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P1 HA LEC AND LAB Reviewer

Health Assessment (Southwestern University PHINMA)

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HEALTH ASSESSMENT LEC AND LAB PRELIMS REVIEWER

MOD1 - INTRODUCTION TO HEALTH ASSESSMENT

HEALTH- is the relative state in w/c a person strives to meet their potential and includes the areas of wellness with the
ultimate goal of improving health.
- A state of complete physical, mental, and social well-being and not merely the absence of disease or in rmity
(WHO)

7 FACETS OF HEALTH:
1) Physical Health - how the body works and adapts
2) Emotional Health- positive outlook and emotions
3) Social well-being- supportive relationships w/ family and friends
4) Cultural In uences- favorable connections
5) Spiritual In uences- living peacefully, morally, and ethically
6) Environmental In uences- favorable conditions
7) Developmental Level - how one thinks, solves problems, and makes decisions

8 DIMENSIONS OF HEALTH AND WELLNESS

1) Physical - physiological
2) Environmental- patient’s surroundings
3) Spiritual- a sense of values and beliefs
4) Social- a sense of inclusiveness and connection
5) Intellectual- ability to advance knowledge
6) Emotional- ability to handle life and its challenges
7) Financial- nances
8) Occupational- the work milieu (type of job, relationship w/ co-workers, stress)

NURSING PROCESS
ASSESSMENT- rst step; the subjective and objective data gathered during the initial health history and physical
exam. It serves as baseline data and is done repeatedly during every patient encounter.
DIAGNOSIS- has a nursing focus and is based on real or potential health problems or human responses to health
problems. Use clinical reasoning to formulate diagnoses based on data gathered and the patient’s problem list.
- Based on NANDA (North American Nursing Diagnosis Association)
PLANNING- devising the best course of action to address the diagnoses. Nurse and patient select goals for each
problem in order to alleviate, decrease, or prevent those problems.
- TYPES: initial planning, ongoing planning, discharge planning
IMPLEMENTATION- interventions done by either the patient, the family, or members of the healthcare team
EVALUATION- continuing process to determine if the goals have been attained. Goals are classi ed into met,
unmet, or partially met.
- TYPES: ongoing, intermittent, terminal/summative (after discharge)

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NURSING HEALTH ASSESSMENT- a comprehensive health history and a complete physical examination, w/c are
used to evaluate the health status of a person
- First part is the HEALTH HISTORY, second is the PHYSICAL EXAMINATION (cephalocaudal)
- It involves a systematic data gathering that provides pertinent information

ASSESSMENT- Systematic and continuous collection, organization, validation, and documentation of information.
- Nurse and patient identify needs and concerns together
-
CLINICAL REASONING PROCESS- used to analyze patient data and develop hypotheses as to the patient’s
problem/s.
- Record assessment ndings and and the plan of care in the patient record to commumicate the patient’s
story and the nurse’s clinical reasoning and plan to other healthacre team members.

STEPS IN CLINICAL REASONING

1) IDENTIFY ABNORMAL/ POSITIVE FINDINGS
2) CLUSTER FINDINGS
3) INTERPRET FINDINGS
4) MAKE HYPOTHESES ABOUT THE NATURE OF THE PATIENT’S PROBLEM
5) TEST HYPOTHESES AND ESTABLISH A WORKING DIAGNOSIS
6) DEVELOP A PLAN

ROLE OF THE NURSE IN HEALTH ASSESSMENT- use ndings to decide which areas the patient is in need of most
care and which levels of prevention are necessary

TYPES OF HEALTH ASSESSMENT:

1) INITIAL COMPREHENSIVE- in-depth assessment of the patient’s health status, physical examination,
risk factors, psychological and social aspects of the patient’s health.
- Usually takes place on admission or transfer of a hospital or healthcare agency
2) ONGOING- TIME LAPSED / PARTIAL ASSESSMENT- continuous assessment accompanied by
monitoring and observation of speci c problems identi ed in a mini, initial assessment or focused
assessment
3) FOCUSED/ PROBLEM-ORIENTED ASSESSMENT- focused on a condition, problem, identi ed risks or
assessment of care.
- Ex: continence assessment, nutritional assessment, neurological assessment, assessment for daycare,
outpatient consultation
4) EMERGENCY/ MINI ASSESSMENT- snapshot view of the patient based on a quick visual and physical
assessment. Consider ABC (airway, breathing, circulation)

TYPES OF DATA

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SUBJECTIVE - verbalized/ described by the patient. COVERT DATA

- Ex: dizziness, pain, fear, nervousness, anxiety, nausea, pain scale
OBJECTIVE- can be observed and measured.
- Ex: pallor, cyanosis, diaphoresis, BP, RR, PR, temperature, skin discoloration, lab results, etc.

METHODS OF DATA COLLECTION

INTERVIEW- planned, purposeful conversation. Data gathering for health history

- admission of the patient to a healthcare facility
- Asking the patient
OBSERVATION- use of senses, use of units of measure (mmHg, degrees C), interpretation of laboratory results.

EVALUATING CLINICAL FINDINGS

RELIABILITY: how well repeated measurements of the same phenomenon will give the same result (consistent data).
May be measured for 1 or more than 1 observer.
- Aka PRECISION
VALIDITY: how closely a given observation agrees with the true state of a airs. The best possible measure of reality.
SENSITIVITY: the observation or test is negative in people WITH THE DISEASE(+), the result is false negative.
SPECIFICITY: the observation or test is positive in people W/OUT THE DISEASE(-), the result is false positive.

MOD 2: STEPS OF HEALTH ASSESSMENT, INTERVIEWING AND COMMUNICATION, THE ADULT

HEALTH HISTORY

HEALTH HISTORY INTERVIEW

Primary Goal: to improve the well-being of the patient
Purpose:
1) establish a trusting and supportive relationship
2) gather information
3) o er information

HEALTH HISTORY FORMAT: structured framework for organizing patient information is written, electronic, and
verbal form to communicate e ectively w/ other healthcare team members.
- Organizedinto 3 categories: PAST, PRESENT, FAMILY HISTORY
*the interview process is uid and demands e ective communication and relational skills

MOTIVATIONAL INTERVIEWING: evidence-based method of therapeutic communication that enhances the

nurse-patient relationship and the patient’s understanding of health needs.
- OARS: Open-ended questions, A rmation, Re ective listening, Summarize and teach back.

PHASES OF THE INTERVIEW (PIWT)

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1) PRE-INTERVIEW: set the stage

- Take time for self re ection(continual part of professional development- brings a deepening personal
awareness to our work w/ patients)
- Review patient record
- Set interview goals
- Review own clinical behavior and appearance
2) INTRODUCTION: put the patient at ease
- Greet the patient and establish RAPPORT
- Establish agenda for the interview.
3) WORKING: obtain patient information
- Invite the patient’s story
- Identify and respond to emotional cues
- Expand and clarify the story
- Generate and test diagnostic hypotheses (inverted triangle: start w/ open ended questions to speci c
Qs like OLDCART to yes or no Qs)
- Negotiate a plan
4) TERMINATION: summarize important information and discuss plan of care

THERAPEUTIC COMMUNICATION TECHNIQUES:

1) Active listening
2) Guided questioning
- Open-ended questions to focused questions
- Graded response Qs (pain scale)
- Asking questions one at a time
- Multiple choices for answers
- Clarifying patient’s meaning
- Encouraging w/ continuers
- re ection
3) Non-verbal communication
4) Empathic responses
5) Validation
6) Reassurance
7) Summarization
8) Transitions
9) Empowering the patient

TYPES OF PATIENTS:

SILENT PATIENT- silence may mean collecting CONFUSING PATIENT- patient presents w/
thoughts, remembering details, trust issues, or part of multiple arrays of symptoms. focus on the meaning or

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their culture. Nurse should be attentive and give brief the function of the symptoms, guide the interview
encouragement to continue when appropriate. into a psychosocial assessment.

W/ ALTERED CAPACITY- obtain their consent TALKATIVE PATIENT- give free rein on the rst
before talking to others about their health, nd a 5-10 mins, note patient’s culture, focus on what seems
surrogate informant or decision maker. important for the patient, set limits when needed,
show interest, be courteous, do not show impatience,
sched another session w/ time limit.

CRYING PATIENT- quiet acceptance, o er tissues W/ IMPAIRED HEARING- eliminate background

and wait for them to recover, be supportive of their noise, face them directly in good light(for lip readers),
feelings speak clearly at a normal volume, use facial expressions
and gestures, have patients repeat information back

ANGRY/DISRUPTIVE PATIENT- acknowledge W/ IMPAIRED VISION- introduce yourself when

and accept their anger, try to make amends, do not get entering the room, shake hands and establish contact
angry in return, when rapport is established, move to a (for blind), encourage wearing of glasses or contact
private area, alert security before approaching when lens(for poor vision), use words.
patient is overly disruptive

DYING PATIENT- give them opportunities to talk, W/ COGNITIVE DISABILITIES- pay attention to
listen, understand patient’s wishes, some have DNRs school records and ability to function independently,
assess sexual history, if unsure make a smooth
transition to MSE, alternative or augmentative
communication(AAC)

W/ LOW LITERACY- assess patient’s ability to read W/ PERSONAL PROBLEMS- let the patient talk
and write by asking them to write down their name through the problem
and other personal info. Respond sensitively, ask the
patient to read instructions

LGBTQIA PATIENTS- provide a non-judgemental environment, emphasize that providing care knows no
discrimination, and ask their preferred name and pronouns
INTERVIEW ACROSS A LANGAUGE BARRIER- INTERPRET
I- introduction P- patient focus
N- note goals R- retain control
T- transparency E- explain
E- ethics T- Thank the interpreter
R- respect beliefs

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SEXUALITY IN THE NURSE-PATIENT RELATIONSHIP: unethical & illegal, calmly but rmly make it clear that
your relationship is professional. If unwelcome overtures continue, leave the room and nd a chaperone before
continuing.

ETHICS OF INTERVIEWING:
ETHICS- a set of principles that de nes right from wrong. Medical ethics guide professional behavior
CONFIDENTIALITY- info may only be shared w/ appropriate healthcare team members

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THE COMPREHENSIVE HEALTH HISTORY
1) BIOGRAPHIC DATA: name, address, contact details, age & birthdate, sex, marital status, race, ethnic
origin, occupation, language & communication needs.

2) CHIEF COMPLAINT- reason for seeking care, make every attempt to quote the patient’s words

3) HISTORY OF PRESENT ILLNESS (HPI) or PRESENT HEALTH: for ill patients, this is the
CHRONOLOGICAL order of the reason for seeking care, from the time the symptom rst began until
now.
- 7 attributes: OLDCART- onset, location, duration, characteristic symptoms, associated
manifestations, relieving factors, treatment
- Self-treatment by patient or family
- Past occurrences of the symptom
- Pertinent positives and/or negatives from the ROS
- Risk factors
- For pain: OPQRST- onset, provoking factors, quality, region/radiating, severity, timing
*PEDIA: statement about usual health of the child
Pain in children: pulling at ears, fussiness, curls up knees over abdomen
E ects of pain: refuses feeding, stops playing, refuses to go to school, stays in bed most of the time.

4) PAST HISTORY:
- allergies(drugs, food, & contact agents),
- childhood illnesses, adult illnesses (medical, surgical, accidents, psychiatric),
- serious/chronic diseases, hospitalizations,
- operations,
- obstetric history,
- immunization, screening tests, safety measures,
- risk factors(smoking, drinking)
- last examination date
*OB PEDIA: prenatal status, labor & delivery, postnatal status
DEVELOPMENTAL HISTORY of PEDIATRICS:
- Growth: height and weight at 1, 2, 5, and 10 years old

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- Milestone: motor development, language, toilet training

- Current development: gross & ne motor skills, language skills, personal-social skills, toilet-training skills
- Nutritional history: breast feeding or bottle feeding, appetite to eat, 24 hour diet recall, vitamins, etc.
- Family history: learning disabilities, birth defects, psychiatric illness, seizure disorders, allergies, blood
dyscrasias, DM, PTB, retardations

5) CURRENT MEDICATIONS/ MEDICATION RECONCILIATION: all OTC, vitamins, medicine

borrowed from others, home remedies, oral contraceptives, mineral or herbal supplements. Ask dosage,
frequency of intake, and route of administration.

6) FAMILY HISTORY: grandparents, parents, siblings, children, and grandchildren. Ask age and health OR
age and cause of death. Outline or diagram on a GENOGRAM.

7) REVIEW OF SYSTEMS (ROS): Cephalocaudal. Prepare the patient for the questions to come.
- General overall: weight, fatigue, dizziness
- Skin: lesions, discoloration, temperature, rashes, etc.
- Head, eyes, ears, neck, throat (HEENT): dry eyes, diplopia, sore throat, ear infections, etc.
- Neck:
- Breast: tenderness, lumps
- Respiratory: shortness of breath, trouble breathings, cough, etc.
- Cardiovascular: chest pains
- Gastrointestinal: bowel movements, abdominal pain
- Peripheral vascular
- Urinary: UTIs, burning sensation during peeing,
- Reproductive: electile dysfunction, abnormal discharges
- Muscuskeletal: ROM
- Psychiatric
- Neurologic
- Hematologic
- Endocrine
8) HEALTH PATTERNS: self-concept, value-belief, activity-exercise, sleep-rest, nutrition, role-relationship,
coping-stress tolerance

9) SEXUAL HISTORY: make no assumptions, determine risk for STIs and pregnancy, be matter-of-fact in
questioning, use speci c langauge

10) MENTAL HEALTH HISTORY:if they seem depressed, ask about suicidal thoughts, ask use of
psychotropic medications, be aware of cultural constructs, ask how they want to kill themselves, not why.

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11) FAMILY VIOLENCE: look for unexplained injuries, inconsistent background stories of the injury, injuries
causing embarrassment, alcoholic or drug user guardian/partner, partner dominating the interview, delayed
treatment for trauma
- If abuse is suspected, spend part of the interview alone with the patient.
- Ask parents how they cope with crying or misbehaving babies
- Do not force the situation

HEALTH HISTORY FOR PREGNANT CLIENTS:

1) AGE: adolescents <19 y.o. Have higher risk of the :
- Anemia - pregnancy induced hypertension(PIH)
- Preterm labor(PTL) - dystocia (prolonged, di cult and painful labor)
- Small for gestational age infants - intrauterine growth retardation (IUGR)
- Cephalopelvic disproportion(CPD)
2) FAMILY HISTORY:
- Maternal and paternal history
- Congenital disorders, hereditary diseases, multiple pregnancies, DM, heart diseases, hypertension,
mental retardation, renal diseases, use of Diethylstilbestrol(DES- synthetic estrogen used to prevent
miscarriage, but can cause abortion and ectopic pregnancy)
3) WOMAN’S MEDICAL HISTORY:
- Childhood diseases: rubella, chickenpox
- Major illnesses, surgery, blood transfusion
- Allergies
- STIs
- Mestrual history (LMP and EDD)
- Use of medications
- PTB, hepatitis, and HIV history
- Oral and other forms of contraceptives
- Endocrine disorders, anemia, hypertension
4) WOMAN’S PRESENT OBSTETRIC HISTORY:

GRAVIDITY # of pregnancies regardless of PARITY #of pregnancies that reached viability (24
outcome or more weeks)

NULLIGRAVIDA Never been pregnant NULLIPARA Never completed a pregnancy to viability

PRIMIGRAVIDA First pregnancy PRIMIPARA Completed 1 pregnancy to viability

MULTIGRAVIDA Been pregnant more than once MULTIPAR Completed multiple pregnancies to stage
A of viability

GTPALM OBSTETRIC HISTORY

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GRAVIDA # of pregnancies

TERM Full term deliveries (37 or more weeks)

PRETERM deliveries 20 to <37 weeks

ABORTION Elective or spontaneous loss of pregnancy before the age of viability (less than 20 weeks)

LIVING CHILDREN A woman has delivered regardless of whether they were live births or still births

MULTIPLE GESTATION & # of times a mom delivered multiple neonates(not the number of neonates).
BIRTH Times carrying more than 1 fetus.

EXPECTED DATE OF CONFINEMENT/ DELIVERY (EDD)

*use the last menstrual period(LMP- day of last menstrual period)
January to March: +9+7+0
April to December: -3+7+1

MOD 4: FUNCTIONAL ASSESSMENT TESTS

CAGE Screening test: to identify excessive or uncontrolled drinking
C- Cut down (have you ever thought that you should cut down your drinking?)
A- Annoyed (have you ever been annoyed by criticism of your drinking?)
G- Guilt (have you ever felt guilty about drinking?)
E- Eye Opener (do you drink in the morning?)
*yes to 2 or more questions = suspect alcohol abuse
*NO to drinking alcohol, ask the reason why (psychological, health, religion, legal)

APGAR: for newborns. Developed by Dr. Virginia Apgar to ascertain e ects of obstetric anaethesia on newborns
- Done @ 1, 5, and 10(w/ complications) minutes
- 7-10 normal; 4-6 some resuscitative measures; 3 below immediate resuscitation

0 1 2
Activity limp/ no movement Some exion of arms and legs Active, spontaneous motion

Pulse No heart rate <100 bpm At least 100 bpm

Grimace No response to airway suctioning Grimaces, no cry during suctioning Grimaces and pulls away,
cough or sneeze during
suctioning

Appearance cyanosis acrocyanosis Pink all over

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Respiration Not breathing Slow, irregular breathing, weak cry Strong cry, normal rate &
e ort

DENVER II DEVELOPMENTAL SCREENING TEST: screens youch children from birth to 6 years
- Not an intelligence test, but shows what a child can do at a particular stage
- Not a predictor of later development
- May determine relative areas of of advancement and/or delay in the development of children
- 125 tasks, 4 major areas: personal-social, ne motor-adaptive, language, gross motor

P- Pass Successfully accomplishes the task

F- Failed Did not successfully complete the task

NO- No Opportunity Not given the opportunity to perform the task

R- Refusal Refused to perform/ complete the task

Interpretation of DDST results:
- Advanced: passed an item completely to the right of age line
- Evaluate failed and refused items to determine number of cautions and /or delayed items
- Normal: no delays and maximum of 1 caution
- Suspect: 2 or more cautions and/or more delays
- Sched follow ups: repeat the test and/or follow up with appropriate health care provider

KATZ INDEX / KATS ADLs: assess patient’s ability to perform activities of daily living independently
- 6 funtions:
-Bathing - Dressing
- Toileting - Feeding
- Transferring - Continence
- score of 6 = full function; 4= moderate impairment; 2= severe functional impairment
- does not assess more advanced ADLs

BARTHEL ACTIVITIES OF DAILY LIVING INDEX: measure a person’s daily functioning specially the ADLs and
mobility
- 10 functions:
- Toilet use - Bowels
- Feeding - Transfers (bed to chair)
- Dressing - Mobility (on level surfaces)
- Grooming - Stairs
-Bladder control -Bathing
- Independence means that they do not need any assistance

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- Record what patient does, not what they could do

- Need for supervision renders the patient not independent
- Middle categories= patient does 50% of the e ort
- Use of aids to be independent is allowed

PHYSICAL EXAMINATION, EQUIPMENT, AND VITAL SIGNS

PREPARING FOR THE PHYSICAL EXAMINATION:

1) REFLECT ON YOUR APPROACH
- Identify yourself
- Try to appear calm, organized, and competent
- Avoid interpreting your ndings
2) ADJUST LIGHTING AND ENVIRONMENT
- Set the stage
- Quiet environment w/ good lighting
- TANGENTIAL LIGHTING: using penlight at a low angle and to one side of the area to be
inspected. Optimal for inspecting the jugular venous pulse, thyroid gland, and apical impulse on the
heart
- Examination table at a level high enough to prevent stooping, head raised 45 degrees
3) MAKE THE PATIENT COMFORTABLE
- Show concern for privacy and modesty
- Make sure that instructions for the patient during the exam are clear
- Use drapes, close doors and curtains
- Tell patient general impressions and what to expect next
- DRAPING goal: to visualize one area at a time
4) CHECK EQUIPMENT
- Protective barriers: gloves, gown, aprons, masks, and protective eyewear
- UNIVERSAL PRECAUTIONS: designed to prevent transmission of HIV, Hepatitis B, and other
blood-borne pathogens
- STANDARD AND MRSA PRECAUTIONS: based on the principle that all body uids,
secretions, and excretions except sweat, non-intact skin, and mucous membranes may contain
transmissible infectious agents. Includes hand hygiene and use of PPEs.
5) CHOOSE SEQUENCE OF EXAMINATION: avoid too many movements for the patient. Maximize
patient comfort. Plan your exam in a way that minimizes asking the patient to move. Stay on the right side of
the table and move to the other side only when necessary. Left-handed nurses are encouraged to practice and
develop use of their right hand dominantly during the physical examination.

CARDINAL TECHNIQUES OF EXAMINATION

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INSPECTION Use eyes. Close observation of the details of patient’s appearance, behavior, and movement.

PALPATION Tactile pressure from the palmar nger or nger pads to assess areas of skin elevation, depression,
temperature, and tenderness. Assess lymph nodes, pulses, contours, size of organs and masses, and joints

PERCUSSION Use of the striking or plexor nger, usually the third, to deliver a rapid tap or blow against the distal
pleximeter of the third nger of the left hand. (search mo sa yt)

AUSCULTATION Use of the diaphragm or bell of the stethoscope to detect characteristics of heart, lung, and bowel
sounds

IPaPeA- general sequence of examination

IAPePa- sequence of examination for the ABDOMEN. palpation is done last to prevent aggravation of the bowel sounds.
Proceed as follows: RLQ-RUQ-LUQ-LLQ
* avoid abdominal palpation in patients with liver tumor, and kidney tumors

*if ophthalmoscope is done, darken the room for better visualization and illumination
*female patient must be examined by a female nurse. If examined by a male nurse, a female nurse must be in attendance.

THE GENERAL SURVEY: enable the nurse to select appropriate subjective questions
- Done BEFORE the physical examination
- General appearance
Apparent state of health Odours of the body and breath
Level of consciousness Skin color and obvious lesions
Facial expression Dress, grooming, and personal hygiene
Posture, gait, motor activity and speech Signs of distress

VITAL SIGNS: aka CARDINAL SIGNS

- Temperature, pulse, respiration, blood pressure, pain
- Provides clues to the physiological functioning of the body
- Routinely done
- Measured when: at home, screenings, upon admission, when certain meds are given, before and after
diagnostic and surgical procedures, before and after certain nursing procedures, emergency situations.
Purpose of Taking VS:
- To observe the general condition of the patient
- Serve as a guide in meeting the needs of the patient
- To aid the physician in making his diagnosis and planning patient care
General Considerations:
- Patient is rested and comfortable in their position
- Inform physician or head nurse for any changes in the VS

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- Explain procedure to the patient

- Frequency of taking TPR depends on the patient’s condition and policy of the agency

BODY TEMPERATURE
- Regulated by the Hypothalamus
Kinds of Body Temp.
1) Core Body Temperature: temperature of the deep tissues. Ex: rectum and tympanic membrane
2) Surface Body Temperature: temp of the skin, the subcutaneous tissue, and fat. Ex: oral and axillary sites

Factors that a ect body’s heat production:

- Age: infants(underdeveloped hypothalamus) and elderly(deteriorating control mechanisms) are sensitive to
temperature extremes
- Infection: fever is the rst sign of infection, in ammation also increases heat
- Temperature of Environment: due to convection
- Amount of Exercise: muscle activity increases metabolism which also increases body temperature(increase in
heat production)
- Metabolism: basal metabolic rate(rate of energy utilization in the body; required to maintain essential
activities)
- Emotional status: physical and emotional stress increases body temperature
- Circadian rhythm: diurnal variations(lowest bet. 1-4 AM, rises steadily until 6 PM, then declines to early
morning levels)
- Hormone level: rise in body temperature following ovulation (0.4-1.0 degrees). Progesterone causes
temperature shift

Processes that involve HEAT LOSS & GAIN

1) Radiation- without direct contact; through waves
2) Evaporation
3) Conduction- with direct contact
4) Convection- by air movement

ABNORMALITIES OF BODY TEMP

1) Hyperthermia/ Pyrexia: elevation of body temp
- High fever= 39-41 C / 103-106 F
- Moderate fever= 38-39 C / 101-103 F
- Slightly febrile= 37-38 C / 99-101 F
- Continuous or constant: steady high temperature (up)
- Intermittent fever: very wide ranges between uctuations (up & down)
- Remittent fever: moderate ranger between highest and lowest points (slight up & down)
- Recurrent or relapsing fever: normal to subnormal; 1-2 days(mawawala then bigla tumataas)
2) Hypothermia: abnormally low temperature

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3) Heat stroke: prolonged exposure to the sun or high environmental temps can overwhelm the body’s heat loss
mechanism
4) Heat exhaustion: profuse diaphoresis results in excessive water and electrolyte loss. Signs and symptoms of
uid volume de cit are common
5) Frostbite: exposed to subnormal temperatures; ice crystals form inside cells= permanent circulatory and
tissue damage. Ear lobes, tips of nose, ngers, and toes

METHODS OF MEASURING TEMPERATURE

1) Axillary: easy, non-invasive, but have to stay steady and time consuming
2) Mouth: easy, rich in blood supply, and comfy for patient. Painful when mouth has lesions, not allowed for
patients with seizures, and not recommended for unconscious and confused patients
3) Rectum: type of core temperature. Needs lubricant, can traumatize infants, need to be side-lying
4) Tympanic: easy, core temperature(near external carotid artery). Cannot be done if ears are lled with ear wax
or infected
5) Temporal artery: safe, non-invasive, and electronic. Equipment is expensive or unavailable, and sweat can
alter reading

TYPES OF THERMOMETERS
a) Glass thermometers: contains mercury, no longer used because of hazards of mercury spill
b) Electronic thermometers: available for oral and rectal use. Thermistor: contain stainless probe to sense temp
c) Tympanic thermometer: electronic- makes use of infrared technology(re ectance)
d) Chemical dot thermometer: disposable, at this plastic with dots that change color. Inexpensive,
unbreakable, suitable for isolation rooms
e) Infrared thermometer: uses blackbody radiation, sometimes called laser thermometers

PULSE: index of heart rate and rhythm, the palpable bounding of blood ow at various points of the body. Can be palpated
or auscultated
● Circulation: means by w/c cells receive nutrients and remove waste products
● Characteristics of pulse: rate, rhythm, quality (amplitude)
● Heart normally pumps 5 liters of blood each minute
● Pulse rates: beats per minute
● Amplitude: quality or fullness of the pulse.
● Pulse rhythm: pattern of the pulsations and the pauses between them
Factors a ecting pulse rate:
- Changes in body temperature - hemorrhage -emotions (stress increases)
- Exercise -heart disease
- Medications - age/ position
● Assessment of pulse is done by palpating peripheral arteries, by using a Doppler ultrasound, or by
auscultating the apical pulse with a stethoscope

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PERIPHERAL PULSES APICAL PULSE

- Located away from the heart and arteries are close to - listen over the apex of the heart: left side of chest, 5th
the surface intercostal space just inside the midclavicular line
- Use tips of index and middle nger to palpate - Use diaphragm of stethoscope and wrist watch w/ seconds
- Temporal, carotid, brachial, radial, femoral, hand
popliteal, dorsalis pedis, posterior tibial - Measure for a full minute
- Easiest to assess in SUPINE position - Apical- radial pulses: assessed when patient have
- Pedal pulses: dorsalis pedis and posterior tibial (assess cardiovascular disorder. 2 people count radial and apical
circulation of the foot) pulse simultaneously and records

ABNORMALITIES OF THE PULSE:

1) Bradycardia: <60 in adults, <70 in children. Caused by decreased thyroid activity, hyperkalemia, and
increased intracranial pressure. (B for Baba= mababang pulse)
2) Tachycardia: >100, but <120 bpm in adults, >140 bpm in children. Caused by stressful conditions,
hypoxia, exercise, fever. (T for Taas= mataas na pulse)
3) Low Tension Pulse: weak pulse. The result of decreased tone of the muscular walls of the arteries and feels
soft to touch and also the destruction and dilation of the arteries.
4) Dicrotic Pulse: a sign of low tension. Feels like a second weak beat, not counted - 2 marked expansions to one
beat
5) Intermittent pulse: there is a missing beat. Intermission of pulsation of regular or irregular intervals
6) Water Hammer or Corrigan’s Pulse: quick powerful beat which suddenly collapses
7) Arrhythmia: absence of rhythm
8) Thready pulse: very ne and scarcely perceptible
9) Dysrhythmia: irregular pulse/ rhythm
10) Running pulse: >120 bpm in adults
11) Infrequent pulse: abnormally slow. Slower than bradycardia

APPROXIMATION OF PULSE RATE BY AGE

Neonate 80-180 1y/o 80-140 5-8y/o 75-120 10y/o 50-90 Teen 50-90 Adults 60-100 Older adult 60-100

RESPIRATORY RATE
- Medulla Oblongata: regulates respiration along with pons
ABNORMALITIES IN RATE AND RHYTHM OF BREATHING
● Eupnea: normal
● Apnea- the absence of breathing or temporary cessation
● Dyspnea- labored or di cult breathing
● Orthopnea- severe dyspnea and the patient can only breath when in sitting position

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● Polypnea- rapid and panting respirations

● Tachypnea- rapid, shallow breathing. >20 breaths per minute. Caused by restrictive lung disease, pleuritic
chest pain, and elevated diaphragm
● Bradypnea- slow breathing, <10 breaths per minute. Caused by diabetic coma, drug-induced respiratory
depression, increased intracranial pressure
● Edematous respiration- characterized by loud, moist, rattling rales. accompanied by dyspnea and cyanosis
● Accelerated respiration- >25 breaths per minute
● Stridulous breathing/ wheezing: noticeable behind the sternum or localized on one side of the chest base. Ex:
stenosis of the bronchi in cavernous tuberculosis
● Hyperpnea / hyperventilation: rapid deep breathing. Caused by anxiety, exercise, metabolic acidosis,
infarction, hypoxia, hypoglycemia
● Hypoventilation : shallow and slow or irregular respirations
● Cheyne-stokes : periods of apnea appear throughout the cycle. Deep and fast -> slow rate -> apnea lasting up
to 60 seconds
● Kussmaul’s breathing: aka air hunger. Di cult breathing that occurs in paroxysms(sudden attack). Precedes
diabetic coma
● Biots : periods of normal breathing (3-4 breaths) to a varying period of apnea (10-60 seconds)

BREATH SOUNDS
1) Stertorous: snoring sound (by secretion in trachea and large bronchi)
2) Stridor: noisy respiration (forced air thru obstructed airway)
3) Wheeze: high ptich (partial obstructions in the smaller bronchi and bronchioles during expiration)
4) Sigh: deep inspiration follow by prolonged expiration
5) Rales: crackles (vibration of uid in the lungs)
6) Ronchi: coarse sound (partial obstruction of airway)

BLOOD PRESSURE
*force of blood against arterial walls
*measured in mmHg (milimiters of mercury)
* systolic - diastolic = pulse pressure
*pulse pressure = 30-40 mmHg normal
* 120/80 mmHg normal
*systolic/diastolic
*let patient rest for 30 mins if they smoked or ingested ca eine
*use appropriate size cu
*determine palpatory BP before auscultated BP
*read lower meniscus of the mercury level of the sphygnomanometer at eye level to prevent parallax
*korotko sounds
* cu too tight= false high
* cu too loose = false low
* in ate, palpate, pulse stop- add 30 then slowly release

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* aneroid manometer
systolic diastolic

normal <120 <80

Elevated 120-129 <80

Stage 1 Hypertension 130-139 80-89

Stage 2 Hypertension > or equal to 140 > or equal to 90

● Systolic BP: highest point of pressure on the arterial walls when VENTRICLES contract
- Pressure of the heart when it beats and pumps blood into arteries
- Results from contraction of the VENTRICLES
● Diastolic BP: lowest pressure present on arterial walls when the heart RESTS bet. Beats
- Between pulses
- Ventricles are at REST

FACTORS AFFECTING BP:

- Activity -Anxiety or strong emotion
- Intake of food(salty) - Disease process
- Pain - Fluid retention (swelling, bloat, edema)
- Drugs -Blood loss/ hemorrhage

PAIN ASSESSMENT: 5TH VITAL SIGN

- A sensation of physical or mental hurt or su ering that causes distress or agony
- It is whatever the patient says it is. It exists whenever the patient says it does.
- It is subjective in nature (only the one experiencing it may describe it)
- It is a protective because it provides a warning signal. It helps minimize injury and is often a protective injury
(prevention mechanism)
- Use OLDCART & OPQRSTU

THEORIES OF PAIN
1) Pattern Theory- pain is perceived whenever the stimulus is intense enough
2) Speci city Theory- there are speci c nerve receptors for particular stimuli
- Nociceptors: for noxious stimuli
- Thermoreceptors: heat or cold
- Mechanoreceptors: pressure, pulling, or tearing sensation
- Chemoreceptors: for chemicals
3) Gate Control Theory: there is a gate in the spinal cord called substantia gelatinosa. When the gate is open,
pain stimulus is transmitted = pain is perceived, and vice versa.
4) A ect Theory: pain is emotional. The intensity perceived depends on the value of the organ a ected to the
individual.

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5) Parallel Processing Theory: physiologic or neurologic deciphering of the pain sensation and the cognitive
emotional properties occur along di erent nerve bers

FACTORS INFLUENCING PAIN EXPERIENCES

- Age -sex - childhood
- Cultural background - psychological factors - previous experience
- Religious beliefs - expected response - setting
- Diagnosis - physical/mental health - knowledge/ understanding
*Pain Threshold: minimum amount of pain stimulation a person requires before feeling pain. Generally uniform
amongst people.
* Pain Tolerance: maximum amount and duration of pain that an individual is willing to tolerate/ endure. Varies
among people
*Pain Perception: the actual feeling of pain
*Bradykinin: the universal stimulus for pain
*Hyperalgesia: excessive sensitivity to pain

TYPES OF RESPONSES TO PAIN

1) Involuntary response
- Mediated by the ANS
- Mild to moderate pain- SNS
- Severe pain- PNS
2) Voluntary response
a) Behavioural responses: crying, moaning, grimacing, tossing in bel, fussiness in children, assuming
fetal position, splinting the painful area
b) Emotional responses: depression, withdrawal, and social isolation

CLASSIFICATION OF PAIN
1) : occurs over body surfaces or skin segment
2) : may be deep or super cial. Occurs in the skin, muscles or joints
3) : arises from stimulation of pain receptors in the abdominal cavity and the thorax
4) : pain is perceived at an area other than the site of injury
5) : resistant to any cure or relief
6) : actual pain felt in a body part that is no longer present. Ex: pain experienced after amputation
7) : felt at the source and extends to the surrounding tissues
8) : primarily due to emotional factors, with no physiologic basis
9) : pain that stops and starts again

PAIN ASSESSMENT TOOLS:

1) Ask bout location, duration, quality of pain, intensity, aggravating/ relieving factors.
- Location: provides info on the organ a ected
- Duration: acute(<6 mos) or chronic(>6 mos)

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- Character/ Quality: description. Ex: pricking, stabbing, dull throbbing

- Intensity / Severity: pain scale (1-3 mild, 4-6 moderate, 7-10 severe)
- Relieving / Aggravating factors: ex: chest pain in angina pectoris can be relieved by rest or
nitroglycerin
- E ects to ADLs
2) Pain Rating Scales: unidimensional and are intended to re ect pain intensity.
3) Infants and children: incapable of “self-report” on pain.
- 2yo: can report pain and point to its location, but cannot rate the pain.
- 4-5 yo: can be introduced to pain rating scales like the Wong-Baker faces
4) Wong-Baker Faces: uses images of faces that show, “how much hurt do you have now?”
5) McCa rey Initial Pain Assessment Tool: a form to be lled out that assesses for pain

MENTAL STATUS EXAMINATION (MSE): tool for assessing psychological dysfunction and identifying need for
concern. Assess level of consciousness, appearance, behavior, speech, mood, a ect, intellectual performance,
judgment, insight, perception, and thought content
*record time and date!!
1) Appearance: sex, age, race, ethnic background, body weight, posture, motor activity, dress and grooming,
hygiene.
2) Attitude toward the examiner: facial expression, interested, bored, hostile, friendly, etc
3) Mood
4) A ect: expansive(contagious), euthymic(normal), constricted(limited variation) , blunted(minimal
variation), at (no variation)
- “Inappropriate” when no clear connection is made between what the patient is saying and what
emotion is being expressed
5) Speech: quality, quantity, rate, and volume of speech
6) Thought Process:
- Looseness of association (irrelevance)
- Flight of ideas (change topics)
- Racing (rapid thoughts)
- Tangential (depart from the topic and no return)
- Circumstantial (beating around the bush)
- Word salad (nonsensical responses)
- Clanging (rhyming words)
- Punning (talking in riddles)
- Thought blocking (speech is halted)
- Poverty (limited content)
- Derailment (extreme irrelevance)
- Neologism (creating new words)
7) Thought Content: Hallucinations, Delusions, and others
- Command-type hallucinations, Auditory hallucinations, Visual hallucinations, Gustatory
hallucinations, Tactile hallucinations, Olfactory hallucinations

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Types of Delusions
- Grandiose
- Religious (special status with God)
- Persecution (someone wants to cause them harm)
- Erotomanic (someone famous is in love with them)
- Jealousy (everyone wants what they have)
- Thought insertion (someone is putting ideas ot thoughts into their mind)
- Ideas of reference (ordinary or commonplace phenomenon are referring speci cally to them)
● Obsession and compulsions
● Phobias = fear (-philia = love)
● Suicidal ideation or intent
● Homicidal ideation or intent
● Sensorium and cognition: perform the “Folstein Mini Mental State Examination”
● Language: spontaneous speech, repetitions
● Comprehension
● Consciousness: Glasgow Coma Scale (GCS 15 highest, GCS 3 Lowest –assesses verbal/speech, eye opening,
and motor)
- coma(unresponsivesness), stuporous (response to pain), lethargic (drowsiness), alert (full
awareness)
- Note stimulus required to arouse patient
● Orientation: name, place, date, time, situation
● Concentration and attention: academic abilities (adding, subtracting, spelling)
● Reading and writing: ask to write simple sentences
● Visuospatial ability: drawing, motor activity
● Memory
● Abstract thoughts: ask patient to determine similarities, understand proverbs
● General fund of knowledge
● Intelligence: estimate the intelligence quotient of the patient (IQ)

8) Insight: patient’s understanding of their condition, attitude towards the clinician

9) Judgement
10) Impulsivity: degree of patient’s impulse control
11) Reliability: reliable, unreliable, or di cult to determine

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