is the examination for the change in papillary size as it
is switched from a distant to a near object.

● Ask the client to stare at the objects across room.

● Then ask the client to fix his gaze on the examiner’s index fingers, which is placed 5
– 5 inches from the client’s nose.
● Visualization of distant objects normally causes papillary dilation and visualization of
nearer objects causes papillary constriction and convergence of the eye.

Normal Findings
 ● Pupillary size ranges from 3 – 7 mm, and are equal in size.
● Equally round.
● Constrict briskly/sluggishly when light is directed to the eye, both directly and
consensual.
● Pupils dilate when looking at distant objects, and constrict when looking at nearer
objects.

If all of which are met, we document the findings using the notation PERRLA, pupils equally
round, reactive to light, and accommodate

Cranial Nerve II (optic nerve)

● The optic nerve is assessed by testing for visual acuity and peripheral vision.
● Visual acuity is tested using a Snellen chart, for those who are illiterate and
unfamiliar with the western alphabet, the illiterate E chart, in which the letter E faces
in different directions, maybe used.
● The chart has a standardized number at the end of each line of letters; these
numbers indicates the degree of visual acuity when measured at a distance of 20
feet.
● The numerator 20 is the distance in feet between the chart and the client, or the
standard testing distance. The denominator 20 is the distance from which the normal
eye can read the lettering, which correspond to the number at the end of each letter
line; therefore the larger the denominator the poorer the version.
● Measurement of 20/20 vision is an indication of either refractive error or some other
optic disorder.

In testing for visual acuity you may refer to the following:

● The room used for this test should be well lighted.

● A person who wears corrective lenses should be tested with and without them to
check fro the adequacy of correction.
● Only one eye should be tested at a time; the other eye should be covered by an
opaque card or eye cover, not with client’s finger.
● Make the client read the chart by pointing at a letter randomly at each line; maybe
started from largest to smallest or vice versa.
● A person who can read the largest letter on the chart (20/200) should be checked if
they can perceive hand movement about 12 inches from their eyes, or if they can
perceive the light of the penlight directed to their yes.

Peripheral Vision or visual fields

 ● The assessment of visual acuity is indicative of the functioning of the macular area,
the area of central vision. However, it does not test the sensitivity of the other areas
of the retina which perceive the more peripheral stimuli. The Visual field
confrontation test, provide a rather gross measurement of peripheral vision.
● The performance of this test assumes that the examiner has normal visual fields,
since that client’s visual fields are to be compared with the examiners.

Follow the steps on conducting the test:

● The examiner and the client sit or stand opposite each other, with the eyes at the
same, horizontal level with the distance of 1.5 – 2 feet apart.
● The client covers the eye with opaque card, and the examiner covers the eye that is
opposite to the client covered eye.
● Instruct the client to stare directly at the examiner’s eye, while the examiner stares at
the client’s open eye. Neither looks out at the object approaching from the periphery.
● The examiner hold an object such as pencil or penlight, in his hand and gradually
moves it in from the periphery of both directions horizontally and from above and
below.
● Normally the client should see the same time the examiners sees it. The normal
visual field is 180 degrees.

Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)

● All the 3 Cranial nerves are tested at the same time by assessing the Extra Ocular
Movement (EOM) or the six cardinal position of gaze.

Follow the given steps:

● Stand directly in front of the client and hold a finger or a penlight about 1 ft from the
client’s eyes.
● Instruct the client to follow the direction the object hold by the examiner by eye
movements only; that is with out moving the neck.
● The nurse moves the object in a clockwise direction hexagonally.
● Instruct the client to fix his gaze momentarily on the extreme position in each of the
six cardinal gazes.
● The examiner should watch for any jerky movements of the eye (nystagmus).
● Normally the client can hold the position and there should be no nystagmus.

Ears

● Inspect the auricles of the ears for parallelism, size position, appearance and skin
color.
 ● Palpate the auricles and the mastoid process for firmness of the cartilage of the
auricles, tenderness when manipulating the auricles and the mastoid process.
● Inspect the auditory meatus or the ear canal for color, presence of cerumen,
discharges, and foreign bodies.
○ For adult pull the pinna upward and backward to straiten the canal.
○ For children pull the pinna downward and backward to straiten the canal
● Perform otoscopic examination of the tympanic membrane, noting the color and
landmarks.

Normal Findings

● The ear lobes are bean shaped, parallel, and symmetrical.

● The upper connection of the ear lobe is parallel with the outer canthus of the eye.
● Skin is same in color as in the complexion.
● No lesions noted on inspection.
● The auricles are has a firm cartilage on palpation.
● The pinna recoils when folded.
● There is no pain or tenderness on the palpation of the auricles and mastoid process.
● The ear canal has normally some cerumen of inspection.
● No discharges or lesions noted at the ear canal.
● On otoscopic examination the tympanic membrane appears flat, translucent and
pearly gray in color.

Nose and Paranasal Sinuses

The external portion of the nose is inspected for the following:

● Placement and symmetry.

● Patency of nares (done by occluding nosetril one at a time, and noting for difficulty in
breathing)
● Flaring of alae nasi
● Discharge

The external nares are palpated for:

● Displacement of bone and cartilage.

● For tenderness and masses

The internal nares are inspected by hyper extending the neck of the client, the ulnar aspect
of the examiners hard over the fore head of the client, and using the thumb to push the tip
of the nose upward while shining a light into the nares.
Inspect for the following:

● Position of the septum.

● Check septum for perforation. (Can also be checked by directing the lighted penlight
on the side of the nose, illumination at the other side suggests perforation).
● The nasal mucosa (turbinates) for swelling, exudates and change in color.

Paranasal Sinuses

● Examination of the paranasal sinuses is indirectly. Information about their condition

is gained by inspection and palpation of the overlying tissues. Only frontal and
maxillary sinuses are accessible for examination.
● By palpating both cheeks simultaneously, one can determine tenderness of the
maxillary sinusitis, and pressing the thumb just below the eyebrows, we can
determine tenderness of the frontal sinuses.

Normal Findings

● Nose in the midline

● No Discharges.
● No flaring alae nasi.
● Both nares are patent.
● No bone and cartilage deviation noted on palpation.
● No tenderness noted on palpation.
● Nasal septum in the mid line and not perforated.
● The nasal mucosa is pinkish to red in color. (Increased redness turbinates are typical
of allergy).
● No tenderness noted on palpation of the paranasal sinuses.

Cranial Nerve I (Olfactory Nerve)

To test the adequacy of function of the olfactory nerve:

● The client is asked to close his eyes and occlude.

● The examiner places aromatic and easily distinguish nose. (E.g. coffee).
● Ask the client to identify the odor.
● Each side is tested separately, ideally with two different substances.

Mouth and Oropharynx Lips

Inspected for:
 ● Symmetry and surface abnormalities.
● Color
● Edema

Normal Findings:

● With visible margin

● Symmetrical in appearance and movement
● Pinkish in color
● No edema

Temporomandibular

Palpate while the mouth is opened wide and then closed for:

● Crepitous
● Deviations
● Tenderness

Normal Findings:

● Moves smoothly no crepitous.

● No deviations noted
● No pain or tenderness on palpation and jaw movement.

Gums

Inspected for:

● Color
● Bleeding
● Retraction of gums.

Normal Findings:

● Pinkish in color
● No gum bleeding
● No receding gums

Teeth

Inspected for:
 ● Number
● Color
● Dental carries
● Dental fillings
● Alignment and malocclusions (2 teeth in the space for 1, or overlapping teeth).
● Tooth loss
● Breath should also be assessed during the process.

Normal Findings:

● 28 for children and 32 for adults.

● White to yellowish in color
● With or without dental carries and/or dental fillings.
● With or without malocclusions.
● No halitosis.

Tongue

Palpated for:

● Texture

Normal Findings:

● Pinkish with white taste buds on the surface.

● No lesions noted.
● No varicosities on ventral surface.
● Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the tongue.
● Gag reflex is present.
● Able to move the tongue freely and with strength.
● Surface of the tongue is rough.

Uvula

Inspected for:

● Position
● Color
● Cranial Nerve X (Vagus nerve) – Tested by asking the client to say “Ah” note that the
uvula will move upward and forward.

Normal Findings:
 ● Positioned in the mid line.
● Pinkish to red in color.
● No swelling or lesion noted.
● Moves upward and backwards when asked to say “ah”

Tonsils

Inspected for:

● Inflammation
● Size

A Grading system used to describe the size of the tonsils can be used.

● Grade 1 – Tonsils behind the pillar.

● Grade 2 – Between pillar and uvula.
● Grade 3 – Touching the uvula
● Grade 4 – In the midline.

Neck

● The neck is inspected for position symmetry and obvious lumps visibility of the
thyroid gland and Jugular Venous Distension

Normal Findings:

● The neck is straight.

● No visible mass or lumps.
● Symmetrical
● No jugular venous distension (suggestive of cardiac congestion).

The neck is palpated just above the suprasternal note using the thumb and the index finger.

Normal Findings:

● The trachea is palpable.

● It is positioned in the line and straight.
● Lymph nodes are palpated using palmar tips of the fingers via systemic circular
movements. Describe lymph nodes in terms of size, regularity, consistency,
tenderness and fixation to surrounding tissues.

Normal Findings:
 ● May not be palpable. Maybe normally palpable in thin clients.
● Non tender if palpable.
● Firm with smooth rounded surface.
● Slightly movable.
● About less than 1 cm in size.
● The thyroid is initially observed by standing in front of the client and asking the client
to swallow. Palpation of the thyroid can be done either by posterior or anterior
approach.

Posterior Approach:

● Let the client sit on a chair while the examiner stands behind him.
● In examining the isthmus of the thyroid, locate the cricoid cartilage and directly below
that is the isthmus.
● Ask the client to swallow while feeling for any enlargement of the thyroid isthmus.
● To facilitate examination of each lobe, the client is asked to turn his head slightly
toward the side to be examined to displace the sternocleidomastoid, while the other
hand of the examiner pushes the thyroid cartilage towards the side of the thyroid
lobe to be examined.
● Ask the patient to swallow as the procedure is being done.
● The examiner may also palate for thyroid enlargement by placing the thumb deep to
and behind the sternocleidomastoid muscle, while the index and middle fingers are
placed deep to and in front of the muscle.
● Then the procedure is repeated on the other side.

Anterior approach:

● The examiner stands in front of the client and with the palmar surface of the middle
and index fingers palpates below the cricoid cartilage.
● Ask the client to swallow while palpation is being done.
● In palpating the lobes of the thyroid, similar procedure is done as in posterior
approach. The client is asked to turn his head slightly to one side and then the other
of the lobe to be examined.
● Again the examiner displaces the thyroid cartilage towards the side of the lobe to be
examined.
● Again, the examiner palpates the area and hooks thumb and fingers around the
sternocleidomastoid muscle.

Normal Findings:

● Normally the thyroid is non palpable.

● Isthmus maybe visible in a thin neck.
● No nodules are palpable.
Auscultation of the Thyroid is necessary when there is thyroid enlargement. The examiner
may hear bruits, as a result of increased and turbulence in blood flow in an enlarged thyroid.

● Check the Range of Movement of the neck.

Thorax (Cardiovascular System)

Inspection of the Heart

● The chest wall and epigastrum is inspected while the client is in supine position.
Observe for pulsation and heaves or lifts

Normal Findings:

● Pulsation of the apical impulse maybe visible. (this can give us some indication of
the cardiac size).
● There should be no lift or heaves.

Palpation of the Heart

● The entire precordium is palpated methodically using the palms and the fingers,
beginning at the apex, moving to the left sternal border, and then to the base of the
heart.

Normal Findings:

● No, palpable pulsation over the aortic, pulmonic, and mitral valves.
● Apical pulsation can be felt on palpation.
● There should be no noted abnormal heaves, and thrills felt over the apex.

Percussion of the Heart

● The technique of percussion is of limited value in cardiac assessment. It can be used

to determine borders of cardiac dullness.

Auscultation of the Heart

Anatomic areas for auscultation of the heart:

 ● Aortic valve – Right 2nd ICS sternal border.
● Pulmonic Valve – Left 2nd ICS sternal border.
● Tricuspid Valve – – Left 5th ICS sternal border.
● Mitral Valve – Left 5th ICS midclavicular line

Positioning the client for auscultation:

● If the heart sounds are faint or undetectable, try listening to them with the patient
seated and learning forward, or lying on his left side, which brings the heart closer to
the surface of the chest.
● Having the client seated and learning forward s best suited for hearing high-pitched
sounds related to semilunar valves problem.
● The left lateral recumbent position is best suited low-pitched sounds, such as mitral
valve problems and extra heart sounds.

Auscultating the heart:

● Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral
● Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of semilunar
valve). S1 sound is best heard over the mitral valve; S2 is best heard over the aortric
valve.
● Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
● Count heart rate at the apical pulse for one full minute.

Normal Findings:

● S1 & S2 can be heard at all anatomic site.

● No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4).
● Cardiac rate ranges from 60 – 100 bpm.

Breast

Inspection of the Breast

There are 4 major sitting position of the client used for clinical breast examination. Every
client should be examined in each position.

● The client is seated with her arms on her side.

 ● The client is seated with her arms abducted over the head.
● The client is seated and is pushing her hands into her hips, simultaneously eliciting
contraction of the pectoral muscles.
● The client is seated and is learning over while the examiner assists in supporting and
balancing her.
● While the client is performing these maneuvers, the breasts are carefully observed
for symmetry, bulging, retraction, and fixation.
● An abnormality may not be apparent in the breasts at rest a mass may cause the
breasts, through invasion of the suspensory ligaments, to fix, preventing them from
upward movement in position 2 and 4.
● Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and
shortened suspensory ligaments.

Normal Findings:

● The overlying the breast should be even.

● May or may not be completely symmetrical at rest.
● The areola is rounded or oval, with same color, (Color va,ies form light pink to dark
brown depending on race).
● Nipples are rounded, everted, same size and equal in color.
● No “orange peel” skin is noted which is present in edema.
● The veins maybe visible but not engorge and prominent.
● No obvious mass noted.
● Not fixated and moves bilaterally when hands are abducted over the head, or is
learning forward.
● No retractions or dimpling.

Palpation of the Breast

● Palpate the breast along imaginary concentric circles, following a clockwise rotary
motion, from the periphery to the center going to the nipples. Be sure that the breast
is adequately surveyed. Breast examination is best done 1 week post menses.
● Each areolar areas are carefully palpated to determine the presence of underlying
masses.
● Each nipple is gently compressed to assess for the presence of masses or
discharge.

Normal Findings:

● No lumps or masses are palpable.

● No tenderness upon palpation.
● No discharges from the nipples.
NOTE: The male breasts are observed by adapting the techniques used for female clients.
However, the various sitting position used for woman is unnecessary.

Abdomen

● In abdominal assessment, be sure that the client has emptied the bladder for
comfort. Place the client in a supine position with the knees slightly flexed to relax
abdominal muscles.

Inspection of the abdomen

● Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus).
● Contour (flat, rounded, scapold)
● Distension
● Respiratory movement.
● Visible peristalsis.
● Pulsations

Normal Findings:

● Skin color is uniform, no lesions.

● Some clients may have striae or scar.
● No venous engorgement.
● Contour may be flat, rounded or scapoid
● Thin clients may have visible peristalsis.
● Aortic pulsation maybe visible on thin clients.

Auscultation of the Abdomen

● This method precedes percussion because bowel motility, and thus bowel sounds,
may be increased by palpation or percussion.
● The stethoscope and the hands should be warmed; if they are cold, they may initiate
contraction of the abdominal muscles.
 ● Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits.
Intestinal sounds are relatively high-pitched, the bell may be used in exploring
arterial murmurs and venous hum.

Peristaltic sounds

● These sounds are produced by the movements of air and fluids through the
gastrointestinal tract. Peristalsis can provide diagnostic clues relevant to the motility
of bowel.

Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:

● Divide the abdomen in four quadrants.

● Listen over all auscultation sites, starting at the right lower quadrants, following the
cross pattern of the imaginary lines in creating the abdominal quadrants. This
direction ensures that we follow the direction of bowel movement.
● Peristaltic sounds are quite irregular. Thus it is recommended that the examiner
listen for at least 5 minutes, especially at the periumbilical area, before concluding
that no bowel sounds are present.
● The normal bowel sounds are high-pitched, gurgling noises that occur approximately
every 5 – 15 seconds. It is suggested that the number of bowel sound may be as low
as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound.

Some factors that affect bowel sound:

● Presence of food in the GI tract.

● State of digestion.
● Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus,
peritonitis).
● Bowel surgery
● Constipation or Diarrhea.
● Electrolyte imbalances.
● Bowel obstruction.

Percussion of the abdomen

● Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites),

gaseous distension, and masses, and in assessing solid structures within the
abdomen.
● The direction of abdominal percussion follows the auscultation site at each
abdominal guardant.
● The entire abdomen should be percussed lightly or a general picture of the areas of
tympany and dullness.
 ● Tympany will predominate because of the presence of gas in the small and large
bowel. Solid masses will percuss as dull, such as liver in the RUQ, spleen at the 6th
or 9th rib just posterior to or at the mid axillary line on the left side.
● Percussion in the abdomen can also be used in assessing the liver span and size of
the spleen.

Percussion of the liver

The palms of the left hand are placed over the region of liver dullness.

● The area is strucked lightly with a fisted right hand.

● Normally tenderness should not be elicited by this method.
● Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.

Renal Percussion

● Can be done by either indirect or direct method.

● Percussion is done over the costovertebral junction.
● Tenderness elicited by such method suggests renal inflammation.

Palpation of the Abdomen

Light palpation

● It is a gentle exploration performed while the client is in supine position. With the
examiner’s hands parallel to the floor.
● The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm
without digging, but gently palpating with slow circular motion.
● This method is used for eliciting slight tenderness, large masses, and muscles, and
muscle guarding.

Tensing of abdominal musculature may occur because of:

● The examiner’s hands are too cold or are pressed to vigorously or deep into the
abdomen.
● The client is ticklish or guards involuntarily.
● Presence of subjacent pathologic condition.

Normal Findings:

● No tenderness noted.
● With smooth and consistent tension.
 ● No muscles guarding.

Deep Palpation

● It is the indentation of the abdomen performed by pressing the distal half of the
palmar surfaces of the fingers into the abdominal wall.
● The abdominal wall may slide back and forth while the fingers move back and forth
over the organ being examined.
● Deeper structures, like the liver, and retro peritoneal organs, like the kidneys, or
masses may be felt with this method.
● In the absence of disease, pressure produced by deep palpation may produce
tenderness over the cecum, the sigmoid colon, and the aorta.

Liver palpation

There are two types of bi manual palpation recommended for palpation of the liver. The first
one is the superimposition of the right hand over the left hand.

● Ask the patient to take 3 normal breaths.

● Then ask the client to breath deeply and hold. This would push the liver down to
facilitate palpation.
● Press hand deeply over the RUQ

The second methods:

● The examiner’s left hand is placed beneath the client at the level of the right 11th
and 12th ribs.
● Place the examiner’s right hands parallel to the costal margin or the RUQ.
● An upward pressure is placed beneath the client to push the liver towards the
examining right hand, while the right hand is pressing into the abdominal wall.
● Ask the client to breath deeply.
● As the client inspires, the liver maybe felt to slip beneath the examining fingers.

Normal Findings:

● The liver usually can not be palpated in a normal adult. However, in extremely thin
but otherwise well individuals, it may be felt the costal margins.
 ● When the normal liver margin is palpated, it must be smooth, regular in contour, firm
and non-tender.

Extremities

Inspection

● Observe for size, contour, bilateral symmetry, and involuntary movement.

● Look for gross deformities, edema, presence of trauma such as ecchymosis or other
discoloration.
● Always compare both extremities.

Palpation

● Feel for evenness of temperature. Normally it should be even for all the extremities.
● Tonicity of muscle. (Can be measured by asking client to squeeze examiner’s fingers
and noting for equality of contraction).
● Perform range of motion.
● Test for muscle strength. (performed against gravity and against resistance)

Table showing the Lovett scale for grading for muscle strength and functional level

Normal Findings

● Both extremities are equal in size.

● Have the same contour with prominences of joints.
● No involuntary movements.
● No edema
● Color is even.
● Temperature is warm and even.
● Has equal contraction and even.
● Can perform complete range of motion.
 ● No crepitus must be noted on joints.

Can counter act gravity and resistance on ROM.

Asepsis

Asepsis is the state of being free from disease-causing contaminants (such as bacteria,
viruses, fungi, and parasites) or, preventing contact with microorganisms. The term asepsis
often refers to those practices used to promote or induce asepsis in an operative field in
surgery or medicine to prevent infection.

Medical asepsis

● Includes all practices intended to confine a specific microorganism to a specific area

● Limits the number, growth, and transmission of microorganisms
● Objects referred to as clean or dirty (soiled, contaminated)

Surgical asepsis

● Sterile technique
● Practices that keep an area or object free of all microorganisms
● Practices that destroy all microorganisms and spores
● Used for all procedures involving sterile areas of the body

Principles of Aseptic Technique Only sterile items are used within sterile field.

● Sterile objects become unsterile when touched by unsterile objects.

● Sterile items that are out of vision or below the waist level of the nurse are
considered unsterile.
● Sterile objects can become unsterile by prolong exposure to airborne
microorganisms.
● Fluids flow in the direction of gravity.
● Moisture that passes through a sterile object draws microorganism from unsterile
surfaces above or below to the surface by capillary reaction.
● The edges of a sterile field are considered unsterile.
 ● The skin cannot be sterilized and is unsterile.
● Conscientiousness, alertness and honesty are essential qualities in maintaining
surgical asepsis

Infection

Signs of Localized Infection

● Localized swelling
● Localized redness
● Pain or tenderness with palpation or movement
● Palpable heat in the infected area
● Loss of function of the body part affected, depending on the site and extent of
involvement

Signs of Systemic Infection

● Fever
● Increased pulse and respiratory rate if the fever high
● Malaise and loss of energy
● Anorexia and, in some situations, nausea and vomiting
● Enlargement and tenderness of lymph nodes that drain the area of infection

Factors Influencing Microorganism’s Capability to Produce Infection

● Number of microorganisms present

● Virulence and potency of the microorganisms (pathogenicity)
● Ability to enter the body
● Susceptibility of the host
● Ability to live in the host’s body

Anatomic and Physiologic Barriers Defend Against Infection

● Intact skin and mucous membranes

● Moist mucous membranes and cilia of the nasal passages
● Alveolar macrophages
 ● Tears
● High acidity of the stomach
● Resident flora of the large intestine
● Peristalsis
● Low pH of the vagina
● Urine flow through the urethra

Chain of Infection

● The chain of infection refers to those elements that must be present to cause an
infection from a microorganism
● Basic to the principle of infection is to interrupt this chain so that an infection from a
microorganism does not occur in client
● Infectious agent; microorganisms capable of causing infections are referred to as an
infectious agent or pathogen
● Modes of transmission: the microorganism must have a means of transmission to get
from one location to another, called direct and indirect
● Susceptible host describes a host (human or animal) not possessing enough
resistance against a particular pathogen to prevent disease or infection from
occurring when exposed to the pathogen; in humans this may occur if the person’s
resistance is low because of poor nutrition, lack of exercise of a coexisting illness
that weakens the host.
● Portal of entry: the means of a pathogen entering a host: the means of entry can be
the same as one that is the portal of exit (gastrointestinal, respiratory, genitourinary
tract).
● Reservoir: the environment in which the microorganism lives to ensure survival; it
can be a person, animal, arthropod, plant, oil or a combination of these things;
reservoirs that support organism that are pathogenic to humans are inanimate
objects food and water, and other humans.
● Portal of exit: the means in which the pathogen escapes from the reservoir and can
cause disease; there is usually a common escape route for each type of
microorganism; on humans, common escape routes are the gastrointestinal,
respiratory and the genitourinary tract.

Breaking the Chain of Infection

Etiologic agent

● Correctly cleaning, disinfecting or sterilizing articles before use

 ● Educating clients and support persons about appropriate methods to clean, disinfect,
and sterilize article

Reservoir (source)

● Changing dressings and bandages when soiled or wet

● Appropriate skin and oral hygiene
● Disposing of damp, soiled linens appropriately
● Disposing of feces and urine in appropriate receptacles
● Ensuring that all fluid containers are covered or capped
● Emptying suction and drainage bottles at end of each shift or before full or according
to agency policy

Portal of exit

● Avoiding talking, coughing, or sneezing over open wounds or sterile fields

● Covering the mouth and nose when coughing or sneezing

Method of transmission

● Proper hand hygiene

● Instructing clients and support persons to perform hand hygiene before handling
food, eating, after eliminating and after touching infectious material
● Wearing gloves when handling secretions and excretions
● Wearing gowns if there is danger of soiling clothing with body substances
● Placing discarded soiled materials in moisture-proof refuse bags
● Holding used bedpans steadily to prevent spillage
● Disposing of urine and feces in appropriate receptacles
● Initiating and implementing aseptic precautions for all clients
● Wearing masks and eye protection when in close contact with clients who have
infections transmitted by droplets from the respiratory tract
● Wearing masks and eye protection when sprays of body fluid are possible

Portal of entry

● Using sterile technique for invasive procedures, when exposing open wounds or
handling dressings
● Placing used disposable needles and syringes in puncture-resistant containers for
disposal
● Providing all clients with own personal care items

Susceptible host
 ● Maintaining the integrity of the client’s skin and mucous membranes
● Ensuring that the client receives a balanced diet
● Educating the public about the importance of immunizations

Modes of Transmission

● Direct contact: describes the way in which microorganisms are transferred from
person to person through biting, touching, kissing, or sexual intercourse; droplet
spread is also a form of direct contact but can occur only if the source and the host
are within 3 feet from each other; transmission by droplet can occur when a person
coughs, sneezes, spits, or talks.
● Indirect contact: can occur through fomites (inanimate objects or materials) or
through vectors (animal or insect, flying or crawling); the fomites or vectors act as
vehicle for transmission
● Air: airborne transmission involves droplets or dust; droplet nuclei can remain in the
air for long periods and dust particles containing infectious agents can become
airborne infecting a susceptible host generally through the respiratory tract

Course of Infection

● Incubation: the time between initial contact with an infectious agent until the first
signs of symptoms the incubation period varies from different pathogens;
microorganisms are growing and multiplying during this stage
● Prodromal Stage: the time period from the onset of nonspecific symptoms to the
appearance of specific symptoms related to the causative pathogen symptoms range
from being fatigued to having a low-grade fever with malaise; during this phase it is
still possible to transmit the pathogen to another host
● Full Stage: manifestations of specific signs & symptoms of infectious agent; referred
to as the acute stage; during this stage, it may be possible to transmit the infectious
agent to another, depending on the virulence of the infectious agent
● Convalescence: time period that the host takes to return to the pre-illness stage; also
called the recovery period; the host defense mechanisms have responded to the
infectious agent and the signs and symptoms of the disease disappear; the host,
however, is more vulnerable to other pathogens at this time; an appropriate nursing
diagnostic label related to this process would be Risk for Infection

Inflammation

● The protective response of the tissues of the body to injury or infection; the
physiological reaction to injury or infection is the inflammatory response; it may be
acute or chronic

Body’s response
 ● The “inflammatory response” begins with vasoconstriction that is followed by a brief
increase in vascular permeability; the blood vessels dilate allowing plasma to escape
into the injured tissue
● WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury and
attack and ingest the invaders (phagocytosis); this process is responsible for the
signs of inflammation
● Redness occurs when blood accumulates in the dilated capillaries; warmth occurs as
a result of the heat from the increased blood in the area, swelling occurs from fluid
accumulation; the pain occurs from pressure or injury to the local nerves.

Immune Response

● The immune response involves specific reactions in the body to antigens or foreign
material
● This specific response is the body’s attempt to protect itself, the body protects itself
by activating 2 types of lymphocytes, the T-lymphocytes and B-lymphocytes
● Cell mediated immunity: T-lymphocytes are responsible for cellular immunity
○ When fungi , protozoa, bacteria and some viruses activate T-lymphocytes,
they enter the circulation from lymph tissue and seek out the antigen
○ Once the antigen is found they produce proteins (lymphokines) that increase
the migration of phagocytes to the area and keep them there to kill the
antigen
○ After the antigen is gone, the lymphokines disappear
○ Some T-lymphocytes remain and keep a memory of the antigen and are
reactivated if the antigen appears again.
● Humoral response: the ability of the body to develop a specific antibody to a specific
antigen (antigen-antibody response)
○ B-lymphocytes provide humoral immunity by producing antibodies that
convey specific resistance to many bacterial and viral infections
○ Active immunity is produced when the immune system is activated either
naturally or artificially.
■ Natural immunity involves acquisition of immunity through developing
the disease
■ Active immunity can also be produced through vaccination by
introducing into the body a weakened or killed antigen (artificially
acquired immunity)
■ Passive immunity does not require a host to develop antibodies, rather
it is transferred to the individual, passive immunity occurs when a
mother passes antibodies to a newborn or when a person is given
antibodies from an animal or person who has had the disease in the
form of immune globulins; this type of immunity only offers temporary
protection from the antigen.
Types of Immunity

Active Immunity

● Host produces antibodies in response to natural antigens or artificial antigens

● Natural active immunity
○ Antibodies are formed in presence of active infection in the body
○ Duration lifelong
● Artificial active immunity
○ Antigens administered to stimulate antibody formation
○ Lasts for many years
○ Reinforced by booster

Passive Immunity

● Host receives natural or artificial antibodies produced from another source

● Natural passive immunity
○ Antibodies transferred naturally from an immune mother to baby through the
placenta or in colostrums
○ Lasts 6 months to 1 year
● Artificial passive immunity
○ Occurs when immune serum (antibody) from an animal or another human is
injected
○ Lasts 2 to 3 weeks

Nosocomial Infection

● Nosocomial Infections: are those that are acquired as a result of a healthcare

delivery system
● Iatrogenic infection: these nosocomial infections are directly related to the client’s
treatment or diagnostic procedures; an example of an iatrogenic infection would be a
bacterial infection that results from an intravascular line or Pseudomonas aeruginosa
pneumonia as a result of respiratory suctioning
● Exogenous Infection: are a result of the healthcare facility environment or personnel;
an example would be an upper respiratory infection resulting from contact with a
caregiver who has an upper respiratory infection
● Endogenous Infection: can occur from clients themselves or as a reactivation of a
previous dormant organism such as tuberculosis; an example of endogenous
infection would be a yeast infection arising in a woman receiving antibiotic therapy;
the yeast organisms are always present in the vagina, but with the elimination of the
normal bacterial flora, the yeast flourish.
Risks for Nosocomial Infections

● Diagnostic or therapeutic procedures

○ Iatrogenic infections
● Compromised host
● Insufficient hand hygiene