UNIT 1.

Special Considerations during the Interview

Phases of the Nursing Process
1. Assessment - Collecting Subjective and objective data 1. Gerontologic Variations
2. Diagnosis - Analyzing subjective and objective data to 2. Cultural Variations
make and prioritize professional clinical judgements 3. Emotional Variations
3. Planning - Generating solutions, developing a plan, and
determining which outcomes need to be met first COLDSPA
- Is designed to help the nurse explore symptoms,
4. Implementation - Taking action. Prioritizing and
signs or health concern
implementing the planned interventions
5. Evaluation - Assessing whether outcomes have been
C - CHARACTER
met and revising the plan if the intervention did not make a
O - ONSET
difference
L - LOCATION

Types of Health Assessment D - DURATION

1. Initial Comprehensive Assessment - involves S - SEVERITY

P - PATTERN
collection of subjective data about the client’s perception
A – ASSOCIATED FACTORS
2. Ongoing or Partial Assessment - occurs after the
comprehensive database. Mini overview of client’s body
POSITIONING THE CLIENT
3. Focused or Problem-Oriented Assessment - exist for
client who comes to the healthcare with specific health
1. SITTING POSITION – Evaluating for the head,
concern.
neck, lungs, chest, back, breast, axillae, heart,
4. Emergency Assessment - performed in life-threatening
vital signs, and upper extremities
situations (choking, cardiac arrest, drowning)

Steps for Health Assessment

1. Collection of Subjective data
2. Collection of Objective data
3. Validation of data
4. Documentation of data

Phases of the Interview

1. Pre-introductory Phase - reviews the medical record
2. Introductory Phase - explain the purpose of the
2. SUPINE POSITION – Back-lying position used
interview
for examination of the abdomen (with one small
3. Working Phase - about biological data, reason for
pillow under the head and under knees); allows
seeking care, history of health concern
also easy access for palpation of peripheral
4. Summary and Closing Phase – validates problem and
pulses
goals with the client

Communication during the interview

1. Non-Verbal Communication

 Appearance
 Demeanor
3. DORSAL RECUMBENT POSITION – Lies down
 Facial Expression
 Attitude
on examination table or bed with the knees bent,

 Silence legs separated, and the feet flat on bed. More

 Listening comfortable than supine for patients that has
pain in the back or abdomen
2. Verbal Communication

 Open-ended question
 Close-ended question
 Laundry List
 Rephrasing
 Well-Placed Phrases
 Inferring
4. SIMS POSITION – Side-lying position used during 9. TRENDELENBURG POSITION - Foot of bed
the rectal examination, assessing the rectal and elevated: used for patients with low blood pressure
vaginal areas (redirects blood flow to brain)

5. STANDING POSITION – Position used to examine 10. FOWLER’S POSITION - examination position in
male genitalia and to assess gait, posture, and which the client is lying on his or her back with the
balance head elevated.

6. PRONE POSITION – Client lies on abdomen with PHYSICAL EXAMINATION TECHNIQUES

head turned to side; may be used to assess the
back and mobility of hip joint 1. INSPECTION – Sense of vision, smell, and
hearing to observe and detect any normal or
abnormal findings.
2. PALPATION – Using parts of the hand to touch
and feel

 TEXTURE
 MOISTURE
 MOBILITY
7. KNEE-CHEST POSITION - on knees, head and  CONSISTENCY
upper chest on table, arms crossed above head.  SIZE, SHAPE, TENDERNES
Used in Ob-gyn and for flushing the intestine.
PARTS OF HANDS TO USE WHEN PALPATING:

 FINGERPADS – Fine discrimination;

pulses, texture, size etc.
 ULNAR OR PALMAR SURFACE
DORSAL SURFACE – Vibrations, thrills,
fremitus temperature

8. LITHOTOMY POSITION – Back-lying position with hips at edge

3. PERCUSSION – Involves tapping body parts to
of examining table and feet supported in stirrups; used for
examination of female genitalia, reproductive tract, and rectum
produce sound waves.
4. AUSCULTATION – Assessment technique that
requires the use of stethoscope to listen for heart
sounds, movement of blood through the
cardiovascular system.

STETHOSCOPE – Is used to listen for body sounds that

cannot ordinarily be heard without amplification
SBAR MODEL OF COMMUNICATION He applied the concepts of schema:

S – SITUATION 1. Assimilation – Adaptive process

B - BACKGROUND 2. Accommodation – Creation of new schema
A – ASSESSMENT 3. Equilibration – Balance between assimilation &
R – RECOMMENDATION accommodation

UNIT 2.
MENTAL STATUS - Client’s level of cognitive functioning
& emotional functioning
MENTAL HEALTH – Essential part to one’s health & more
than just the absence of mental disorder
MENTAL DISORDER – Any condition characterized by
cognitive & emotional disturbance
Factors affecting mental health:
1. Economic & social health
2. Unhealthy lifestyle choices
3. Exposure to violence

SUBSTANCE ABUSE – Harmful or hazardous use of LAWRENCE KOHLBERG – Psychologist, expanded

psychoactive substances including alcohol and illicit drugs. Piaget’s thought on morality

It can lead to dependence syndrome

1. Pre-conventional (premoral) – make

ASSESSMENT FOR MENTAL STATUS INCLUDE: mental representation

2. Conventional (maintaining external
 Appearance expectations of others)
 General behavior 3. Post-conventional (maintaining

 Cognitive function & memory internal principles of self)

 Thought processes
GENERAL SURVEY – First part of physical examination

GROWTH – Addition of new skills or improvement

 Physical development
DEVELOPMENT – Refinement and expansion
 Gender &sexual develop
ERIK ERIKSON – Psychoanalyst who adapt & expand
 Skin condition
Sigmund Freud psychosexual theory
 Dress & hygiene
PSYCHOSOCIAL – Intrapersonal & interpersonal
responses
VITAL SIGNS – Provide data that reflect the status of
ERIKSON’S STAGES OF PSYCHOSOCIAL
sexual of several body systems
DEVELOPMENT

 Temperature – core body temperature:

36.5 C & 37.7 C
o Pulse –
arterial / peripheral pulse – shock
waves travel along fibers of
arteries
- 0 Absent
- + 1 Weak (easy to obliterate)
- + 2 Normal (obliterate w/
moderate pressure)
- + 3 Bounding (unable to
obliterate)
DR. JEAN PIAGET – Genetic epistemologist studies the
RESPIRATION – Additional clues to the client overall
origin of knowledge
health status
COGNITION – Obtaining understanding about one’s world
BLOOD PRESSURE – Pressure exerted on the walls of
arteries
FACTORS CONTRIBUTING TO BLOOD PRESSURE PHYSIOLOGIC PROCESS OF PAIN PROCESS

1. CARDIAC OUTPUT – More blood pumps, the 1. TRANSDUCTION

greater the pressure 2. TRANSMISSION
2. PERIPHERAL VASCULAR RESISTANCE – 3. PERCEPTION
Increase in resistance in peripheral vascular 4. MODULATION
system
3. CIRCULATING BLOOD VOLUME - Increase in CLASSIFICATION OF PAIN

volume will increase blood pressure

 PSYCHOLOGICAL PAIN – Emotional / Mental
4. VISCOSITY – When blood thickens, the pressure
 PSYCHOGENIC PAIN – Psychological pain
of blood pressure will increase
becomes physical
5. ELASTICITY OF VESSEL WALLS – Increase
stiffness of vessel walls will increase blood  NOCICEPTIVE PAIN – Caused by nerve receptors

pressure  NEUROPATHIC PAIN – Damage of nervous

system
NORMAL BLOOD PRESSURE  INFLAMMATORY PAIN – Back & shoulder pain
 SOMATIC PAIN – Stimuli tissue that activated
 Normal: <120 / 80 mmHg  VISCERAL PAIN – Nerves in internal organs
 Elevated: S – 120 & 129 D – 80 & 89  RADICULAR PAIN – Stimuli at nerve root
 Stage 1: S – 130 &139 D – 80 &89  REFFERED PAIN – Sensation of pain to actual
 Stage 2: S: 140 D – 90 source
 Hypertensive crisis: S – 180 D – 120  PHANTOM PAIN – Pain that been removed
 CANCER PAIN –
NORMAL ROUTE TO MEASURE BODY TEMPERATURE

DIMENSIONS OF PAIN
1. TEMPORAL (36 – 37.1 C)
2. TYMPANIC (36 – 38 C) 1. PHYSICAL
3. RECTAL (36 – 37 C) 2. SENSORY
4. ORAL (35 – 37 C) 3. BEHAVIORAL
5. AXILLARY (35 – 37 C) 4. SOCIOCULTURAL
5. COGNITIVE
DEVIATION RELATED TO PHYSICAL DEV, BODY
6. AFFECTIVE
BUILD & FAT DISTRI.
7. SPIRITUAL

1. DWARFISM – Decreased height & skeletal

PAINAD – Pain Assessment In Advance Dimentia
malformation
BPS - Behavioral Pain Scale
2. GIGANTISM – Disparity in height
VAS – Visual Analog Scale
3. ACROMEGALY – Overgrowth of bones in face,
VDS – Verbal Descriptor Scale
head & hands
FPS – Face Pain Scale
4. ANOREXIA NERVOSA – Self-starvation &
NPIS – Numeric Pain Intensity Scale
extreme weight loss
5. OBESITY – Excessive amount of body fat DOMESTIC VIOLENCE – Pattern for abusive behaviors
6. MARFAN SYNDROME – Elongated fingers VIOLENCE – Use of physical force to harm someone
7. CUSHING SYNDROME – Centralized weight gain
5 THEORIES ABOUT DOMESTIC VIOLENCE
IASP – INTERNATIONAL ASSOCIATION FOR THE
STUDY OF PAIN 1. PSYCHOPATHOLOGY THEORY
2. SOCIAL LEARNING THEORY
PAIN – Unpleasant sensory & emotional exp, tissue 3. BIOLOGIC THEORY
damage 4. FAMILY SYSTEM THEORY
5. FEMINIST THEORY
NOCICEPTORS – Source of pain stimulates peripheral
nerve endings INTIMATE PARTNER VIOLENCE – Physical, sexual, or
harm by current or former partner
TRANSDUCTION – Mechanical stimulus results in tissue
ELDER MISTREATMENT - Abuse of over the age 60
injury stimulating nociceptors
years of age
TYPES OF FAMILY VIOLENCE EPIDERMIS
the outer layer of skin, is composed of four distinct layers:
the stratum corneum, stratum lucidum, stratum granulosum,
1. PHYSICAL ABUSE
and stratum germinativum.
2. PSYCHOLOGICAL ABUSE
3. PSYCHOLOGICAL ABUSE DERMIS
the inner layer of the skin and the unique pattern of friction
4. SEXUAL ABUSE ridges commonly known as fingerprint., is composed of two
5. CHILD ABUSE glands:

1. Sebaceous glands - are attached to hair follicles.

OTHER TYPES OF VIOLENCE They secrete an oily substance called sebum.
2. Sweat glands – composed of two types:
1. SCHOOL VIOLENCE
 eccrine glands - are located over the
2. HATE CRIMES entire skin. Their primary function is
secretion of sweat and
3. HUMAN TRAFFICKING thermoregulation, which is
4. WAR CRIMES accomplished by evaporation of sweat
from the skin surface.
 apocrine glands - are associated with
CULTURE – Shared system of values, beliefs and learned hair follicles in the axillae, perineum,
and areolae of the breasts. are small
patterns and nonfunctional until puberty, at
which time they are activated and
VALUES – Learned beliefs
secrete a milky sweat.
BEHAVIORS – Learned behaviors
SUBCUTANEOUS TISSUE
WHY CULTURE & RELIGION IS IMPORTANT?
Beneath the dermis and it is a loose connective tissue
containing fat cells, blood vessels and nerves.
Culture and religion play crucial roles in health
Two general types of hair:
assessment due to their influence on individual beliefs,
1. Vellus hair (peach fuzz) is short, pale, fine, and
behaviors, and perceptions of health and illness. present over much of the body.
Understanding a person's cultural background helps 2. Terminal hair (particularly scalp and eyebrows) is
longer, generally darker, and coarser than vellus
healthcare professionals tailor care that respects their hair.
values, traditions, and preferences, fostering trust and NAILS
cooperation in the healthcare process. Moreover, are hard, transparent plates of keratinized epidermal cells
that grow from the cuticle.
cultural and religious practices often shape dietary
COMMON VARIATIONS: SKIN VARIATIONS
habits, healthcare-seeking behaviors, and attitudes
1. Freckles - Flat, small macules of pigment that appear
toward treatment, impacting health outcomes and following sun exposure.
2. Vitiligo - depigmentation of the skin.
treatment adherence. Recognizing the significance of 3. Striae (sometimes called stretch marks).
4. Seborrheic keratosis - a warty or crusty pigmented
culture and religion in health assessment promotes lesion.
5. Mole (also called nevus) - a flat or raised tan/ brownish
effective communication, enhances patient-provider marking up to 6 mm wide.

relationships, and ultimately leads to more holistic and Primary Skin Lesions

culturally competent care. 1. Pustule - Pus-filled vesicle or bulla.

2. Cyst - Encapsulated fluid-filled or semisolid mass

Secondary Skin Lesions

ASSESSING THE SKIN, HAIRS, AND NAILS 1. Erosion - Loss of superficial epidermis that does not
extend to the dermis.
2. Scar (Cicatrix) - Skin mark left after healing of wound or
Structure and Function lesion.
3. Ulcer - Skin loss extending past epidermis, with necrotic
The integumentary system consists of the skin, hair, and tissue loss.
nails, which are external structures that serve a variety of ABCDE – Asymmetry, Borders, Color, Diameter, Elevated
specialized functions.
The most commonly detected skin cancers include basal cell
carcinoma, squamous cell carcinoma, and melanoma.
SKIN
Common Nail Disorders
The skin is the largest organ of the body. It is a physical
1. Longitudinal ridging - Parallel ridges running lengthwise.
barrier that protects the underlying tissues and organs from 2. Half-and-Half Nails - Nails that are half white on the
upper proximal half and pink on the distal half.
microorganisms, physical trauma, ultraviolet radiation, and
3. Pitting - Seen with psoriasis.
dehydration.

3 TYPES OF SKIN: EPIDERMIS, DERMIS, SUBCUTANEOUS

TISSUE
 ASSESSING THE HEAD AND NECK EXTERNAL STRUCTURES OF THE EYE

Structure and Function

Head and neck assessment focuses on the cranium, face, thyroid

gland, and lymph nodes contained within the head and neck. The
sensory organs (eyes, ears, nose, and mouth) are discussed in
separate chapters.

The Head

Framework of the skull and divided into two subsections:

cranium and face

1. Cranium - The cranium houses and protects the brain

and major sensory organs. Consist of 8 bones
2. Face - Facial bones give shape to the face. Consist of
14 bones

The neck

The structure of the neck is composed of muscles, ligaments, and INTERNAL STRUCTURES OF THE EYE
the cervical vertebrae.

Muscles and Cervical Vertebrae

The sternomastoid (sternocleidomastoid) and trapezius muscles

are two of the paired muscles that allow movement and provide
support to the head and neck

Blood Vessels

The internal jugular veins and carotid arteries are located

bilaterally, parallel, and anterior to the sternomastoid muscles

Thyroid Gland

The thyroid gland is the largest endocrine gland in the body.

LACRIMAL DUCT AND SAC

Abnormalities of the Head and Neck

1. Acromegaly - is characterized by enlargement of the

facial features and the hands and feet.
2. Cushing’s syndrome - may present with a moon-
shaped face with reddened cheeks and increased facial
hair.
3. Scleroderma - A tightened-hard face with thinning facial
skin is seen in scleroderma
4. Bell’s palsy - usually begins suddenly and reaches a
peak within 48 hours. Symptoms may include twitching,
weakness, and paralysis
5. Hyperthyroidism - Exophthalmos is seen

ASSESSING THE EYES VISION

Visual Fields and Visual Pathways
Structure and Function
A visual field refers to what a person sees with one eye. Visual
The eye transmits visual stimuli to the brain for interpretation and, perception occurs as light rays strike the retina, where they are
in doing so, functions as the organ of vision. The eyeball is in the transformed into nerve impulses.
eye orbit, a round, bony hollow formed by several different bones
of the skull. In the orbit, a cushion of fat surrounds the eye. The
bony orbit and fat cushion protect the eyeball.

1.
VISUAL FIELDS AND VISUAL PATHWAYS DYSFUNCTION - Abnormalities found during an assessment of
extraocular muscle

CORNEAL LIGHT REFLEX TEST ABNORMALITIES

1. Pseudo strabismus - Normal in young children,

the pupils will appear at the inner canthus
2. Strabismus (or Tropia) - A constant malalignment
of the eye axis
POSITIONS TEST ABNORMALITIES

1. Paralytic strabismus - is usually the result of

weakness or paralysis of one or more extra-ocular
muscles.
COVER TEST ABNORMALITIES

1. Phoria (Mild Weakness) - Noticeable only with the

cover test, phoria is less likely to cause amblyopia
than strabismus.

Abnormalities of the External Eye

1. Ptosis (drooping eye)

2. Ectropion (outwardly turned lower lid)
3. Conjunctivitis (generalized inflammation of the
conjunctiva)
4. Exophthalmos (protruding eyeballs and retracted
eyelids)

ASSESSING THE EARS

Structure and Function

The ear is the sense organ of hearing and equilibrium. It

The pupils admit light that travels over the visual pathways
consists of three distinct parts: the external ear, the middle
ear, and the inner ear.

STRUCTURES OF THE EAR

The external ear is composed of

 the auricle,
 or pinna,
 and the external auditory canal

Cerumen - has bacteriostatic properties, and its sticky

consistency serves as a defense against foreign bodies.

Tympanic membrane or eardrum - has a translucent,

pearly gray appearance

Middle Ear or tympanic cavity - is a small, air-filled

chamber in the temporal bone

inner ear, or labyrinth - is fluid filled and made up of the

bony labyrinth and an inner membranous labyrinth.

Structures in the outer, middle, and inner divisions are

shown:

Visual Reflexes

The pupillary light reflex causes pupils immediately to constrict

when exposed to bright light.

Accommodation is a functional reflex allowing the eyes to focus

on near objects

Vision Charts

1. Snellen Chart - Used to test distant visual acuity, the

Snellen chart consists of lines of different letters stacked
one above the other
2. E Chart - If the client cannot read or has a handicap that
prevents verbal communication
3. Jaeger Test - Near vision is assessed in clients over 40
years of age by holding the pocket screener

Ophthalmoscope - is a hand-held instrument that allows the

examiner to view the fundus of the eye by the projection of light
through a prism that bends the light 90 degrees.
 ASSESSING THE MOUTH, THROAT, Abnormalities of the Mouth and Throat

NOSE AND SINUSES 1. Leukoplakia

2. Cheilosis of lips.
MOUTH
3. Carcinoma of lip.
The mouth—or oral cavity—is formed by the lips, cheeks, hard 4. Candida albicans infection (thrush).
and soft palates, uvula, and the tongue and its muscles 5. Gingivitis
6.

THROAT

The throat (pharynx), located behind the mouth and nose, serves
as a muscular passage for food and air.

NOSE

The nose consists of an external portion covered with skin and an

internal nasal cavity.

SINUSES

These air-filled cavities decrease the weight of the skull and act
as resonance chambers during speech.