HEALTH

ASSESSMENT
NCM - 101
MORSID K. TULAO, RN, MAN, CHA, PHDM
DAY 1
 PRELIM
JANUARY 16, 2024 – FEBRUARY 22, 2024
NURSING PROCESS
IS A FUNDAMENTAL PART OF NURSING PRACTICE
A – ASSESSMENT
D – DIAGNOSIS
P – PLANNING
I – INTERVENTION
E - EVALUATION
Assessment
Taking health history
Conducting Physical Examination
Assessing Vital Signs
Diagnosis
Types of Diagnosis
A. Medical Diagnosis
Example:
1. Hypertension
2. DM II
B. Nursing Diagnosis – NANDA HANDBOOK
Example:
1. Alteration of Normal Body Temperature Febrile related to Abdominal Infection
Planning
 At the end of an eight hours duty the patient will be able to:
A. Control
B. Maintain
Intervention
Independent
Example:
A. TSB
B. Elevate Legs
Dependent
Example:
A. Administering Prescribed Medication
Interdependent
Example:
A. Collaborating Physical Therapies
B. Laboratories, X-ray
 Evaluation
Partially Met
Example:
A. At the end of an eight hours duty the goal / plan was partially met as evidenced by:
1. Not Totally Control
2. Maintain
Goal Met
Example:
A. At the end of an eight hours duty the goal / plan was met as evidenced by:
1. Pain Controlled
2. Maintained Normal Blood Pressure
HEALTH ASSESSMENT
IT IS A PROCESS THAT IDENTIFIES THE SPECIFIC NEEDS OF A PERSON AND THE
WAY TO ADDRESS A WAY TO MEET THEIR NEEDS BY THE HEALTHCARE SYSTEM.
DYNAMIC AND CONTINUOS PROCESS THAT INVOLVES COLLECTING,
ANALYZING, AND INTERPRETING DATA TO UNDERSTAND A PATIENTS HEALTH
STATUS.
TYPES OF HEALTH ASSESSMENT
1. INITIAL COMPREHENSIVE ASSESSMENT

DESCRIBES IN DETAILS THE CLIENTS MEDICAL, PHYSIOCAL AND PSYCHOSOCIAL CONDITION AND NEEDS

EXAMPLE:

A. Personal Profile

B. Present Problem

C. History of Present Illness

D. Current Symptoms

E. Psychosocial Assessment ( Family, Education, & Housing, Living Status)

F. Mental Status Examination (Appearance & Behavior, Mood & Affect, Cognition)

G. Risk Assessment (Suicidal/Homicidal, Safety Concerns)

H. Diagnosis (Preliminary)

I. Treatment Recommendations
2. ON-GOING OR PARTIAL ASSESSMENT
REFERS TO THE CONTINUOS OR INTERMITTEN PROCESS OF EVALUATING AND MONITORING A PATIENS
PROGRESS AND CHANGES IN THEIR CONDITION AFTER THE INITIAL COMPREHENSIVE ASSESSMENT

EXAMPLE:
A. Patient undergoing therapy
Progress since last assessment (symptomatology, functioning, social interaction, & sleep and appetite.
B. Goals Review
Reduce problem, Improve, Increase social engagement,
C. Therapeutic Relationship
D. Medication Management
E. Lifestyles changes
F. Adjustment to Treatment Plan
Next Steps
Follow up
3. FOCUSED OR PROBLEM ORIENTED ASSESSMENT
SYSTEMATIC APPROACH USED IN VARIOUS FIELDS, INCLUDING HEALTHCARE
AND SOCIAL WORK TO THOROUGHLY EVALUATEA SPECIFIC ISSUE OR SET OF
ISSUES FACE BY AN INDIVIDUAL.

EXAMPLE:
Chronic Pain Management
A. Apply ADPIE

What is ADPIE?
4. Emergency Assessment
Performed during emergency procedures, when it is crucial to evaluate the patient's airway,
breathing and circulation, as well as the exact cause of the problem.
Nurses Role in Health Assessment
Critical Role
Contributing Significantly to the overall healthcare team and
Ensuring comprehensive patient care.
 The role of nurses in health assessment encompasses several key
responsibilities

1. Data
Collection
2. Communication and Patient Interview
3. Physical Examination
3. Health Promotion and Education
3. Collaboration
4. Documentation and Reporting
5. Monitoring and Follow-up
 ACTIVITY: “ Exploring the Role of Nurses in
Health Assessment”
Engage the students in a discussion about their perceptions of the nursing
profession and the role nurses play in healthcare. Encourage them to share any
personal experiences or observations they may have had with nurses.

“One by One”
DAY 2
 STEPS IN HEALTH ASSESSMENT

A. Collection of Subjective Data through interview and health history

 Personal Data
 Reason for Seeking Healthcare or Chief Complaint

Example:
A. Abdominal Pain
B. Fever
C. Coughing
D. Weakness
 History of:

A. Present Illness
Example:
o 55 years old, alert, married female
present to ED with a cc: of lower
abdominal pain x 3-4 days, worst last
1-2 days, now sharp severe and
cramping with pain scale 10/10, no
pain medication has been taking.
B. Past Health/Medical History
Example:
o The patient’s past medical history states that
she has never experienced that kind of rash
before. However, looking at the patient’s
history, we notice that she had been admitted
for tonsillectomy at the age of nine which was
as a result of a chronic strep throat infection.
Other than the strep throat infection, the
patient has never suffered from any serious
illness since she has never been hospitalized.
C. Family Health/Medical History
Example:
o A study of the family history shows that she has
a mother who has rheumatoid arthritis. Her father
is healthy and has not been diagnosed with any
ailment or disease that could shed light on the
patient’s ailment. There is no medical information
provided by her siblings.
D. Current Medication
Example:
o
E. Lifestyle
Example:
o Fitness Body-Centered
o Academic and Intellectual
o Activities
o Diet
o Job
F. Developmental Level
Example:
o
H. Psychosocial History – Functional Status
and Living Status
Example:
o Family Problems
o Depression
o Anxiety
o Substance Abuse
o Sexual Abuse
o Violence.
ACTIVITY: “Nursing Process”
utilizing ADPIE
 CASE SCENARIO 1

Emergency Room Triage:

It's a busy evening at PCDS Emergency Hospital, and the staff is

dealing with a steady stream of patients seeking medical attention.
Among them is Mr. Mosqueda, a 65-year-old man who arrives
complaining of severe chest pain. As the triage nurse, you need to
apply the nursing process using the ADPIE framework to ensure
efficient and effective care.
 CASE SCENARIO 2

Patient with Shortness of Breath on a Medical Ward

 CASE SCENARIO 3

Managing a Diabetic Patient's Elevated Blood Sugar Levels

DAY 3
B. Collection of Objective Data

 Physical Examination – a routine activity of a

primary care provider that PCP performs to check
over all health of an individual.
1. Preparation
o Escorting patients from the waiting room to the
examination rooms
oInterviewing the patient, including leading a
discussion of medical history and recent test
performed.
oRecord the patients vital signs
oMeasure height and weight
2. Positioning
Used for:
1. Supine – Intracranial, cardiac, abdominal, lower
extremity procedures, ENT, neck and face.
2. Sims – Rectal examination, enemas, examining
vaginal wall
3. Prone – provide surgical access to the dorsal
(back) aspects of the body.
4. Knee-Chest – spine surgery
5. Dorsal Recumbent – vaginal examination
6. Standing – Genitalia, posture, balance
7. Lithotomy – Surgery in pelvic area, child birth
8. Squatting – Muscle of the thigh, hips, buttocks
9. Sitting – Spinal anesthesia,
 FOR ABDOMINAL
3. Techniques EXAMINATION

1. Inspection 1. Inspection

2. Palpation 2. Auscultation

3. Percussion 3. Palpation

4. Auscultation 4. Percussion
INSPECTION
It consists of a systematic visual
examination and purposeful
observations of the patient. It entails
paying attention to shape, color, size,
symmetry, location, and movements.
It also employs the senses of smell
and hearing to detect odors and
sounds.
AUSCULTATION
It is the process of listening to
sounds produced by the body.
The heart and blood vessels are
auscultated for blood circulation,
while the lungs are auscultated
for air movement (Breath Sound).
Auscultation of the abdomen is
performed to detect movement of
gastrointestinal contents (Bowel
Sounds)
PERCUSSION
The examination of the internal
organs by tapping the fingers on
the body to evaluate the state of
the internal organs based on the
sounds produced. Percussion
notes or Percussion tones are the
sound waves created by striking
the body tissues. Percussion is
also used to identify whether a
structure is air-filled, fluid-filled,
or solid-filled.
 PALPATION
It is the process of using
one’s hands to feel the body
or a part in order to determine
the size and position of the
organs. Temperature, turgor,
texture, moisture, vibrations,
size, position, masses, and
fluid can all be assessed
using the hands and fingers.
 Diagnostic Test  Laboratory Test

Biopsy CBC
Imaging Urinalysis
Ultrasound Stool Examination
Hearing Test Blood Culture
Kidney Function Test Urine Culture
ACTIVITY: Choose the best answer

A. Clinical Laboratory Test

B. Diagnostic Test
C. Normal Test
D. Abnormal Test
A. Clinical Laboratory Test
B. Diagnostic Test
C. Normal Test
D. Abnormal Test
A. Clinical Laboratory Test
B. Diagnostic Test
C. Normal Test
D. Abnormal Test
A. Clinical Laboratory Test
B. Diagnostic Test
C. Normal Test
D. Abnormal Test
A. Urinalysis
B. Stool Examination
C. Chest X-ray
D. Complete Blood Count
A. Urinalysis
B. Stool Examination
C. Chest X-ray
D. Complete Blood Count
A. Urinalysis
B. Stool Examination
C. Chest X-ray
D. Complete Blood Count
A. Urinalysis
B. Stool Examination
C. Chest X-ray
D. Complete Blood Count
 Others Source
What ELSE???
 “Masakit po ang aking ulo” as
 Flushing of skin
verbalized by the patient.  Skin warm to touch
 BP 140/100 mmhg
“Medyo mainit init ang aking  Temp 38 ⁰C
pakiramdam” as verbalized by the  O2 Sat – 85 %
patient.  What else?
DAY 4
C. Validation of Data
Is a crucial step that ensures the
accuracy, reliability, and
completeness of information collected
during patient assessments.

The primary purpose:

To ensure data is as free from error,
bias, and misinterpretation as
possible.
 How to VALIDATE?
 Cross Verification “Subjective + Objective”
 Communication with Interdisciplinary Team –
“Common Goal”
Reassessment and Monitoring
 Critical Thinking and Clinical Judgement
 Document Accuracy
 D. Documentation of Data
Vital component that ensures accurate, comprehensive, and organized recording of patient
information

1. Adhere to LEGAL and ETHICAL STANDARDS – confidentiality

2. Standardized Terminology
Guidelines: 3. Documentation in REAL TIME – ASAP
4. Relevant
5. Timely and Consistent
6. Avoid Abbreviations
7. Review and SIGN Entries
 WRITTEN NOTES EXAMPLE

Subjective Data: Patient reports feeling a dull ache in the lower back (rated 5/10 on the pain scale) that started
yesterday. No recent injuries reported. Patient states, "I noticed the pain after lifting a heavy box.“
Objective Data:
• Vital Signs:
• Blood Pressure: 120/80 mmHg
• Heart Rate: 78 bpm
• Respiratory Rate: 16 breaths per minute
• Temperature: 98.6°F (oral) ADPIE
• Physical Assessment:
• Lower back tenderness on palpation
• Limited range of motion; pain exacerbated with movement
• No signs of inflammation or discoloration
 ELECTRONIC NOTES EXAMPLE

Subjective Data: Patient reports feeling a dull ache in the lower back (rated 5/10 on the pain scale) that started
yesterday. No recent injuries reported. Patient states, "I noticed the pain after lifting a heavy box.“
Objective Data:
• Vital Signs:
• Blood Pressure: 120/80 mmHg
• Heart Rate: 78 bpm
• Respiratory Rate: 16 breaths per minute
• Temperature: 98.6°F (oral)
• Physical Assessment:
• Lower back tenderness on palpation
• Limited range of motion; pain exacerbated with movement
• No signs of inflammation or discoloration
WHAT IS THE DIFEERENCE BETWEEN WRITTEN AND
ELECTRONIC NOTES?
 PRE MIDTERM
FEBRUARY 26, 2024 – MARCH 16, 2024
HOLISTIC NURSING ASSESSMENT
Topics Day
1. General Status and Vital Signs
2. Mental Status
2.1 Adults 5
2.2 Children and Adolescents

3. Psychosocial, Cognitive and Moral Development

4. Pain
5. Violence 6
6. Culture and Ethnicity
7. Spiritual and Religious Practice
8. Nutritional Status 7
DAY 5
 A. General Status
Let’s understand what we mean by
“GS”.

It refers to a comprehensive
evaluation of the patient's overall
condition, beyond the specific
complaint or ailment they might be
presenting with.
 Components of General Status
A. Appearance
For Example:
patient's age
Pallor might indicate anemia,
gender while jaundice could signal liver dysfunction.
body habitus
Hygiene
skin color
and any visible
abnormalities.
 Components of General Status
B. Behavior
Observation of the
patient's behavior can
provide valuable clues.
For Example:
Restless or
These observations can Calm
indicate pain, anxiety, or
neurological conditions.
Cooperative
o Agitated
 Vital Signs

BLOOD RESPIRATION OXYGEN

MEAN TEMPERATURE PULSE RATE
PRESSURE RATE SATURATION
ARTERIAL
PRESSURE OR OR
OR OR OR
OR MAP TEMP PR, HR RR
BP SPO2
BLOOD PRESSURE OR BP:
The pressure of blood pushing against the walls of your arteries. Arteries carry blood from
your heart to other parts of your body. Your blood pressure normally rises and falls
throughout the day.
Mean Arterial Pressure or MAP:
The average arterial pressure throughout one cardiac cycle, systole,
and diastole.
Temperature:
Is the degree of hotness or coldness of a body.
Practice Time:
Guess what type of thermometer.
 Convert the following:
1. What is the Fahrenheit of 37 Degree Celsius?
2. What is the Fahrenheit of 36.5 Degree Celsius?
3. What is the Fahrenheit of 38 Degree Celsius?
4. What is the Degree Celsius of 98 Fahrenheit?
5. What is the Degree Celsius of 100 Fahrenheit?
6. What is the Degree Celsius of 95 Fahrenheit?
Pulse Rate / Heart Rate:

- A measurement of the heart

rate, or the number of times the
heart beats per minute.

- As the heart pushes blood

through the arteries, the arteries
expand and contract with the
flow of the blood.
Pulse Sites
Pulse O_ _m_t_y
Respiration Rate:
is the rate at which breathing occurs; it is set and controlled by the
respiratory center of the brain. A person's respiratory rate is usually
measured in breaths per minute.
 Oxygen Saturation / SPO2:

Oxygen saturation is the fraction of

oxygen-saturated hemoglobin
relative to total hemoglobin in the
blood.

The human body requires and

regulates a very precise and specific
balance of oxygen in the blood.

Normal arterial blood oxygen

saturation levels in humans are 96–
100 percent
 B. Mental Status
The descriptions of the patient's
appearance and general behavior, level of
consciousness and attentiveness, motor and
speech activity, mood and affect, thought
and perception, attitude and insight, the
reaction evoked in the examiner, and,
finally, higher cognitive abilities.

The mental status examination is an

important part of the clinical assessment
process in neurological and psychiatric
practice.
 Level Consciousness
A term used to describe a
person's awareness and LEVEL OF CONCIOUSNESS
understanding of what is
Conscious
happening in his or her
surroundings. Un Responsive

Lethargic

Obtunded

Stupor

Coma

On Sedation

GCS: __________________

Please refer to E.R. assessment

 Conscious Unconscious & Possible Dead (u)

Unresponsive Response slowly to external stimulation (o)

Lethargic Sleepy & Relaxes (o)

MATCHING Disoriented to surroundings (c)

Obtunded
TYPE

Stupor No observable response (C)

Coma Drowsy, Needs Gentle Verbal (L)

On Sedation Response only minimally w/ vigorously (s)

Glasgow Coma Scale
ADULT
Glasgow Coma Scale
Pediatric
Difference between Decorticate and Decerebrate
DAY 6
 C. Psychosocial Assessment
A comprehensive evaluation that
examines an individual's mental,
emotional, and social well-being.
It considers various factors that
influence psychological health,
including personal experiences,
relationships, coping mechanisms, and
societal influences.
This assessment is essential for
understanding an individual's
strengths, challenges, and overall
quality of life.
Component of Psychosocial Assessment
1. Psychological Assessment : focuses on evaluating an individual's cognitive processes,
emotions, and behaviors
2. Social Assessment : explores an individual's relationships, support systems, and social
functioning
3. Environmental Assessment : examines the individual's living conditions, work
environment, access to resources, and cultural background. Socioeconomic status, housing
stability, and exposure to stressors are evaluated to identify potential sources of support or
risk.
4. Cultural Assessment : Culture influences beliefs, values, and norms related to mental
health and well-being
 Psychosocial Social Environmental Culture

Common questions
Common questions Common questions
include asking a client
Common questions include asking a client include asking a client
about family
include asking a client housing condition, cultural background,
relationship,
to list his or her work environment, health belief &
friendship & social
stressors, the access to resources, practices, attitude
support, school & peer
symptoms he or she is transportation & towards illness, &
relationship, and
having, and whether mobility, treatment, family &
community
the client has thoughts environmental community support,
involvement and
of suicide or harming exposure “ smoking” language preferences,
social integration,
others. and community safety cultural celebration
digital & online
& security. and practices.
relationship.
 METHOD IMPORTANCE

1. Interview
1. Early Detection &
2. Questionnaire &
Intervention
Rating Scales
2. Patient Centered Care
3. Observation
3. Treatment Planning &
4. Collateral
Monitoring
Information or
4. Promotion of resilience
Significant Others
& Coping
 Cognitive Assessment
Understanding and evaluating cognitive function are crucial for diagnosing and managing
various neurological and psychological conditions, as well as for promoting optimal
cognitive well-being.

Is a systematic evaluation of an individual's cognitive abilities, including memory, attention,

executive function, language, and reasoning.

It provides valuable insights into an individual's cognitive strengths, weaknesses, and

overall functioning, guiding clinical decision-making and intervention strategies.
 Components of Cognitive Assessment
1. History & Clinical Review : includes present medical history,
2. Standardize Cognitive Test : used to assess specific cognitive domains, such as memory,
attention, language, and executive function.
3. Observational and Informal Assessment : Observations of attention, memory, problem-
solving, and social interaction during the assessment process can offer valuable clinical
information.
4. Neuropsychological Assessment : Neuropsychological assessment involves a
comprehensive evaluation of cognitive function, typically conducted by a neuropsychologist
Standardized Cognitive Test Sample
 IMPORTANCE

1. Early Detections and Diagnosis

2. Treatment and Planning Monitoring

3. Base Assessment

4. Research & Clinical Trials

 C. Moral Development
A person goes through as they grow
and develop.

The gradual acquisition of moral

values, beliefs, and principles that
guide individuals' decisions and
actions in social and ethical contexts.

It encompasses the development of

empathy, fairness, justice, and
integrity, shaping individuals'
understanding of what is morally right
and wrong.
 Theory of Moral Development

Piaget's Theory of Moral Development: Jean

Piaget proposed a cognitive-developmental
approach to moral development, suggesting that
children progress through stages of moral
reasoning as they mature. According to Piaget,
young children exhibit heteronomous morality,
characterized by a strict adherence to rules and
authority. As children grow older, they develop
autonomous morality, which involves a greater
understanding of mutual respect, reciprocity,
and individual rights.
 Piaget's Theory Kohlberg's Theory

A. Pre-Conventional
1. Heteronomous Morality: •Stage 1: They obey rules to avoid getting in trouble.
judge actions based on the •Stage 2: They follow rules that satisfy their own needs and may break
consequences, rather than rules if it benefits them.
intentions.
B. Conventional
2. Autonomous Morality: They •Stage 3: They want to be seen as good and caring.
begin to consider intentions •Stage 4: They obey rules to maintain social harmony and stability.
behind actions and understand
that rules can sometimes be C. Post-Conventional
broken if there's a justifiable •They value individual rights and the greater good.
reason. •Stage 6: They act according to these principles, even if it means
breaking laws.
 Factors Influencing Moral Development

1.Parental Influence: Parents play a crucial role in shaping children's moral development through their
modeling of moral behavior, values transmission, and moral guidance.
2.Peer Influence: Peers also influence moral development through socialization, peer interactions, and peer
pressure. Positive peer relationships characterized by cooperation, empathy, and prosocial behavior promote
moral growth, whereas negative peer influences may undermine moral values and ethical decision-making.
3.Cultural and Societal Factors: Cultural norms, values, and traditions significantly impact moral
development by shaping individuals' perceptions of morality, ethical standards, and social norms. Cultural
diversity enriches moral development by exposing individuals to diverse perspectives, ethical dilemmas,
and moral reasoning approaches.
4.Educational Practices: Schools and educational institutions play a vital role in fostering moral
development through moral education programs, character education initiatives, and ethical leadership
development. Moral education promotes critical thinking, moral reasoning skills, and ethical decision-
making abilities, preparing individuals to navigate complex moral dilemmas and contribute positively to
society.
 D. Pain
is a universal human experience
that serves as a crucial signal of
potential or actual tissue
damage.
It can manifest in various forms,
including acute pain, which
typically arises suddenly in
response to injury or illness, and
chronic pain, which persists over
time and often lacks a clear
physiological cause.
 Nature of Pain
1.Biological Basis: Pain is a complex biological process involving sensory receptors, nerve
pathways, and the central nervous system. When tissue damage occurs, specialized nerve endings
called nociceptors detect harmful stimuli and transmit signals to the brain, where pain is
perceived and processed.
2.Psychological Factors: Pain perception is influenced by psychological factors such as
emotions, beliefs, and past experiences. Negative emotions like anxiety and depression can
amplify pain perception, while positive emotions and coping strategies can help mitigate pain
intensity.
3.Social and Cultural Influences: Sociocultural factors also play a significant role in shaping the
experience of pain. Cultural norms, beliefs about pain, and social support systems can impact
how individuals perceive, express, and cope with pain.
 Biological Psychological Social & Cultural Influences

1. Complex regional Pain Syndrome 1. Depression 1. Shame

2. Inflammatory response 2. Anxiety 2. Fear
3. Pain Originating from the hip 3. Frustration 3. Guilt
4. Angry
 Types of Pain Examples
1. Acute – happens quickly and goes away when 1. Burning, Sharp Pain, Labor Pain, Headache
there is no cause.
2. Arthritis, Nerve Damage, Cancer
2. Chronic - lasts longer than six months and can
continue when the injury or illness has been
treated. 3. Multiple Sclerosis “Spinal Cord” , BKA
3. Neuropathic - happens for no apparent reason “Amputation”, Stroke
“Nerve”
4. Nociceptive - pain arises from tissues damaged 4. Surgery, Chemical Burn, Stubbing, Sports injury
by physical or chemical agents
Pain Scale
 Management of Pain
1. Pharmacological Interventions:
analgesic medications such as nonsteroidal anti-inflammatory drugs
(NSAIDs), opioids, and adjuvant medications, are commonly used to
manage pain.
Identify which management of
pain refers to
2. Non-Pharmacological Approaches:
focus on addressing the psychological and social aspects of pain. These 1. Independent
may include cognitive-behavioral therapy, relaxation techniques, 2. Dependent
mindfulness meditation, acupuncture, physical therapy, and massage 3. Inter dependent
therapy.
3. Multidisciplinary Pain Management: ???
holistic approach to pain care, involving collaboration among
healthcare professionals from various disciplines, including physicians,
psychologists, physical therapists, and pain specialists.
 E. Violence
R. A. 9262
AN ACT DEFINING VIOLENCE AGAINST WOMEN AND THEIR CHILDREN, PROVIDING FOR PROTECTIVE MEASURES
FOR VICTIMS, PRESCRIBING PENALTIES THEREFORE, AND FOR OTHER PURPOSES

Encompasses a range of behaviors that cause physical,

psychological, or emotional harm to individuals.

It can occur in various forms, including intimate

partner violence, child abuse, elder abuse, sexual
violence, and community violence.

Violence not only inflicts immediate injuries but also

has long-lasting consequences for individuals, families,
and communities.
 Prevalence and Impact of Violence
1. Global Burden of Violence:
Violence is a pervasive public health issue with significant global implications. According to
the World Health Organization (WHO), an estimated 1.3 million people die each year worldwide due
to violence, with many more experiencing non-fatal injuries and long-term health consequences.
2. Health Consequences:
Violence can have profound physical and psychological health consequences, including
injuries, chronic pain, mental health disorders (such as depression and post-traumatic stress disorder),
substance abuse, and increased risk of chronic diseases (such as cardiovascular disease and cancer).
3. Interpersonal and Social Impacts:
Violence not only affects individuals' health but also disrupts interpersonal relationships,
family dynamics, and social cohesion. It can lead to social isolation, loss of trust, and community
disintegration, perpetuating cycles of violence across generations.
 Screening for Violence in Healthcare Setting
1. Importance of Screening:
Healthcare settings provide a unique opportunity to
identify and intervene in cases of violence, as individuals
may seek care for injuries or related health concerns. Routine
screening for violence is recommended by leading healthcare
organizations to identify victims, offer support services, and
prevent further harm.
2. Screening Tools and Protocols:
Various screening tools and protocols are available
to assess for violence in healthcare settings, including
validated questionnaires, clinical interviews, and standardized
assessment protocols. These tools help healthcare providers
identify individuals at risk of violence, initiate conversations
about safety, and offer appropriate interventions and referrals.
Intervention and Prevention Strategies
1. Immediate Intervention:
Providing medical treatment for injuries, offering
psychological support and counseling, facilitating safety planning, and
connecting individuals with community resources and support
services.
2. Collaborative Care:
Requires a multidisciplinary approach involving collaboration
among healthcare providers, social service agencies, law enforcement,
and community organizations.
3. Prevention Efforts:
Include public education campaigns, community-based
initiatives, policy advocacy, and efforts to address social determinants
of health (such as poverty, inequality, and lack of access to resources).
 DAY 7

Today, we delve into an essential aspect of healthcare: understanding culture and ethnicity in health assessment. In our
increasingly diverse society, healthcare providers encounter patients from various cultural backgrounds. Recognizing and
respecting these differences is crucial for delivering effective care. Let's explore why culture and ethnicity matter in health
assessment and how we can integrate this awareness into our practice.
 F. Culture and Ethnicity
CULTURE ETHNICITY
- encompasses a broad - Describe as the shared
range of factors, including identity based on common
beliefs, values, customs, ancestry, heritage,
traditions, language, and nationality, or geographic
communication styles. origin

Individuals' health
beliefs, behaviors,
attitudes toward
healthcare, and
responses to illness.

INFLUENCE
Example of Culture
Example of Ethnicity
 Here are some practical strategies for incorporating cultural and ethnic
considerations into nursing assessment:
1. Culture Awareness :
Respect patients' cultural preferences and incorporate them into their care plans whenever
possible.
2. Effective Communication:
Use clear and simple language, avoid medical jargon, and encourage patients to ask questions.
Be attentive to nonverbal cues and adapt your
3. Respect for Diversity:
Treat each patient as an individual, recognizing that cultural and ethnic.
4. Collaborative Approach:
Involve patients in decision-making regarding their care and respect their autonomy. Work
collaboratively with patients to develop culturally appropriate treatment plans that align with
their values and preferences.
 G. Spirituality and Religious Practice
Spirituality Religious practice
In nursing assessment,
it is essential to
deeply personal aspect of recognize that involves organized
human existence, spirituality and religious beliefs, rituals, and
encompassing one's search beliefs can profoundly traditions within a
for meaning, purpose, and influence patients' specific faith tradition or
connection to something perceptions of health, community.
illness, and healing.
greater than oneself.

By acknowledging and
addressing these aspects of
patients' lives, nurses can
provide more holistic and
patient-centered care.
Which of the given image is the spiritual and religious practice or vice
versa.
 Why do spirituality and religious practice matter in
nursing assessment?
1. Impact on Health Outcomes:
Increase better health outcomes including improved psychological well-being, coping skills, and quality of life. By
addressing patients' spiritual needs, nurses can support their overall health and healing process.
2. Source of Comfort and Support:
Nurses can offer emotional and spiritual support, fostering a sense of connection and meaning.
3. Cultural and Ethical Considerations:
Acknowledging and respecting patients' cultural and religious backgrounds, nurses demonstrate cultural competence
and uphold ethical principles of respect for patient autonomy and dignity.
4. Enhanced Communication and Trust:
Addressing spirituality and religious practice in nursing assessment can strengthen the nurse-patient relationship by
fostering open communication, trust, and mutual understanding. Patients may feel more comfortable discussing their
concerns and preferences when they know that their spiritual and religious beliefs will be respected and valued.
 How nurses effectively integrate spirituality and religious
practice into nursing assessment?
1.Open-Ended Questions:
2.Active Listening and Empathy:
3.Assessment Tools: “Use validated
assessment tools, such as the FICA
Spiritual History Tool or the HOPE
Spiritual Assessment”
4.Collaborative Care Planning:
5.Ongoing Education and Self-
Reflection:
 H. Nutritional Status
Refers to the balance
between nutrient intake
and requirements, as
well as the body's ability
to utilize nutrients for Assessing nutritional status
is crucial for identifying
growth, development, risk factors, addressing
and maintenance of nutritional deficiencies,
health. and developing
individualized care plans
to support patients' health
and well-being.
 Why does nutritional status matter in nursing assessment?

1. Impact on Health Outcomes:

Adequate nutrition is essential for maintaining overall health and well-
being.
Nutritional deficiencies or imbalances can lead to a wide range of health
problems, including impaired immune function, delayed wound healing,
muscle wasting, and increased susceptibility to infections and chronic
diseases.
2. Relevance to Patient Populations:
Certain patient populations are particularly vulnerable to nutritional
issues, including children, older adults, pregnant women, individuals with
chronic illnesses, and those undergoing medical treatments or surgical
procedures.
Assessing and addressing their nutritional needs are critical for
optimizing health outcomes and promoting recovery.
3. Role in Disease Prevention and Management:
Nutrition plays a significant role in preventing and
managing various health illnesses.
4. Interconnection with Medications and
Treatments:
Some medications and medical treatments can
impact nutritional status by affecting appetite,
nutrient absorption, metabolism, or nutrient
excretion.
Nurses must consider these factors when assessing
patients' nutritional status and monitoring for
potential complications or side effects.
Now, how do we conduct a comprehensive nutritional assessment
as part of nursing practice?
1. Dietary History:
Begin by obtaining a detailed dietary history, including
typical eating patterns, food preferences, cultural and
religious dietary practices, and any recent changes in
appetite or dietary intake. Use open-ended questions
and food diaries to gather accurate information about
patients' nutritional habits.
2. Anthropometric Measurements:
Perform anthropometric measurements, such as height,
weight, body mass index (BMI), waist circumference,
and body composition analysis, to assess nutritional
status and identify signs of malnutrition, obesity, or
other body composition abnormalities.
3. Clinical Assessment:
Conduct a thorough clinical assessment to identify signs and
symptoms of nutritional deficiencies or imbalances, such as fatigue,
weakness, poor wound healing, hair loss, dry skin, and oral or
gastrointestinal abnormalities.
4. Laboratory Tests:
Order appropriate laboratory tests to assess nutritional biomarkers,
such as serum albumin, prealbumin, transferrin, hemoglobin,
hematocrit, vitamin levels, electrolytes, and glucose levels. These
tests can provide objective data to confirm suspected nutritional
deficiencies and guide nutritional interventions.
5. Nutritional Screening Tools:
Utilize validated nutritional screening tools, such as the Malnutrition
Universal Screening Tool (MUST), Mini Nutritional Assessment
(MNA), or Nutritional Risk Screening (NRS), to identify patients at
risk of malnutrition and prioritize interventions accordingly.
Now, how can we promote optimal nutrition in our care?
1. Individualized Care Plans:
Develop individualized care plans that address patients'
nutritional needs, preferences, and goals.
Collaborate with registered dietitians, nutritionists, and other
members of the interdisciplinary team to develop tailored
dietary interventions and monitor progress over time.
2. Patient Education:
Provide patients with evidence-based nutrition education and
counseling to promote healthy eating habits, meal planning,
and food safety practices.
Empower patients to make informed choices about their
dietary intake and lifestyle behaviors to support their overall
health and well-being.
3. Nutritional Support:
Offer nutritional support interventions, such as oral
nutritional supplements, enteral nutrition, or
parenteral nutrition, for patients who are unable to
meet their nutritional requirements through oral
intake alone.
Monitor patients' tolerance to nutritional
interventions and adjust as needed to optimize
outcomes.
4. Collaborative Approach:
Work collaboratively with patients, families, and
caregivers to address barriers to optimal nutrition,
such as limited access to affordable and nutritious
foods, food insecurity, cultural or religious dietary
restrictions, and functional limitations that impact
meal preparation and consumption.
 MIDTERM
MARCH 25 – APRIL 13, 2024
Physical Assessment
Topics Day
A. Skin, Hair, and Nails
B. Head and Neck
C. Eyes 8
D. Ears
E. Mouth, Throat, Noses, and Sinus
F. Thorax and Lungs
G. Breast and Lymphatic System
H. Heart and Neck Vessels 9
I. Peripheral Vascular System
J. Assessing Abdomen
K. Musculo-Skeletal System
L. Neurologic System
10
M. Male Genital and Rectum
N. Female Genital and Rectum
DAY 8
 Comprehensive Physical Assessment of the Skin, Hair, and Nails

I. Introduction to the Integumentary

System:
•The skin, hair, and nails collectively form
the integumentary system.
•Functions:
 Protection,
 Thermoregulation,
 Sensation,
 Vitamin D synthesis,
and Excretion.
II. Importance of Physical
Assessment:

•Early detection of
abnormalities or pathology.
•Monitoring changes over
time.
•Assessing overall health and
well-being.
III. Physical Assessment of the Skin:
A. Inspection:
1. Color:
Note variations such as pallor, erythema,
cyanosis, or jaundice.
2. Texture:
Assess for smoothness, roughness, or
lesions.
3. Moisture:
Evaluate for dryness or excessive
perspiration.
Sample of Pressure Ulcer Risk Assessment Tool
B. Palpation:
1. Temperature:
Assess for warmth or coolness.
2. Turgor:
Check skin elasticity by gently
pinching and releasing then interpret
either Good or Poor
3. Edema:
Look for swelling or pitting.
4. Integrity:
Intact or non-intact
C. Lesion Assessment:
1. Size, shape, color, and
distribution.
2. Note characteristics of lesions:
macules, papules, plaques,
nodules, vesicles, pustules, ulcers,
etc.
3. Document any changes in
existing lesions or the appearance
of new ones.
Macules
Papules
Plaques
Nodules
Vesicles
Pustules
Ulcer
IV. Physical Assessment of the Hair:
A. Inspection:
1. Color, distribution, and texture.
2. Scalp condition: Presence of dandruff,
lesions, or infestations.
B. Palpation:
1. Texture: Assess for brittleness,
thickness, or thinning.
2. Scalp mobility: Check for tenderness or
masses.
C. Note any changes in hair growth
patterns or loss.
V. Physical Assessment of the Nails:
A. Inspection:
1. Shape, contour, and consistency.
2. Color: Observe for variations or abnormalities.
3. Nail bed: Check for capillary refill and signs of
cyanosis.
B. Palpation:
1. Texture: Assess for smoothness, ridges, or brittleness.
2. Integrity: Look for signs of injury, infection, or
inflammation.
3. Clubbing: Evaluate the angle between the nail bed
and nail plate.
C. Assess for signs of nail pathology such as Beau's lines,
leukonychia, or onycholysis.
VI. Clinical Considerations:
•Recognizing normal variations across
different ages, ethnicities, and genders.

•Understanding common skin, hair, and

nail disorders.

•Importance of interdisciplinary
collaboration for comprehensive
assessment and management.
 Comprehensive Physical Assessment of the Head and Neck

I. Introduction to Head and Neck

Assessment:
•The head and neck contain critical
anatomical structures, including the
brain, eyes, ears, nose, mouth, throat,
lymph nodes, and thyroid gland.
•Assessment of these regions is crucial
for identifying abnormalities,
diagnosing diseases, and providing
appropriate interventions.
II. Approach to Head and Neck Assessment:

A. Inspection:
1. External structures: Note
symmetry, size, and shape of the
head and face.
2. Skin: Assess for color, texture,
lesions, and any abnormalities.
3. Facial expressions: Observe for
signs of pain, discomfort, or
neurological deficits.
B. Palpation:
1. Skull: Assess for tenderness,
deformities, or masses.
2. Temporomandibular joint
(TMJ): Check for tenderness,
range of motion, and clicking.
3. Lymph nodes: Palpate for
size, tenderness, and mobility.
C. Auscultation:

1. Carotid arteries: Listen for bruits

using a stethoscope.

2. Thyroid gland: Assess for the

presence of bruits or murmurs.
 III. Physical Assessment of the Eyes

A. Inspection:
1. Eyebrows, eyelids, and lashes: Note
symmetry, position, and any
abnormalities.
2. Conjunctiva and sclera: Assess for
color, vascularity, and presence of lesions.
3. Pupils: Check for size, shape,
symmetry, and reaction to light
(PERRLA).
.

PERRLA is an acronym for “pupils are equal, round The normal pupil size varies from 2 to 4 mm in diameter in
and reactive to light and accommodation. bright light to 4 to 8 mm in the dark..
B. Ocular Movements:
1. Assess extraocular muscle function using the H pattern or cardinal gaze directions.
2. Evaluate for nystagmus or strabismus.
 IV. Physical Assessment of the Ears

A. Inspection:
1. External ear: Note size,
shape, symmetry, and
presence of lesions or
deformities.
2. Ear canal and tympanic
membrane: Assess for
redness, discharge, or
foreign bodies.
B. Palpation:

1. Tragus and mastoid process:

Check for tenderness or swelling.
2. Evaluate for lymphadenopathy
around the ear and neck.
C. Audiometric Testing:
1. Perform basic hearing tests
such as whisper or finger rub tests.
2. Refer for formal audiometry if
hearing loss is suspected.
V. Physical Assessment of the Mouth
A. Inspection:
1. Lips: Assess for color, moisture, symmetry, and
any lesions.
2. Gums (gingiva): Check for color, contour,
texture, and signs of inflammation or bleeding.
3. Teeth: Note alignment, color, integrity, and
presence of caries or dental restorations.
4. Tongue: Inspect for size, shape, color, coating,
and any abnormalities such as ulcers or lesions.
5. Palate and mucosa: Evaluate for color, texture,
lesions, and signs of infection or trauma.
B. Palpation:
1. Gums and mucosa: Palpate for
tenderness, swelling, or masses.

2. Submandibular and sublingual

glands:
Assess for enlargement or
tenderness.
C. Functional Assessment:
1. Range of motion:
Evaluate tongue movement and ability to
protrude, retract, and move side to side.

2. Swallowing function:
Observe swallowing process for any signs of
dysphagia or difficulty.
 VI. Physical Assessment of the Throat
A. Inspection:
1. External structures:
Assess for symmetry, skin color, and
presence of swelling or masses.
2. Oral cavity:
Evaluate the soft palate, uvula, tonsils, and
posterior pharyngeal wall for color, texture,
and any lesions.
3. Oropharynx:
Use a tongue depressor and flashlight to
visualize the tonsils, posterior pharyngeal
wall, and uvula.
B. Palpation:
1. Neck lymph nodes:
Palpate for tenderness, size, and
mobility.
2. Thyroid gland:
Assess for enlargement or nodules.
C. Functional Assessment:
1. Swallowing:
Observe the patient's ability to swallow
saliva and liquids.
2. Voice quality:
Assess for hoarseness, dysphonia, or changes
in pitch.
VII. Physical Assessment of
the Nose and Sinuses
A. Inspection:
1. External nose: Note symmetry, shape, and
presence of lesions.
2. Nasal mucosa:
Assess for color, moisture, and presence of
discharge or polyps.
3. Sinuses: Palpate for tenderness over the frontal
and maxillary sinuses.
B. Nasal Patency:
1. Evaluate airflow through each nostril by asking
the patient to occlude one nostril at a time.
2. Assess for signs of nasal obstruction or deviation.
Clinical Considerations
•Recognizing common head
and neck disorders such as
migraines, sinusitis, otitis
media, and thyroid
disorders.

•Importance of thorough
documentation and
interdisciplinary
collaboration for
comprehensive patient care.
DAY 9
 RLE HEALTH ASSESSMENT HAND BOOK

RESPIRATORY SYSTEM
Labored Breathing
Non – Labored Breathing
Shallow
Productive Cough
Non – Productive Cough
Symmetrical
Asymmetrical
Retraction
Clear
Crackles
Wheeze
Stridor
Others: _____________________________________
Oxygen: ____________LPM Via: ________________
 A comprehensive physical assessment of the thorax and lungs

1.General Appearance:

 Assess the patient's posture,

breathing pattern, and
overall comfort level.

 Note any signs of distress,

such as the use of accessory
muscles, nasal flaring, or
pursed-lip breathing.
 Sample Chest Wall Deformities

2. Inspection of the Thorax:

 Look for any asymmetry,

deformities, or abnormalities in
the chest wall.

 Observe the respiratory rate,

and depth.

 Note the presence of any scars,

lesions, or rashes.
3. Palpation:

 Start with palpation

of the chest wall for
tenderness, and
masses.

 Check for any areas

of decreased or
increased chest
expansion during
deep breathing.
4. Percussion:

 Perform percussion over

each lung field, comparing
resonance bilaterally.

 Note any areas of dullness

which could indicate
consolidation, effusion, or
tumor.
 MATCHING TYPE

5. Auscultation:
 Use a stethoscope to auscultate lung sounds Clear Turbulent Sound
systematically, moving from apex to base and
comparing bilaterally.
Crackles Smooth and Soft
 Listen for breath sounds (vesicular, bronchial,
or bronchovesicular), any adventitious sounds Continuous low-
(crackles, wheezes, Stridor or rhonchi). Wheezes pitched sound
during exhale
 Pay attention to the presence of any added High-Pitched
Stridor
sounds, their location, timing, and whistling
characteristics.
Ronchi Bubbling, Popping
6. Documentation and Reporting:

 Document findings accurately,

including any abnormalities
observed during the assessment.

 Provide a clear and concise

report to the healthcare team,
highlighting any significant
findings that may require further
evaluation or intervention.
 A comprehensive physical assessment of the Breast and
Lymphatic System

1.Introduction and Explanation:

 Introduce yourself to the patient

and explain the purpose of the
examination.

 Ensure privacy and provide

draping for the patient's
comfort.
2. General Inspection:

 Observe the patient's breast size,

shape, symmetry, and skin
integrity.

 Note any asymmetry, dimpling, and

or changes in contour.

 Look for skin changes such as

redness, and or rash.
3. Nipple Assessment:

 Inspect the nipples for

symmetry, position, and any
discharge.

 Note any abnormalities

such as retraction,
inversion, or ulceration.
4. Palpation of the Breasts:

 Start with the patient in a supine position with one

arm behind the head.

 Use the pads of your fingers in a systematic pattern

(e.g., circular or vertical strip) to palpate each
breast thoroughly.

 Assess for any lumps, masses, or areas of

tenderness.

 Note the location, size, shape, consistency, mobility,

and tenderness of any palpable abnormalities.

 Pay attention to any nodules or areas of induration.

 The best time to do a
monthly breast self-exam is
about 3 to 5 days after your
period starts. Do it at the
same time every month. Your
breasts are not as tender or
lumpy at this time in your
monthly cycle.
5. Axillary Lymph Node Assessment:

 Palpate the axillary lymph nodes with gentle pressure using the pads of your
fingers.

 Assess for any enlargement, tenderness, or irregularity.

 Note the location, size, and mobility of any palpable lymph nodes.
6. Supraclavicular and Infraclavicular Lymph Node
Assessment:

1. Palpate the supraclavicular and infraclavicular

lymph nodes bilaterally.

2. Note any enlargement, tenderness, or firmness.

7. Documentation and Reporting:
 Document findings accurately, including breast size,
shape, symmetry, and any abnormalities observed
during the examination.
 Provide a clear and concise report to the healthcare
team, highlighting any significant findings that may
require further evaluation or intervention.
8. Education and Self-Examination Instruction:
 Educate the patient about breast self-examination
techniques and the importance of regular screening.
 Encourage the patient to report any changes or
concerns promptly.
 A comprehensive Physical Assessment of the Heart and Neck
Vessels

1.Introduction and Explanation:

 Introduce yourself to the patient

and explain the purpose of the
examination.

 Ensure privacy and provide

draping for the patient's comfort.
 RLE Requirements Hand Book
CARDIOVASCULAR SYSTEM

Regular Pulse

Irregular Pulse

Weak Pulse

Strong Pulse

Bounding Pulse

CRT: _____ seconds

Edema: ___________ Location: __________________

Others: ______________________________________
2. General Inspection:

Observe the patient's general

appearance, skin color, and overall
condition.

Note any signs of distress, such as

pallor, diaphoresis, or cyanosis.
 Irregular Pulse Weak Pulse
CRT

Bounding Pulse
Strong Pulse

1. 60 to 100 BPM Edema

Regular Pulse 2. Beats too quickly, too slowly
3. Poor heart beat
4. Feels as through your heart is like racing
beat
5. Rapid heart beat
6. 1 to 2 seconds
7. Too much fluid trapped in the body tissues
3. Assessment of Neck Vessels:

Inspect the jugular venous pulsations

(JVP) for waveform, height, and any
abnormalities.

Note any distention, visible

pulsations, or asymmetry.
4. Palpation of Carotid Arteries:

Palpate the carotid arteries one at a

time, gently, and one at a time, to
assess pulse amplitude, symmetry,
and contour.

Assess for thrills or bruits, which

may indicate arterial stenosis or
turbulence.
5. Auscultation of Carotid Arteries:

Use the bell of the stethoscope to

auscultate each carotid artery for
bruits.

Note any abnormal sounds, such as

murmurs or bruits, which may
suggest vascular pathology.
6. Assessment of Heart Sounds:

 Auscultate the heart using the

diaphragm and bell of the stethoscope in
the traditional cardiac auscultation
areas: aortic, pulmonic, erb's point,
tricuspid, and mitral.

 Listen for S1 (lub), S2 (dub), and any

additional heart sounds such as S3 and
S4.

 Note the timing, intensity, and quality of

each heart sound.
7. Auscultation for Murmurs:
Listen for any murmurs, noting their timing in the
cardiac cycle, location, radiation, and characteristics
(e.g., systolic, diastolic, continuous).
Grade murmurs based on intensity (e.g., 1/6 to 6/6)
and describe their quality (e.g., harsh, blowing,
musical).
8. Assessment of Peripheral Edema:

Assess for peripheral edema,

particularly in the lower extremities,
which may indicate fluid retention or
heart failure.

Note the location, extent, and pitting

characteristics of any edema present.
9. Documentation and Reporting:

 Document findings accurately, including

heart sounds, murmurs, vascular
assessment findings, and any abnormalities
observed during the examination.

 Provide a clear and concise report to the

healthcare team, highlighting any
significant findings that may require further
evaluation or intervention.
A comprehensive physical assessment of the peripheral vascular
system
1. Introduction and Explanation:

 Introduce yourself to the patient and

explain the purpose of the
examination.

 Ensure privacy and provide draping

for the patient's comfort.
2. General Inspection:

 Observe the patient's skin color,

temperature, and overall
condition of the extremities.

 Note any signs of pallor,

cyanosis, erythema, or
ulcerations.
3. Assessment of Arterial Circulation:

 Evaluate arterial circulation by

assessing peripheral pulses in the
upper and lower extremities.

 Palpate the radial, brachial, ulnar,

femoral, popliteal, dorsalis pedis, and
posterior tibial pulses bilaterally.

 Note pulse amplitude, symmetry, and

regularity. Document any
abnormalities such as weak or absent
pulses.
4. Capillary Refill:

 Assess capillary refill time by pressing

firmly on the patient's nail bed and
noting the time it takes for color to
return.

 Normal capillary refill time is less than 2

seconds.
5. Assessment of Venous Circulation:

 Inspect the extremities for signs of

venous insufficiency, such as varicose
veins, edema, or venous stasis ulcers.

 Palpate for superficial veins and assess

for tenderness, warmth, or swelling.
6. Assessment of Lymphatic Circulation:

 Palpate the lymph nodes in the neck, axilla,

and inguinal regions for size, tenderness,
and mobility.

 Note any enlargement, firmness, or

asymmetry.
7. Assessment of Skin Integrity:

 Inspect the skin of the extremities for any

lesions, ulcers, or discolorations.

 Note the presence of any scars, bruises, or

signs of trauma.
8. Assessment of Peripheral Edema:

 Palpate for pitting edema by

applying pressure to the skin over
bony prominences and observing
for the indentation to persist.

 Note the location, extent, and

pitting characteristics of any edema
present.
9. Documentation and Reporting:

 Document findings accurately,

including pulse quality, capillary
refill time, presence of venous
insufficiency, lymph node
assessment, and any abnormalities
observed during the examination.

 Provide a clear and concise report to

the healthcare team, highlighting any
significant findings that may require
further evaluation or intervention.
 A comprehensive physical assessment of the abdomen

1.Introduction and Explanation:

1.Inspection
 Introduce yourself to the patient and
explain the purpose of the examination.

2. A u s c u lt a tio n
 Ensure privacy and provide draping for
the patient's comfort.
3.Palpation
4 .P e r c u s s i o n
2. General Inspection:

 Begin by observing the patient's

overall demeanor and posture.

 Inspect the abdomen for any

visible distension, asymmetry, or
scars.

 Note the presence of any visible

pulsations, masses, or abnormal
movements.
3. Assessment of Skin:

 Inspect the skin of the abdomen for color,

texture, and any lesions or rashes.

 Note any signs of bruising, jaundice, or

striae (stretch marks).
 Hypoactive – Less than 5
gurgle/minute

Normoactive – 5 – 3-
gurgles/minute

Hyperactive – more than 30

gurgle/minute

Borborygmi – more than 30

4. Auscultation: gurgle/minute, high pitched,
tinkling, bell-like
 Use a stethoscope to auscultate bowel
sounds in all four quadrants of the
abdomen.

 Note the frequency, intensity, and

quality of bowel sounds.

 Listen for any abnormal sounds such

as hypoactive or hyperactive bowel
sounds, or the presence of bruits.
5. Palpation:

 Begin with light palpation of the abdomen using gentle,

circular motions.

 Assess for tenderness, guarding, or rigidity.

 Note any areas of localized tenderness or rebound

tenderness.

 Progress to deep palpation to assess for organ

enlargement, masses, or fluid accumulation.

 Palpate for the liver edge, spleen, and kidneys, noting

any enlargement or tenderness.
6. Liver and Spleen Assessment:

 Palpate for the liver edge using the

hooking technique, starting in the right
lower quadrant and moving upward.

 Palpate for the spleen by reaching under

the left costal margin and gently pressing
downward, asking the patient to take a
deep breath.

 Perform a liver span measurement by

percussing the liver dullness and noting
the upper and lower borders.
7. Kidney Assessment:

 Palpate for the kidneys by placing

one hand under the patient's back
and the other hand on the
abdomen, below the costal margin.

 Ask the patient to take a deep

breath and palpate for the kidneys
as they descend with inspiration.
8. Assessment of Hernias:

 Check for any abdominal hernias by

palpating along the inguinal canal,
femoral canal, and umbilicus.

 Note any bulges or areas of weakness.

9. Percussion
Assess the anterior gas-filled abdomen,
normally has a tympanitic sound, which is
replaced by dullness where solid viscera,
fluid, or stool predominate.

Percuss the flanks normally it is duller as

posterior solid structures predominate, and
the right upper quadrant is somewhat
duller over the liver.
Don’t FORGET
10. Documentation and Reporting:

 Document findings accurately, including

abdominal contour, skin condition, bowel
sounds, palpation findings, and any
abnormalities observed during the
examination.

 Provide a clear and concise report to the

healthcare team, highlighting any significant
findings that may require further evaluation
or intervention.
DAY 10