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.
a. Examples:
! Imbalanced Nutrition: Less than body requirements r/t decreased appetite
nausea.
! Disturbed Sleep Pattern r/t cough, fever and pain.
! Constipation r/t long term use of laxative.
! 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.
a. Examples:
! Possible nutritional deficit
! Possible low self-esteem r/t loss job
! Possible altered thought processes r/t unfamiliar surroundings
3. 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.
a. 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.
2. 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
1 Observe the face for shape.
2 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
▪
3 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.
a To examine the lacrimal gland, the examiner, lightly slide the pad of the index finger against the
client’s upper orbital rim.
b Inquire for any pain or tenderness.
3. Palpate for the nasolacrimal duct to check for obstruction.
a 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.
b 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.
▪ Symmetrical.
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:
1 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.
2 Gently grasp the upper eyelashes and pull gently downward. Do not pull the lashes outward or
upward; this, too, causes muscles contraction.
3 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.
4 Hold the lashes of the everted lid against the upper ridge of the bony orbit, just beneath the
eyebrow, never pushing against the eyebrow.
5 Examine the lid for swelling, infection, and presence of foreign objects.
6 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:
1 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.
2 The client covers the eye with opaque card, and the examiner covers the eye that is opposite to
the client covered eye.
3 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.
4 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.
5 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:
1 Stand directly in front of the client and hold a finger or a penlight about 1 ft from the client’s
eyes.
2 Instruct the client to follow the direction the object hold by the examiner by eye movements
only; that is with out moving the neck.
3 The nurse moves the object in a clockwise direction hexagonally.
4 Instruct the client to fix his gaze momentarily on the extreme position in each of the six cardinal
gazes.
5 The examiner should watch for any jerky movements of the eye (nystagmus).
6 Normally the client can hold the position and there should be no nystagmus.
Ears
1 Inspect the auricles of the ears for parallelism, size position, appearance and skin color.
2 Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles,
tenderness when manipulating the auricles and the mastoid process.
3 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
4 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:
1 Placement and symmetry.
2 Patency of nares (done by occluding nosetril one at a time, and noting for difficulty in breathing)
3 Flaring of alae nasi
4 Discharge
The external nares are palpated for:
1 Displacement of bone and cartilage.
2 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:
1 Position of the septum.
2 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).
3 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:
1 The client is asked to close his eyes and occlude.
2 The examiner places aromatic and easily distinguish nose. (E.g. coffee).
3 Ask the client to identify the odor.
4 Each side is tested separately, ideally with two different substances.
Mouth and Oropharynx Lips
Inspected for:
1 Symmetry and surface abnormalities.
2 Color
3 Edema
Normal Findings:
1 With visible margin
2 Symmetrical in appearance and movement
3 Pinkish in color
4 No edema
Temporomandibular
Palpate while the mouth is opened wide and then closed for:
1 Crepitous
2 Deviations
3 Tenderness
Normal Findings:
1 Moves smoothly no crepitous.
2 No deviations noted
3 No pain or tenderness on palpation and jaw movement.
Gums
Inspected for:
1 Color
2 Bleeding
3 Retraction of gums.
Normal Findings:
1 Pinkish in color
2 No gum bleeding
3 No receding gums
Teeth
Inspected for:
1 Number
2 Color
3 Dental carries
4 Dental fillings
5 Alignment and malocclusions (2 teeth in the space for 1, or overlapping teeth).
6 Tooth loss
7 Breath should also be assessed during the process.
Normal Findings:
1 28 for children and 32 for adults.
2 White to yellowish in color
3 With or without dental carries and/or dental fillings.
4 With or without malocclusions.
5 No halitosis.
Tongue
Palpated for:
1 Texture
Normal Findings:
1 Pinkish with white taste buds on the surface.
2 No lesions noted.
3 No varicosities on ventral surface.
4 Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the tongue.
5 Gag reflex is present.
6 Able to move the tongue freely and with strength.
7 Surface of the tongue is rough.
Uvula
Inspected for:
1 Position
2 Color
3 Cranial Nerve X (Vagus nerve) – Tested by asking the client to say “Ah” note that the uvula will
move upward and forward.
Normal Findings:
1 Positioned in the mid line.
2 Pinkish to red in color.
3 No swelling or lesion noted.
4 Moves upward and backwards when asked to say “ah”
Tonsils
Inspected for:
1 Inflammation
2 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:
1 The neck is straight.
2 No visible mass or lumps.
3 Symmetrical
4 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:
1 The trachea is palpable.
2 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:
1 Let the client sit on a chair while the examiner stands behind him.
2 In examining the isthmus of the thyroid, locate the cricoid cartilage and directly below that is
 the isthmus.
3 Ask the client to swallow while feeling for any enlargement of the thyroid isthmus.
4 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.
5 Ask the patient to swallow as the procedure is being done.
6 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.
7 Then the procedure is repeated on the other side.
Anterior approach:
1 The examiner stands in front of the client and with the palmar surface of the middle and index
fingers palpates below the cricoid cartilage.
2 Ask the client to swallow while palpation is being done.
3 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.
4 Again the examiner displaces the thyroid cartilage towards the side of the lobe to be examined.
5 Again, the examiner palpates the area and hooks thumb and fingers around the
sternocleidomastoid muscle.
Normal Findings:
1 Normally the thyroid is non palpable.
2 Isthmus maybe visible in a thin neck.
3 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:
1 Pulsation of the apical impulse maybe visible. (this can give us some indication of the cardiac
size).
2 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:
1 No, palpable pulsation over the aortic, pulmonic, and mitral valves.
2 Apical pulsation can be felt on palpation.
3 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:
1 Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral
2 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.
3 Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
4 Count heart rate at the apical pulse for one full minute.
Normal Findings:
1 S1 & S2 can be heard at all anatomic site.
2 No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4).
3 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.
1 The client is seated with her arms on her side.
2 The client is seated with her arms abducted over the head.
3 The client is seated and is pushing her hands into her hips, simultaneously eliciting contraction
of the pectoral muscles.
4 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:
1 The overlying the breast should be even.
2 May or may not be completely symmetrical at rest.
3 The areola is rounded or oval, with same color, (Color va,ies form light pink to dark brown
depending on race).
4 Nipples are rounded, everted, same size and equal in color.
5 No “orange peel” skin is noted which is present in edema.
6 The veins maybe visible but not engorge and prominent.
7 No obvious mass noted.
8 Not fixated and moves bilaterally when hands are abducted over the head, or is learning
forward.
9 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:
1 Divide the abdomen in four quadrants.
2 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.
3 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.
4 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:
1 Presence of food in the GI tract.
2 State of digestion.
3 Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus, peritonitis).
4 Bowel surgery
5 Constipation or Diarrhea.
6 Electrolyte imbalances.
7 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.
1 The area is strucked lightly with a fisted right hand.
2 Normally tenderness should not be elicited by this method.
3 Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.
Renal Percussion
1 Can be done by either indirect or direct method.
2 Percussion is done over the costovertebral junction.
3 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:
1 The examiner’s hands are too cold or are pressed to vigorously or deep into the abdomen.
2 The client is ticklish or guards involuntarily.
3 Presence of subjacent pathologic condition.
Normal Findings:
1 No tenderness noted.
2 With smooth and consistent tension.
3 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.
1 Ask the patient to take 3 normal breaths.
2 Then ask the client to breath deeply and hold. This would push the liver down to facilitate
palpation.
3 Press hand deeply over the RUQ
The second methods:
1 The examiner’s left hand is placed beneath the client at the level of the right 11th and 12th ribs.
2 Place the examiner’s right hands parallel to the costal margin or the RUQ.
3 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.
4 Ask the client to breath deeply.
5 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
1 Observe for size, contour, bilateral symmetry, and involuntary movement.
2 Look for gross deformities, edema, presence of trauma such as ecchymosis or other
discoloration.
3 Always compare both extremities.
Palpation
1 Feel for evenness of temperature. Normally it should be even for all the extremities.
2 Tonicity of muscle. (Can be measured by asking client to squeeze examiner’s fingers and noting
for equality of contraction).
3 Perform range of motion.
4 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
1 Includes all practices intended to confine a specific microorganism to a specific area
2 Limits the number, growth, and transmission of microorganisms
3 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
4 Using sterile technique for invasive procedures, when exposing open wounds or handling
dressings
5 Placing used disposable needles and syringes in puncture-resistant containers for disposal
6 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
c Diagnostic or therapeutic procedures
Iatrogenic infections
d Compromised host
e Insufficient hand hygiene


References:

Fundamentals of Nursing by Kozier
Fundamentals of Nursing by Potter and Perry