EPAPHRAS NURSING NLE REVIEW

Concepts
 Abstract ideas or mental images of phenomena or reality
 Often called the “building blocks” of THEORIES
 Examples: MASS, ENERGY, EGO and ID

Paradigm
 A pattern of shared understanding and assumptions about reality and
the world
 Include notions of reality that are largely unconscious or taken for granted
 Derived from CULTURAL BELIEFS
 Examples: TIME, SPACE

Metaparadigm
 Concepts that can be superimposed on other concepts
 Four major metaparadigms in nursing
 Person
 Environment
 Health
 Nursing
Theory
 Supposition or system of ideas proposed to explain a given phenomenon
 Attempt to explain relationships between concepts
 Offer ways to conceptualize central interests of a discipline
 Example: Freud’s theory of the Unconscious

Purposes of Nursing Theory

1. Link among nursing theory, education, research, and clinical practice
2. Contributes to knowledge development
3. May direct education, research, and Practice

Nursing

 As by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written

by Virginia Henderson: The unique function of the nurse is to assist the
individual, sick or well, in the performance of those activities contributing to
health. Its recovery, or to a peaceful death that the client would perform
unaided if he had the necessary strength, will or knowledge.
 Help the client gain independence as rapidly as possible.
 Conceptual and Theoretical Models of Nursing Practice

 
Theorist Description

 Developed the first theory of nursing. 14

CANNONS
 FLORENCE  Focused on changing and manipulating
NIGHTINGALE the environment in order to put the patient in the
best possible conditions for nature to act.

 Introduced the Interpersonal Model.

 She defined nursing as a therapeutic,
interpersonal process which strives to develop
 HILDEGARD a nurse-patient relationship in which the nurse
PEPLAU serves as a resource person, counselor and
surrogate.

  Defined nursing as having a problem-solving

 FAYE approach, with key nursing problems related to
ABDELLAH health needs of people; developed list 21 nursing
problem areas

  Developed the three elements – client behavior,

nurse reaction and nurse action – compose the
nursing situation. She observed that the nurse
 IDA JEAN provide direct assistance to meet an immediate
ORLANDO need for help in order to avoid or to alleviate
distress or helplessness.

  Described the Four Conservation Principles.

1.
1. Conservation of Energy
2. Conservation of Structured Integrity
 MYRA LEVINE 3. Conservation of Personal Integrity
4. Conservation of Social Integrity

  Developed the Behavioral System Model.

1.
1. Patient’s behavior as a system that is
a whole with interacting parts
2. how the client adapts to illness
 DOROTHY 3. Goal of nursing is to reduce so that the
JOHNSON client can move more easily through
recovery.
   Conceptualized the Science of Unitary Human
Beings. She asserted that human beings are
 MARTHA more than different from the sum of their parts;
ROGERS the distinctive properties of the whole are
significantly different from those of its parts.

 Emphasizes the CLIENT’S SELF CARE NEEDS;

 DOROTHEA nursing care becomes necessary when client is
OREM unable to fulfill biological, psychological,
developmental or social needs.

 IMOGENE  Nursing process is defined as

KING dynamic  interpersonal process  between nurse,
client and health care system.

 Stress reduction is a goal of system model of

 BETTY nursing practice. Nursing actions are in PRIMARY,
NEUMAN SECONDARY or TERTIARY LEVEL of
PREVENTION

  Presented the Adaptation Model. She viewed

each person as a unified bio-psychosocial
system in constant interaction with a changing
environment. The goal of nursing is to help the
 SISTER person adapt to changes in physiological needs,
CALLISTA ROY self-concept, role function and interdependent
relations during health and illness.

  Introduced the notion that nursing centers around

 LYDIA HALL three components: person (CORE), pathologic
state and treatment (CURE) and body(CARE).

 Conceptualized the Human Caring Model. She

emphasized that nursing is the application of the art
and human science through transpersonal caring
transactions to help persons achieve mind-body-
JEAN WATSON soul harmony, which generates self-knowledge,
self-control, self-care and self-healing.

 Introduced the  Theory of Human Becoming. She

emphasized free choice of personal meaning in
relating to value priorities, co-creating of rhythmical
ROSEMARIE patterns, in exchange with the environment and
RIZZO PARSE contranscending in many dimensions as
possibilities unfold.

 MADELEINE  Developed the  Transcultural Nursing Model. She

 advocated that nursing is a humanistic and scientific
mode of helping a client through specific cultural
LENINGER caring processes (cultural values, beliefs and
practices) to improve or maintain a health condition

HISTORY OF NURSING
Intuitive Nursing
 From Prehistoric times up to the early Christian Era
 Untaught and Instinctive
 Nursing performed out of COMPASSION
 Nursing belonged to WOMEN
Apprentice Nursing
 From the founding of the Religious orders in the 11th century up to 1836 with
the establishment of the Kaiserwerth Institute for training of Deaconesses
 Period of “on-the-job training”
 Nursing performed without any formal education and by people who
were directed by more experienced nurses
 Important personalities in this period:
 St. Clare-gave nursing care to the sick and the afflicted
 St. Elizabeth of Hungary- Patrones of nurses
 St. Catherine of Siena- First lady with a lamp
 Dark period of Nursing
 From the 17th century up to 19th century
 Nursing became the work of the least desirable of women

Educated Nursing
Began on June 15, 1860 when Florence Nightingale School of nursing
opened St. Thomas Hospital in London
 Development of nursing was strongly influenced by trends resulting from
wars, from an arousal of social consciousness, from the increased
educational opportunities offered to women
Contemporary Nursing
 Covers the period after the world war II to the present
 Marked by scientific and technological developments as well as social
changes
 Nursing as a profession
Profession

 Is a calling that requires special knowledge, skill and preparation.

 An occupation that requires advanced knowledge and skills and that it grows
out of society’s needs for special services.
Professional Nursing
 Is an art and a science, dominated by an ideal of service in which certain
principles are applied in the skillful care of the well and the ill, and through
relationship with the client/ patient, significant others, and other members of
the health team.
Criteria of Profession
1. To provide a needed service to the society.
2. To advance knowledge in its field.
3. To protect its members and make it possible to practice effectively.
Characteristics of a Profession

1. Education. A profession requires an extended education of its members, as

well as basic liberal foundation.
2. Theory. A profession has a theoretical body of knowledge leading to defined
skills, abilities and norms.
3. Service. A profession provides basic service.
4. Autonomy. Members of a profession have autonomy in decision making and
in practice.
5. Code of Ethics. The profession as a whole has a code of ethics for practice.
A profession has sufficient self-impelling power o retain its members
throughout life. It must not be a mere steppingstone to other occupations.
6. Caring. The most unique characteristic of nursing as a profession is that, it is
a CARING profession.
Nursing
 Is a disciplined involved in the delivery of health care to the society.
 Is a helping profession
 Is service-oriented to maintain health and well-being of people.
 Is an art and a science.
 Nurse – originated from a Latin word NUTRIX, to nourish.
Characteristics of Nursing
1. Nursing is caring.
2. Nursing involves close personal contact with the recipient of care.
3. Nursing is concerned with services that take humans into account as
PHYSIOLOGICAL, PSYCHOLOGICAL, and SOCIOLOGICAL
ORGANISMS.
4. Nursing is committed to promoting individual, family, community, and
national health goals in its best manner possible.
 5. Nursing is committed to personalized services for all persons without regard
to color, creed, social or economic status.
6. Nursing is committed to involvement in ETHICAL, LEGAL, and POLITICAL
ISSUES in the delivery of health care.

Personal Qualities of a Nurse

1. Must have a Bachelor of Science degree in nursing.
2. Must be physically and mentally fit.
3. Must have a license to practice nursing in the country.
A professional nurse therefore, is a person who has completed a basic nursing
education program and is licensed in his country to practice professional nursing.
Roles of a Professional
1. Caregiver/ Care provider
 the traditional and most essential role
 functions as nurturer, comforter, provider
 “mothering actions” of the nurse
 provides direct care and promotes comfort of client
 activities involves knowledge and sensitivity to what matters and what is
important to clients
 show concern for client welfare and acceptance of the client as a person
2. Teacher
 provides information and helps the client to learn or acquire new knowledge
and technical skills
 Encourages compliance with prescribed therapy.
 promotes healthy lifestyles
 interprets information to the client
3. Counselor
 helps client to recognize and cope with stressful psychologic or social
problems; to develop an improve interpersonal relationships and to promote
personal growth
 provides emotional, intellectual to and psychologic support
 Focuses on helping a client to develop new attitudes, feelings and behaviors
rather than promoting intellectual growth.
 Encourages the client to look at alternative behaviors recognize the choices
and develop a sense of control.
4. Change agent
 Initiate changes or assist clients to make modifications in themselves or in
the system of care.

5. Client advocate
 Involves concern for and actions in behalf of the client to bring about a
change.
  Promotes what is best for the client, ensuring that the client’s needs
are met and protecting the client’s right.
 Provides explanation in client’s language and support clients decisions.
6. Manager
 makes decisions, coordinates activities of others, allocate resource
 evaluate care and personnel
 Plans, give direction, develop staff, monitor operations, give the
rewards fairly and represent both staff and administrations as needed.
7. Researcher
 participates in identifying significant researchable problems
 participates in scientific investigation and must be a consumer of research
findings
 Must be aware of the research process, language of research, a sensitive to
issues related to protecting the rights of human subjects.

Expanded role as of the nurse

1. Clinical Specialists
 Is a nurse who has completed a master’s degree in specialty and has
considerable clinical expertise in that specialty. She provides expert care
to individuals, participates in educating health care professionals and
ancillary, acts as a clinical consultant and participates in research.
2. Nurse Practitioner
 Is a nurse who has completed either as certificate program or a master’s
degree in a specialty and is also certified by the appropriate specialty
organization. She is skilled at making nursing assessments, performing P.
E., counseling, teaching and treating minor and self- limiting illness.
3. Nurse-midwife
 A nurse who has completed a program in midwifery; provides prenatal
and postnatal care and delivers babies to woman with uncomplicated
pregnancies.
4. Nurse anesthetist
 A nurse who completed the course of study in an anesthesia school and
assess, prescribe, deliver, and manage care during the preoperative,
perioperative, and postoperative phases of a patient’s
operative/interventional procedure(s). 
5. Nurse Educator
 A nurse usually with advanced degree, who beaches in clinical or
educational settings, teaches theoretical knowledge, clinical skills and
conduct research.
6. Nurse Entrepreneur
 A nurse who has an advanced degree, and manages health-related
business.

7. Nurse administrator
  A nurse who functions at various levels of management in health
settings; responsible for the management and administration of
resources and personnel involved in giving patient care.

Fields and Opportunities in Nursing
1. Hospital/Institutional Nursing
 A nurse working in an institution with patients
 Example: rehabilitation, lying-in, etc.
2. Public Health Nursing/Community Health Nursing
 Usually deals with families and communities. (no confinement, OPD only)
 Example: Barangay, Health Center
3. Private Duty/special Duty Nurse
 Privately hired
4. Industrial/Occupational Nursing
 A nurse working in factories, office, companies
5. Nursing Education
 Nurses working in school, review center and in hospital as a CI.
6. Military Nurse
 Nurses working in a military base.
7. Clinic Nurse
 Nurses working in a private and public clinic.
8. Independent Nursing Practice
 Private practice, BP monitoring, home service.
 Independent Nurse Practitioner.
 HISTORY OF NURSING IN THE PHILIPPINES
Early Beliefs, Practices and Care of the sick
 Early Filipinos subscribed to superstitious belief and practices in relation to
health and sickness
 Diseases, their causes and treatment were associated with mysticism and
superstitions
 Cause of disease was caused by another person (an enemy of witch) or evil
spirits
 Persons suffering from diseases without any identified cause were believed
bewitched by “mangkukulam”
 Difficult childbirth were attributed to “nonos”
 Evil spirits could be driven away by persons with powers to expel demons
 Belief in special Gods of healing: priest-physician, word doctors,
herbolarios/herb doctors
Early Hospitals during the Spanish Regime
 Religious orders exerted efforts to care for the sick by building hospitals in
different parts of the Philippines:
1. Hospital Real de Manila San Juan de Dios Hospital
2. San Lazaro Hospital Hospital de Aguas Santas
3. Hospital de Indios
Prominent personages involved during the Philippine Revolution
1. Josephine Bracken – wife of Jose Rizal installed a field hospital in an estate
in Tejeros that provided nursing care to the wounded night and day.
2. Rose Sevilla de Alvaro – converted their house into quarters for Filipino
soldiers during the Phil-American War in 1899.
3. Hilaria de Aguinaldo –wife of Emlio Aginaldo organized the Filipino Red
Cross.
4. Melchora Aquino – (Tandang Sora) nursed the wounded Filipino soldiers,
gave them shelter and food.
5. Captain Salomen – a revolutionary leader in Nueva Ecija provided nursing
care to the wounded when not in combat.
6. Agueda Kahabagan – revolutionary leader in Laguna also provided nursing
services to her troops.
7. Trinidad Tecson (Ina ng Biak na Bato) – stayed in the hospital at Biac na
Bato to care for the wounded soldiers.

School Of Nursing
1. St. Paul’s Hospital School of Nursing, Intramuros Manila – 1900
2. Iloilo Mission Hospital Training School of Nursing – 1906

Health
1. Health Is the fundamental right of every human being. It is the state of
integration of the body and mind
2. Health and illness are highly individualized perception. Meanings and
descriptions of health and illness vary among people in relation to geography
and to culture.
3. Health – is the state of complete physical, mental, and social well-being, and
not merely the absence of disease or infirmity. (WHO)
4. Health – is the ability to maintain the internal milieu. Illness is the result of
failure to maintain the internal environment.(Claude Bernard)
5. Health – is the ability to maintain homeostasis or dynamic equilibrium.
Homeostasis is regulated by the negative feedback mechanism.(Walter
Cannon)
6. Health – is being well and using one’s power to the fullest extent. Health is
maintained through prevention of diseases via environmental health factors.
(Florence Nightingale)
7. Health – is viewed in terms of the individual’s ability to perform 14
components of nursing care unaided. (Henderson)
8. Positive Health – symbolizes wellness. It is value term defined by the culture
or individual. (Rogers)
9. Health – is a state of a process of being becoming an integrated and whole
as a person.(Roy)
10. Health – is a state the characterized by soundness or wholeness of
developed human structures and of bodily and mental functioning.(Orem)
11. Health– is a dynamic state in the life cycle; illness is interference in the life
cycle. (King)
12. Wellness – is the condition in which all parts and subparts of an individual
are in harmony with the whole system. (Neuman)
13. Health – is an elusive, dynamic state influenced by biologic, psychologic, and
social factors. Health is reflected by the organization, interaction,
interdependence and integration of the subsystems of the behavioral system.
(Johnson)
 Health And Illness
Health
As defined by the World Health Organization (WHO): state of complete
physical, mental and social well-being, not merely the absence of disease or
infirmity.
Characteristics
1. A concern for the individual as a total system
2. A view of health that identifies internal and external environment
3. An acknowledgment of the importance of an individual’s role in life
*A dynamic state in which the individual adapts to changes in internal and external
environment to maintain a state of well being

Models of Health and Illness

1. Health-Illness Continuum (Neuman) – Degree of client wellness that exists at any
point in time, ranging from an optimal wellnesscondition, with available energy at its
maximum, to death which represents total energy depletion.
2. High – Level Wellness Model (Halbert Dunn) – It is oriented toward maximizing the
health potential of an individual.This model requires the individual to maintain a
continuum of balance and purposeful direction within the environment.
3. Agent – Host – environment Model (Leavell) – The level of health of an individual or
group depends on the dynamic relationship of the agent, host and environment
 Agent – any internal or external factor that disease or illness.
 Host – the person or persons who may be susceptible to a particular illness
or disease
 Environment – consists of all factors outside of the host
4. Health – Belief Model – Addresses the relationship between a person’s belief and
behaviors. It provides a way of understanding and predicting how clients will behave in
relation to their health and how they will comply with health care therapies.
Four Components
 The individual is perception of susceptibility to an illness
 The individual’s perception of the seriousness of the illness
 The perceived threat of a disease
 The perceived benefits of taking the necessary preventive measures
5. Evolutionary – Based Model – Illness and death serves as a evolutionary function.
Evolutionary viability reflects the extent to which individual’s function to promote survival
and well-being. The model interrelates the following elements:
 Life events
  Life style determinants
 Evolutionary viability within the social context
 Control perceptions
 Viability emotions
 Health outcomes
6. Health Promotion Model – A “complimentary counterpart models of health protection”.
Directed at increasing a client’s level of well being. Explain the reason for client’s
participation health-promotion behaviors. The model focuses on three functions:
 It identifies factors (demographic and socially) enhance or decrease the
participation in health promotion
 It organizes cues into pattern to explain likelihood of a client’s participation
health-promotion behaviors
 It explains the reasons that individuals engage in health activities
Illness
 State in which a person’s physical, emotional, intellectual, social
developmental or spiritual functioning is diminished or impaired. It is a
condition characterized by a deviation from a normal, healthy state.
3 Stages of Illness
1. Stage of Denial – Refusal to acknowledge illness; anxiety, fear, irritability and
aggressiveness.
2. Stage of Acceptance – Turns to professional help for assistance
3. Stage of Recovery (Rehabilitation or Convalescence) – The patient goes
through of resolving loss or impairment of function
Rehabilitation
1. A dynamic, health oriented process that assists individual who is ill or
disabled to achieve his greatest possible level of physical, mental, spiritual,
social and economical functioning.
2. Abilities not disabilities are emphasized.
3. Begins during initial contact with the patient
4. Emphasis is on restoring the patient to independence or regain his pre-
illness/predisability level of function as short a time as possible
5. Patient must be an active participant in the rehabilitation goal setting an din
rehabilitation process.
Focuses of Rehabilitation
1. Coping pattern
2. Functional ability – focuses on self-care: activities of daily living (ADL);
feeding, bathing/hygiene, dressing/grooming, toileting and mobility
3. Mobility
4. Integrity of skin
5. Control of bowel and bladder function
 HEALTH AND WELLNESS
WELLNESS is more than being free from illness, it is a dynamic process of change and
growth. “…a state of complete physical, mental, and social well-being, and not merely
the absence of disease or infirmity.” – The World Health Organization.

Health
 Presence or absence of disease
 Complete physical, mental, social well-being
 Ability to maintain normal roles
 Process of adaptation to physical and social environment
 Striving toward optimal wellness
 Individual definitions
Wellness
 State of well-being
Basic aspects include:
 Self-responsibility
 An ultimate goal
 A dynamic, growing process
 Daily decision-making in areas related to health
 Whole being of the individual
Well-being
 Subjective perception of vitality and feeling well
 Described objectively, experienced, measured
 Can be plotted on a continuum
 Dimensions of Wellness

Physical Dimension
 Ability to carry out daily tasks
 Achieve fitness
 Maintain nutrition
 Avoid abuses
Social Dimension
 Interact successfully
 Develop and maintain intimacy
 Develop respect and tolerance for others
Emotional Dimension
 Ability to manage stress
 Ability to express emotion
Intellectual Dimension
 Ability to learn
 Ability to use information effectively
Spiritual Dimension
 Belief in some force that serves to unite
Occupational Dimension
 Ability to achieve balance between work and leisure
Environmental Dimension
 Ability to promote health measure that improves
 Standard of living
 Quality of life
 Models of Health
 Medical Model
 Agent-Host-Environment Model
 Health-Illness Continuum
Medical Model
 Provides the narrowest interpretation of health
 People viewed as physiologic systems
 Health identified by the absence of signs and symptoms of disease or injury
 State of not being “sick”
 Opposite of health is disease or injury
Agent-Host-Environment Model
 Each factor constantly interacts with the others
 When in balance, health is maintained
 When not in balance, disease occurs
Travi’s Health-Illness Continuum
 Measure person’s perceived level of wellness
 Health and illness/disease opposite ends of a health continuum
 Move back and forth within this continuum day by day
 Wide ranges of health or illness
 Ardell’s Wellness Model
5 Dimensions of Wellness
Nutritional Awareness
 Making healthy food choices on a regular basis.
Physical Fitness
 Regular exercise program.
Stress Management
Determining the stress factors in one’s life is one thing, but doing something about it is
another thing you could do to manage their stress levels

 Meditation
 positive visualization
 taking time out
 listening to music
 journal writing
 regular physical activity are all
Environmental Sensitivity
 Living lightly on the earth, helping in anyway you can to keep the planet
healthy is important as personal wellness depends on planetary wellness.
Self- Responsibility
 Ardell says, all dimensions of wellness are important, but self-responsibility
seems more equal than all the rest. Personal accountability for our own
lifestyle is of utmost importance
 Bellin’s Model for Competency Improvement
 Bellin’s Health System, focus is health care delivery system
 is based upon the belief that outcomes are the results of processes that can
be improved through:
 Identification of success metrics,
 Setting of goals and the Plan Do Study Act (PDSA) change
process.
 Statistical process control charts are used to track identified processes for
stability and response to improvement efforts. Measurement is focused on:
 Growth
 Effectiveness
 Efficiency
 Engagement
 Innovation

Iceberg Model
 The Iceberg Model shows us that our state of physical health or illness is
only the visible “tip” of the iceberg.
 In order to completely understand our physical condition, we need to look
beneath the surface to our
 Choices of lifestyle (our eating habits, exercise level, addictions to
alcohol, food, adrenaline, shopping, drugs, etc),
 Psychological beliefs (the thoughts, feelings, attitudes and beliefs
we hold)
 Spirituality (our inner life, our belief in a higher power and our
degree of acceptance and love of self and others).
 Factors Affecting Health Status, Beliefs, and Practices
Internal Variables
Biologic dimension (genetic makeup, gender, age, and developmental level)

Psychologic dimension (mind-body interactions and self-concept)

Cognitive dimension (intellectual factors include lifestyle choices and spiritual

and religious beliefs)
External Variables
 Physical environment
 Standards of living
 Family and cultural beliefs
 Social support networks
Factors Affecting Health Care Adherence
 Client motivation
 Degree of lifestyle change necessary
 Perceived severity of problem
 Value placed on reducing the threat of illness
 Difficulty in understanding and performing specific behaviors
 Degree of inconvenience of the illness itself or of the regimens
 Complexity, side effects, and duration of the proposed therapy
 Specific cultural heritage that may make adherence difficult
 Degree of satisfaction and quality and type of relationship with the health
care providers
 Overall cost of prescribed therapy
Illness
 A highly personal state
 Person’s physical, emotional, intellectual, social, developmental, or spiritual
functioning is diminished
 Not synonymous with disease
 May or may not be related to disease
 Only person can say he or she is ill
Disease
 Alteration in body function
 A reduction of capacities or a shortening of the normal life span
Acute Illness
 Characterized by severe symptoms of relatively short duration
 Symptoms often appear abruptly, subside quickly
 May or may not require intervention by health care professionals
 Most people return to normal level of wellness
Chronic Illness
 Lasts for an extended period
 Usually has a slow onset
 Often have periods of remissions and exacerbations
 Care includes promoting independence, sense of control, and wellness
 Learn how to live with physical limitations and discomfort
Parson’s Four Aspects of the Sick Role
 Clients are not held responsible for their condition
 Clients are not excused from certain social roles and tasks
 Clients are obligated to try to get well as quickly as possible
 Clients or their families are obligated to seek competent help
Schuman’s Stages of Illness
Stage 1: Symptom experience
 Believe something is wrong
Stage 2: Assumption of the sick role
 Accepts the sick role and seeks confirmation
Stage 3: Medical care contact
 Seeks advice of a health professional
Stage 4: Dependent client role
 Becomes dependent on the professional for help
Stage 5: Recovery or rehabilitation
 Relinquish the dependent role – Resume former roles and responsibilities
Impact of Illness on the Client
 Behavioral and emotional changes
 Loss of autonomy
 Self-concept and body image changes
 Lifestyle changes On the Family
 Depends on:
 Member of the family who is ill
 Seriousness and length of the illness
 Cultural and social customs the family follows
Impact of Illness: Family Changes
 Role changes
 Task reassignments
 Increased demands on time
 Anxiety about outcomes
 Conflict about unaccustomed responsibilities
 Financial problems
 Loneliness as a result of separation and pending loss
 Change in social customs
 Ethico moral aspects in nursing
Description
Ethos 
 comes from Greek work w/c means character/culture
 Branch of Philosophy w/c determines right and wrong
Moral 
 personal/private interpretation from what is good and bad.
Ethical Principles:
1. Autonomy – the right/freedom to decide (the patient has the right to refuse
despite the explanation of the nurse) Example: surgery, or any procedure
2. Nonmaleficence – the duty not to harm/cause harm or inflict harm to others
(harm maybe physical, financial or social)
3. Beneficence– for the goodness and welfare of the clients
4. Justice – equality/fairness in terms of resources/personnel
5. Veracity – the act of truthfulness
6. Fidelity – faithfulness/loyalty to clients
Moral Principles:
1. Golden Rule
2. The principle of Totality – The whole is greater than its parts
3. Epikia – There is always an exemption to the rule
4. One who acts through as agent is herself responsible – (instrument to the
crime)
5. No one is obliged to betray herself – You cannot betray yourself
6. The end does not justify the means
7. Defects of nature maybe corrected
8. If one is willing to cooperate in the act, no justice is done to him
9. A little more or a little less does not change the substance of an act.
10. No one is held to impossible
 Law – Rule of conduct commanding what is right and what is wrong. Derived
from an Anglo-Saxon term that means“that which is laid down or fixed”
 Court – Body/agency in government wherein the administration of justice is
delegated.
 Plaintiff – Complainant or person who files the case (accuser)
 Defendant – Accused/respondent or person who is the subject of complaint
  Witness– Individual held upon to testify in reference to a case either for the
accused or against the accused.

Written orders of court

Writ – legal notes from the court
1. Subpoena
1. Subpoena Testificandum – a writ/notice to an individual/ordering
him to appear in court at a specific time and date as witness.
2. Subpoena Duces Tecum- notice given to a witness to appear in
court to testify including all important documents
2. Summon – notice to a defendant/accused ordering him to appear in court to
answer the complaint against him
3. Warrant of Arrest – court order to arrest or detain a person
4. Search warrant – court order to search for properties.
Public law  
 body of law that deals with relationship between individuals and the
State/government and government agencies. Laws for the welfare of the
general public.
Private/Civil Law 
 body of law that deals with relationships among private individuals
Private/Civil Law 
1. Contract law – involves the enforcement of agreements among private
individuals or the payment of compensation for failure to fulfill the
agreements
 Ex. Nurse and client nurse and insurance
 Nurse and employer client and health agency
 An agreement between 2 or more competent person to do or not
to do some lawful act.
 It maybe written or oral= both equally binding
Types of Contract:
1. Expressed –when 2 parties discuss and agree orally or in writing the terms
and conditions during the creation of the contract.
 Example: nurse will work at a hospital for only a stated length of
time (6 months),under stated conditions (as volunteer, straight
AM shift, with food/transportation allowance)
2. Implied – one that has not been explicitly agreed to by the parties, but that
the law considers to exist.
 Example: Nurse newly employed in a hospital is expected to be
competent and to follow hospital policies and procedures even
though these expectations were not written or discussed.
 Likewise: the hospital is expected to provide the necessary
supplies, equipment needed to provide competent, quality nursing
care.
Feature/Characteristics/Elements of a lawful contract:
1. Promise or agreement between 2 or more persons for the performance of an
action or restraint from certain actions.
 2. Mutual understanding of the terms and meaning of the contract by all.
3. A lawful purpose – activity must be legal
4. Compensation in the form of something of value-monetary
Persons who may not enter into a contract: minor, insane, deaf, mute and ignorant

Tort law
 Is a civil wrong committed against a person or a person’s property.
 Person/person’s responsible for the tort are sued for damages
 Is based on:
 ACT OF COMMISSION –something that was done incorrectly
 ACT OF OMMISION – something that should have been done but
was not.
Classification of Tort
Unintentional Tort
1. Negligence
 Misconduct or practice that is below the standard expected of ordinary,
reasonable and prudent person
 Failure to do something due to lack of foresight or prudence
 Failure of an individual to provide care that a reasonable person would
ordinarily use in a similar circumstance.
 An act of omission or commission wherein a nurse fails to act in accordance
with the standard of care.
Doctrines of Negligence:
1. Res ipsa loquitor – the thing speaks for itself – the injury is enough proof of
negligence
2. Respondeat Superior – let the master answer command responsibility
3. Force majuere – unforeseen event, irresistible force
2. Malpractice
 stepping beyond one’s authority
6 elements of nursing malpractice:
1. Duty – the nurse must have a relationship with the client that involves
providing care and following an acceptable standard of care.
2. Breach of duty
 the standard of care expected in a situation was not observed by
the nurse
 is the failure to act as a reasonable, prudent nurse under the
circumstances
 something was done that should not have been done or nothing
was done when it should have been done
3. Foreseeability – a link must exist between the nurse’s act and the injury
suffered
 4. Causation – it must be proved that the harm occurred as a direct result of the
nurse’s failure to follow the  standard of care and the nurse should or could
have known that the failure to follow the standard of care could result in such
harm.
5. harm/injury –physical, financial, emotional as a result of the breach of duty to
the client Example: physical injury, medical cost/expenses, loss of wages,
pain and suffering
6. damages – amount of money in payment of damage/harm/injury
Intentional Tort
 Unintentional tort – do not require intent bur do require the element of HARM
 Intentional tort – the act was done on PURPOSE or with INTENT
 No harm/injury/damage is needed to be liable
 No expert witnesses are needed
Assault
 An attempt or threat to touch another person unjustifiably
 Example:
 A person who threatens someone with a club or closed fist.
 Nurse threatens a client with an injection after refusing to take the
meds orally.
Battery
 Willful touching of a person, person’s clothes or something the person is
carrying that may or may not cause harm but the touching was done without
permission, without consent, is embarrassing or causes injury.
 Example:
 A nurse threatens the patient with injection if the patient refuses
his meds orally. If the nurse gave the injection without client’s
consent, the nurse would be committing battery even if the client
benefits from the nurse’s action.
False Imprisonment
 Unjustifiable detention of a person without legal warrant to confine the
person
 Occurs when clients are made to wrongful believe that they cannot leave the
place
 Example:
 Telling a client no to leave the hospital until bill is paid
 Use of physical or chemical restraints
 False Imprisonment Forceful Restraint=Battery
Invasion of Privacy
 intrusion into the client’s private domain
 right to be left alone
Types of Invasion the client must be protected from:
1. use of client’s name for profit without consent – using one’s name,
photograph for advertisements of HC agency or provider without client’s
permission
2. Unreasonable intrusion – observation or taking of photograph of the client for
whatever purpose without client’s consent.
 3. Public disclosure of private facts – private information is given to others who
have no legitimate need for that.
4. Putting a person in a false/bad light – publishing information that is normally
considered offensive but which is not true.
Defamation
 communication that is false or made with a careless disregard for the truth
and results in injury to the reputation of a person
Types:
1. Libel – defamation by means of print, writing or picture
1. Example:
2. o writing in the chart/nurse’s notes that doctor A is incompetent
because he didn’t respond immediately to a call
2. Slander – defamation by the spoken word stating unprivileged (not legally
protected) or false word by which a reputation is damaged
1. Example:
 Nurse A telling a client that nurse B is incompetent
 Person defamed may bring the lawsuit
 The material (nurse’s notes) must be communicated to
a 3rd party in order that the person’s reputation maybe
harmed
Public Law:
Criminal Law – deals with actions or offenses against the safety and welfare of the
public.
1. homicide – self-defense
2. arson- burning or property
3. theft – stealing
4. sexual harassment
5. active euthanasia
6. illegal possession of controlled drugs
 Illness and disease
Illness
 Is a personal state in which the person feels unhealthy.
 Illness is a state in which a person’s physical, emotional, intellectual, social,
developmental, or spiritual functioning is diminished or impaired compared
with previous experience.
 Illness is not synonymous with disease.
Disease
An alteration in body function resulting in reduction of capacities or a

shortening of the normal life span.
Common Causes of Disease
1. Biologic agent – e.g. microorganism
2. Inherited genetic defects – e.g. cleft palate
3. Developmental defects – e.g. imperforate anus
4. Physical agents – e.g. radiation, hot and cold substances, ultraviolet rays
5. Chemical agents – e.g. lead, asbestos, carbon monoxide
6. Tissue response to irritations/injury – e.g. inflammation, fever
7. Faulty chemical/metabolic process – e.g. inadequate insulin in diabetes
8. Emotional/physical reaction to stress – e.g. fear, anxiety
Stages of Illness
1. Symptoms Experience– experience some symptoms, person believes
something is wrong 3 aspects –physical, cognitive, emotional
2. Assumption of Sick Role – acceptance of illness, seeks advice
3. Medical Care Contact– Seeks advice to professionals for validation of real
illness, explanation of symptoms, reassurance or predict of outcome
4. Dependent Patient Role
 The person becomes a client dependent on the health
professional for help.
 Accepts/rejects health professional’s suggestions.
 Becomes more passive and accepting.
5. Recovery/Rehabilitation – Gives up the sick role and returns to former roles
and functions.
Risk Factors of a Disease
1. Genetic and Physiological Factors
 For example, a person with a family history of diabetes mellitus, is
at risk in developing the disease later in life.
2. Age
 Age increases and decreases susceptibility ( risk of heart
diseases increases with age for both sexes
3. Environment
 The physical environment in which a person works or lives can
increase the likelihood that certain illnesses will occur.
 4. Lifestyle
 Lifestyle practices and behaviors can also have positive or
negative effects on health.
Classification of Diseases
1. According to Etiologic Factors
a. Hereditary – due to defect in the genes of one or other parent which is
transmitted to the offspring
b. Congenital – due to a defect in the development, hereditary factors, or
prenatal infection
c. Metabolic – due to disturbances or abnormality in the intricate processes of
metabolism.
d. Deficiency – results from inadequate intake or absorption of essential dietary
factor.
e. Traumatic– due to injury
f. Allergic – due to abnormal response of the body to chemical and protein
substances or to physical stimuli.
g. Neoplastic – due to abnormal or uncontrolled growth of cell.
h. Idiopathic –Cause is unknown; self-originated; of spontaneous origin
i. Degenerative –Results from the degenerative changes that occur in the
tissue and organs.
j. Latrogenic – result from the treatment of the disease
2. According to Duration or Onset
 Acute Illness – An acute illness usually has a short duration and is severe.
Signs and symptoms appear abruptly, intense and often subside after a
relatively short period.
 Chronic Illness – chronic illness usually longer than 6 months, and can also
affects functioning in any dimension. The client may fluctuate between
maximal functioning and serious relapses and may be life threatening. Is
characterized by remission and exacerbation.
 Remission– periods during which the disease is controlled and
symptoms are not obvious.
 Exacerbations – The disease becomes more active given again at
a future time, with recurrence of pronounced symptoms.
 Sub-Acute – Symptoms are pronounced but more prolonged than the acute
disease.
3. Disease may also be Described as:
a. Organic – results from changes in the normal structure, from recognizable
anatomical changes in an organ or tissue of the body.
b. Functional – no anatomical changes are observed to account from the
symptoms present, may result from abnormal response to stimuli.
c. Occupational – Results from factors associated with the occupation engage
in by the patient.
d. Venereal – usually acquired through sexual relation
e. Familial – occurs in several individuals of the same family
f. Epidemic – attacks a large number of individuals in the community at the
same time. (E.g. SARS)
g. Endemic – Presents more or less continuously or recurs in a community.
(E.g. malaria, goiter)
h. Pandemic –An epidemic which is extremely widespread involving an entire
country or continent.
i. Sporadic – a disease in which only occasional cases occur. (E.g. dengue,
leptospirosis)
 HISTORICAL EVOLUTION OF NURSING
Period of Intuitive Nursing/Medieval Period
 Nursing was “untaught” and instinctive. It was performed of compassion for
others, out of the wish to help others.
 Nursing was a function that belonged to women. It was viewed as a natural
nurturing job for women. She is expected to take good care of the children,
the sick and the aged.
 No caregiving training is evident. It was based on experience and
observation.
 Primitive men believed that illness was caused by the invasion of the victim’s
body of evil spirits. They believed that the medicine man, Shaman or witch
doctor had the power to heal by using white magic, hypnosis, charms,
dances, incantation, purgatives, massage, fire, water and herbs as a mean
of driving illness from the victim.
 Trephining – drilling a hole in the skull with a rock or stone without
anesthesia was a last resort to drive evil spirits from the body of the afflicted.
Period of Apprentice Nursing/Middle Ages
 Care was done by crusaders, prisoners, religious orders
 Nursing care was performed without any formal education and by people
who were directed by more experienced nurses (on the job training). This
kind of nursing was developed by religious orders of the Christian Church.
 Nursing went down to the lowest level
 Wrath/anger of Protestantism confiscated properties of hospitals
and schools connected with Roman Catholicism.
 Nurses fled their lives; soon there was shortage of people to care
for the sick
 Hundreds of Hospitals closed; there was no provision for the sick,
no one to care for the sick
 Nursing became the work of the least desirable of women –
prostitutes, alcoholics, prisoners
 Pastor Theodore Fliedner and his wife, Frederika established the
Kaiserswerth Institute for the training of Deaconesses (the 1st formal training
school for nurses) in Germany.
 This was where Florence Nightingale received her 3-month
course of study in nursing.

Period of Educated Nursing/Nightingale Era 19th-20th century

 The development of nursing during this period was strongly influenced by:
1. trends resulting from wars – Crimean, civil war
2. arousal of social consciousness
3. Increased educational opportunities offered to women.
 Florence Nightingale was asked by Sir Sidney Herbert of the British War
Department to recruit female nurses to provide care for the sick and injured
in the Crimean War.
  In 1860, The Nightingale Training School of Nurses opened at St. Thomas
Hospital in London.
 The school served as a model for other training schools. Its
graduates traveled to other countries to manage hospitals and
institute nurse-training programs.
 Nightingale focus vision of nursing Nightingale system was more
on developing the profession within hospitals. Nurses should be
taught in hospitals associated with medical schools and that the
curriculum should include both theory and practice.
 It was the 1st school of nursing that provided both theory-based
knowledge and clinical skill building.
 Nursing evolved as an art and science
 Formal nursing education and nursing service begun
Facts about Florence Nightingale
 Mother of modern nursing. Lady with the Lamp because of her achievements
in improving the standards for the care of war casualties in the Crimean war.
 Born may 12, 1800 in Florence, Italy
 Raised in England in an atmosphere of culture and affluence
 Not contended with the social custom imposed upon her as a Victorian Lady,
she developed her self-appointed goal: To change the profile of Nursing
 She compiled notes of her visits to hospitals and her observations of the
sanitary facilities, social problems of the places she visited.
 Noted the need for preventive medicine and god nursing
 Advocated for care of those afflicted with diseases caused by lack of
hygienic practices
 At age 31, she entered the Deaconesses School at Kaiserswerth in spite of
her family’s resistance to her ambitions. She became a nurse over the
objections of society and her family.
 Worked as a superintendent for Gentlewomen Hospital, a charity hospital for
ill governesses.
 Disapproved the restrictions on admission of patients and considered this
unchristian and incompatible with health care
 Upgraded the practice of nursing and made nursing an honorable profession
for women.
 Led nurses that took care of the wounded during the Crimean war
 Put down her ideas in 2 published books: Notes on Nursing, What It Is and
What It Is Not and Notes on Hospitals.
 She revolutionized the public’s perception of nursing (not the image of a
doctor’s handmaiden) and the method for educating nurses.
Period of Contemporary Nursing/20th Century
 Licensure of nurses started
 Specialization of Hospital and diagnosis
 Training of Nurses in diploma program
 Development of baccalaureate and advance degree programs
 Scientific and technological development as well as social changes marks
this period.
1. Health is perceived as a fundamental human right
2. Nursing involvement in community health
3. Technological advances – disposable supplies and equipments
4. Expanded roles of nurses was developed
5. WHO was established by the United Nations
6. Aerospace Nursing was developed
7. Use of atomic energies for medical diagnosis, treatment
8. Computers were utilized-data collection, teaching, diagnosis,
inventory, payrolls, record keeping, and billing.
9. Use of sophisticated equipment for diagnosis and therapy
 MORAL THEORISTS
Freud (1961)
 Believed that the mechanism for right and wrong within the individual is the
superego, or conscience. He hypnotized that a child internalizes and adopts
the moral standards and character or character traits of the model parent
through the process of identification.
 The strength of the superego depends on the intensity of the child’s feeling
of aggression or attachment toward the model parent rather than on the
actual standards of the parent.

Erikson (1964)
 Erikson’s theory on the development of virtues or unifying strengths of the
“good man” suggests that moral development continuous throughout life. He
believed that if the conflicts of each psychosocial developmental stages
favorably resolved, then an ‘egostrength” or virtue emerges.

Kohlberg
 Suggested three levels of moral development. He focused on the reason for
the making of a decision, not on the morality of the decision itself.

1. At first level called the premolar or the preconventional level, children are
responsive to cultural rules and labels of good and bad, right and wrong.
However children interpret these in terms of the physical consequences of
the actions, i.e., punishment or reward.
2. At the second level, the conventional level, the individual is concerned about
maintaining the expectations of the family, groups or nation and sees this as
right.
3. At the third level, people make postconventional, autonomous, or principal
level. At this level, people make an effort to define valid values and principles
without regard to outside authority or to the expectations of others. These
involve respect for other human and belief that relationships are based on
mutual trust.
 Maslow’s hierarchy of needs
Definition
 Each individual has unique characteristics, but certain needs are common to
all people.
 A need is something that is desirable, useful or necessary. Human needs are
physiologic and psychological conditions that an individual must meet to
achieve a state of health or well-being.
Physiologic
1. Oxygen
2. Fluids
3. Nutrition
4. Body temperature
5. Elimination
6. Rest and sleep
7. Sex
Safety and Security
1. Physical safety
2. Psychological safety
3. The need for shelter and freedom from harm and danger
Love and belonging
1. The need to love and be loved
2. The need to care and to be cared for.
3. The need for affection: to associate or to belong
4. The need to establish fruitful and meaningful relationships with people,
institution, or organization
Self-Esteem Needs
1. Self-worth
2. Self-identity
3. Self-respect
4. Body image
Self-Actualization Needs
1. The need to learn, create and understand or comprehend
2. The need for harmonious relationships
3. The need for beauty or aesthetics
4. The need for spiritual fulfillment
Characteristics of Basic Human Needs
1. Needs are universal.
2. Needs may be met in different ways
3. Needs may be stimulated by external and internal factor
4. Priorities may be deferred
5. Needs are interrelated
Maslow’s Characteristics of a Self-Actualized Person
1. Is realistic, sees life clearly and is objective about his or her observations
2. Judges people correctly
3. Has superior perception, is more decisive
4. Has a clear notion of right or wrong
5. Is usually accurate in predicting future events
6. Understands art, music, politics and philosophy
7. Possesses humility, listens to others carefully
8. Is dedicated to some work, task, duty or vocation
9. Is highly creative, flexible, spontaneous, courageous, and willing to make
mistakes
10. Is open to new ideas
11. Is self-confident and has self-respect
12. Has low degree of self-conflict; personality is integrated
13. Respect self, does not need fame, and possesses a feeling of self-control
14. Is highly independent, desires privacy
15. Can appear remote or detached
16. Is friendly, loving and governed more by inner directives than by society
17. Can make decisions contrary to popular opinion
18. Is problem centered rather than self-centered
19. Accepts the world for what it is
 Nursing Process
 The term Nursing Process was first used/ mentioned by Lydia Hall, a nursing
theorist, in 1955 wherein she introduced 3 STEPs: observation,
administration of care and validation.
 Since then, nursing process continue to evolve: it used to be a 3-step
process, then a 4-step process (APIE), then a 5-step (ADPIE), now a 6-step
process (ADOPIE) Assessment, Diagnosis, Outcome, Identification,
Planning, Implementaton and Evaluation.
Definition
 Is a systematic, organized method of planning, and providing quality and
individualized nursing care.
 It is synonymous with the PROBLEM SOLVING APPROACH that directs the
nurse and the client to determine the need for nursing care, to plan and
implement the care and evaluate the result.
 It is a G O S H approach (goal-oriented, organized, systematic and
humanistic care) for efficient and effective provision of nursing care.

 Goal-oriented – nurse make her objective based on client’s health needs.

 Remember: Goals and plan of care should be base according to clients
problems/needs NOT according to your own problem as the nurse.
 Organized/Systematic – the nursing process is composed of 6 sequential
and interrelated steps and these 6 phases follow a logical sequence.
Humanistic care
 Plan to care is developed and implemented taking into consideration the
unique needs of the individual client.
 plan of care therefore is individualized (no 2 person has the same health
needs even with same health condition/illness)
 in providing care, it involves respect of human dignity
 Efficient – plan of case is relevant/ related to the needs of the client thereby
promoting client satisfaction and progress.
 Effective – in planning care, utilized resources wisely (staff, time,
money/cost)
Aside from GOSH, other characteristic of Nursing Process:
 Cyclic and Dynamic in nature – data from each phase provides the input into
the next phase so that is becomes a sequence of events (cycle) that are
constantly changing (dynamic) base on client’s health status.
 Involves skill in Decision-making – nurse makes important decisions related
to client care, she choose the best action/steps to meet a desired goal or to
solve a problem. She must make decisions whenever several choices or
options are available.
 Uses Critical Thinking skills – the nurse may encounter new ideas or less-
than-routine or non-ordinary situations where decisions must be made using
critical thinking.
Purpose of Nursing Process:

1. To identify a client’s health status; his Actual/Present and potential/possible

health problems or needs.
2. To establish a plan of care to meet identified needs.
3. To provide nursing interventions to meet those needs.
4. To provide an individualized, holistic, effective and efficient nursing care.

Steps/Phases of the Nursing Process:

1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation

Assessment
Description
 It is systematic and continuous collection, validation and communication of
client data as compared to what is standard/norm.
 It includes the client’s perceived needs, health problems, related
experiences, health practices, values and lifestyles.
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
 Ex: nursing admission assessment
2. Problem-focused assessment – use to determine status of a specific
problem identified in an earlier assessment
 Ex: problem on urination-assess on fluid intake & urine output
hourly
3. Emergency assessment – rapid assessment done during any
physiologic/physiologic crisis of the client to identify life threatening
problems.
 Ex: assessment of a client’s airway, breathing status & circulation
after a cardiac arrest.
 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
1. Collection of data
2. Validation of data
3. Organization of data
4. Analyzing of data
5. Recording/documentation of data
Assessment
 Observation of the patient + Interview of patient, family & SO + examination
of the patient + Review of medical record
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, ringing of ears/Tinnitus
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.
 Reason for visit/Chief complaint – primary reason why client seek
consultation or hospitalization.
 History of present Illness – includes: usual health status, chronological story,
family history, disability assessment.
 Past Health History – includes all previous immunizations, experiences with
illness.
 Family History – reveals risk factors for certain disease diseases (Diabetes,
hypertension, cancer, mental illness).
 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
Cues
 Subjective or objective data observed by the nurse; it is what the client says,
or what the nurse can see, hear, feel, smell or measure.
Inferences
 The nurse interpretation or conclusion based on the cues.
 Example:
 Red swollen wound = infected wound
 Dry skin = dehydrated
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
 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.
 ASSESSMENT:
OBJECTIVE AND SUBJECTIVE DATA
 assessment is the systematic and continuous collection organization
validation and documentation of data.
 The nurse gathers information to identify the health status of the patient.
 Assessments are made initially and continuously throughout patient care.
 The remaining phases of the nursing process depend on the validity and
completeness of the initial data collection.

Review of clinical record

1. Client records contain information collected by many members of the
healthcare team, such as demographics, past medical history, diagnostic test
results and consultations
2. Reviewing the client’s record before beginning an assessment prevents the
nurse from repeating questions that the client has already been asked and
identifies information that needs clarification.
Interview
1. The purpose of an interview is to gather and provide information, identify
problems of concerns, and provide teaching and support.
2. The goals of an interview are to develop a rapport with the client and to
collect data
3. An interview has 3 major stages:
 1. Opening: purpose is to establish rapport by creating goodwill and
trust; this is often achieved through a self – introduction,
nonverbal gestures (a handshake), and small talk about the
weather, local sports team, or recent current event; the purpose
of the interview is also explained to the client at this time.
2. Body: during this phase, the client responds to open and closed-
ended questions asked by the nurse.
3. Closing: either the client or the nurse may terminate the interview,
it is important fro the nurse to try to maintain the rapport and trust
that was developed thus far during the interview process.
4. Types of questions
1. Closed questions used in directive interview
 Re____ short factual answers; e.g. “Do you have
pain?”
 Answers usually reveal limited amounts of information
 Useful with clients who are highly stressed and/or
have difficulty communicating
2. Open-ended questions used in nondirective interview
 Encourage clients to express and clarify their thoughts
and feelings; e.g. “How have you been sleeping
lately?’
 Specify the broad area to be discussed and invite
longer answers
 Useful at the start of an interview or to change the
subject
3. Leading questions
 Direct the client’s answer; e.g. “You don’t have any
questions about your medications, do you?”
 Suggests what answer is expected
 Can result in client giving inaccurate data to please the
nurse
 Can limit client choice of topic for discussion
Nursing History
1. Collection of information about the effect of the client’s illness on daily
functioning and ability to cope with the stressor (the human response)
2. Subjective data
 May be called “covert data”
 Not measurable or observable
 Obtained from client (primary source), significant others, or health
professionals (secondary sources).
 For example, the client states, “I have a headache”
3. Objective data
 May be called “overt data”
 Can be detected by someone other than the client
 Includes measurable and observable client behavior
 For example, a blood pressure reading of 190/110 mmHg.
Physical assessment
1. Systematic collection of information about the body systems through the use
of observation, inspection, auscultation, palpation and percussion
2. A body system format for physical assessment is found below:
 General assessement
 Integumentary system
 Head, ears, eyes, nose, throat
 Breast and axillae
 Thorax and lungs
 Cardiovascular system
 Nervous system
 Abdomen and gastrointestinal system
 Anus and rectum
 Genitourinary system
 Reproductive system
 Musculoskeletal system
Psychosocial assessment
1. Helpful framework for organizing data
2. A suggested format for psychosocial assessment is found below:
 Vocation/education/financial
 Home and Family
 Social, leisure, spiritual and cultural
 Sexual
 Activities of daily living
 Health Habits
 Psychological
3. The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may
also be helpful for guiding data collection
Purposes of assessment
1. To establish Database: all the information about a client: it includes:
o The nursing health history
o Physical examination
o The physician’s history
o Results of laboratory and diagnostic tests
2. Assessment is part of each activity the nurse does for and with the patient.
The purposes is
o To validate a diagnosis
o To provide basis for effective nursing care.
o It helps in effective decision making
o Basis for accurate diagnosis
o It promote holistic nursing care
 To provide effective and innovative nursing care (1. To
collecting data for nursing research 2. To evaluation of
nursing care)
 PHYSICAL EXAMINATION
Consultation
1. The nurse collects data from multiple sources: primary (client) and
secondary (family members, support persons, healthcare professionals and
records)
2. Consultation with individuals who can contribute to the client’s database is
helpful in achieving the most complete and accurate information about a
client
3. Supplemental information from secondary sources (any source other then
the client) can help verify information, provide information for a client who
cannot do so, and convey information about the client’s status prior to
admission
Review of literature
1. A professional nurse engages in continued education to maintain knowledge
of current information related to health care
2. Reviewing professional journals and textbooks can help provide additional
data to support or help analyze the client database

The nurse uses physical assessment for the following reasons:

 To gather baseline data about the client’s health
 To supplement, confirm or refute data obtained in the nursing history
 To confirm and identify nursing diagnoses
 To make clinical judgments about a client’s changing health status and
management
Preparation of Examination

 Environment – A physical examination requires privacy. An examination

room that is well equipped for all necessary procedures is preferable
 Equipment – Hand washing is done before equipment preparation and the
examination. Hand washing reduces the transmission of microorganisms
 Client
1. Psychological Preparation – clients are easily embarrassed when
forced to answer sensitive questions about bodily functions or
when body parts are exposed and examined. The possibility that
the examination will find something abnormal also creates anxiety
so reduction of this anxiety may be the nurse’s highest priority
before the examination
2. Physical Preparation – the client’s physical comfort is vital to the
success of the examination. Before starting, the nurse asks if the
client needs to use the toilet.
3. Positioning – during the examination, the nurse asks the clients to
assume proper positions so that body parts are accessible and
clients stay comfortable. Client’s abilities to assume positions will
depend on their physical strength and degree of wellness.
Order of Examination
1. General Survey – includes observation of general appearance and behavior,
vital signs, height and weight measurement
2. Review of systems
3. Head to toe examination
Skills in Physical Examination

1. Inspection – to detect normal characteristics or significant physical signs. To

inspect body parts accurately the nurse observes the following principles:
 Make sure good lighting is available
 Position and expose body parts so that all surface can be viewed
 Inspect each areas fro size, shape, color, symmetry, position and
abnormalities
 If possible, compare each area inspected with the same area of
the opposite side of the body
 Use additional light (for example, a penlight) to inspect body
cavities
2. Palpation – the hands can make delicate and sensitive measurements of
specific physical signs, so palpation is used to examine all accessible parts
of the body. The nurse uses different parts of the hand to detect
characteristics such as texture, temperature and the perception of
movement.
3. Percussion – examination by striking the body’s surface with a finger,
vibration and sound are produced. This vibration is transmitted through the
body tissues and the character of the sound depends on the density of the
underlying tissue
4. Auscultation – is listening to sound created in body organs to detect
variations from normal. Some sounds can be heard with the unassisted ear,
although most sounds can be heard only through a stethoscope.
 Bowel sounds
 Breath sounds:

 Vesicular
 Bronchovesicular
 Bronchial
        Examples of Adventitious Breath Sounds
1. Crackles (previously called rales)
2. Rhonchi
3. Wheeze
4. Friction rub
 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.
 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

Lovett Grad Percentage of

Functional level Scale e normal

No evidence of contractility Zero (Z) 0 0

Evidence of slight contractility Trace (T) 1 10

Complete ROM without gravity Poor (P) 2 25

Complete ROM with gravity Fair (F) 3 50

 Complete range of motion against gravity with
some resistance Good (G) 4 75

Complete  range of motion against gravity with Normal

full resistance (N) 5 100

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.
 VITAL SIGNS

 These are indices of health, or signposts in determining client’s condition.

This is also known as cardinal signs and it includes body temperature, pulse,
respirations, and blood pressure. These signs have to be looked at in total,
to monitor the functions of the body.

Different considerations in taking Vital signs

1. The frequency of taking TPR and BP depends upon the condition of the
client and the policy of the institution.
2. The procedure should be explained to the client before taking his TPR and
BP.
3. Obtain baseline data.
Vital Signs or Cardinal Signs are:
 Body temperature
 Pulse
 Respiration
 Blood pressure
 Pain
Body Temperature
 The balance between the heat produced by the body and the heat loss from
the body.
Types of Body Temperature
 Core temperature –temperature of the deep tissues of the body.
 Surface body temperature
Alteration in body Temperature
 Pyrexia – Body temperature above normal range( hyperthermia)
 Hyperpyrexia – Very high fever, 41ºC(105.8 F) and above
 Hypothermia – Subnormal temperature.
Normal Adult Temperature Ranges
 Oral 36.5 –37.5 ºC
 Axillary 35.8 – 37.0 ºC
 Rectal 37.0 – 38.1 ºC
 Tympanic 36.8 – 37.9ºC
Methods of Temperature-Taking
I. Oral – most accessible and convenient method.
1. Put on gloves, and position the tip of the thermometer under the patients
tongue on either of the frenulun as far back as possible. It promotes contact
to the superficial blood vessels and ensures a more accurate reading.
2. Wash thermometer before use.
3. Take oral temp 2-3 minutes.
4. Allow 15 min to elapse between client’s food intakes of hot or cold food,
smoking.
5. Instruct the patient to close his lips but not to bite down with his teeth to
avoid breaking the thermometer in his mouth.
Contraindications
 Young children an infant
 Patients who are unconscious or disoriented
 Who must breathe through the mouth
 Seizure prone
 Patient with N/V
 Patients with oral lesions/surgeries
II. Rectal- most accurate measurement of temperature
1. Position- lateral position with his top legs flexed and drapes him to provide
privacy.
2. Squeeze the lubricant onto a facial tissue to avoid contaminating the
lubricant supply.
3. Insert thermometer by 0.5 – 1.5 inches
4. Hold in place in 2minutes
5. Do not force to insert the thermometer
Contraindications
 Patient with diarrhea
 Recent rectal or prostatic surgery or injury because it may injure inflamed
tissue
 Recent myocardial infarction
 Patient post head injury
III. Axillary – safest and non-invasive
1. Pat the axilla dry
2. Ask the patient to reach across his chest and grasp his opposite shoulder.
This promote skin contact with the thermometer
3. Hold it in place for 9 minutes because the thermometer isn’t close in a body
cavity
Note:
 Use the same thermometer for repeat temperature taking to ensure more
consistent result
 Store chemical-dot thermometer in a cool area because exposure to heat
activates the dye dots.
IV. Tympanic thermometer
1. Make sure the lens under the probe is clean and shiny
2. Stabilized the patient’s head; gently pull the ear straight back (for children up
to age 1) or up and back (for children 1 and older to adults)
3. Insert the thermometer until the entire ear canal is sealed
4. Place the activation button, and hold it in place for 1 second
V. Chemical-dot thermometer
1. Leave the chemical-dot thermometer in place for 45 seconds
2. Read the temperature as the last dye dot that has change color, or fired.
Factors that Affect Body Temperature
1. Age
 The infant is greatly influenced by the temperature of the
environment and must be protected from extreme changes.
Children’s temperature continues to be more labile than those of
adults until puberty. Elderly people are at risk of hypothermia for
variety of reasons. Such as lack of central heating, inadequate
diet, loss of subcutaneous fat, lack of activity, and reduced
thermoregulatory efficiency.
2. Diurnal variations (circadian rhythms)
 This refers to the sleep – wake rhythm of the body, a pattern that
varies slightly from person to person. Body temperature normally
changes throughout the day, varying as much as 1.0C between
the early morning and the late afternoon.
3. Exercise
 Hard work or strenuous exercise can increase body temperature
4. Hormones
 Women usually experience more hormones fluctuations than men
do. Progesterone secretion at the time of ovulation raises body
temperature above basal temperature
5. Stress
 Stimulation of SNS can increase the production of epinephrine
and norepinephrine, thereby increasing metabolic activity and
heat production
6. Environment
 Extremes in environmental temperatures can affect a person’s
temperature regulatory systems.
Nursing Interventions in Clients with Fever
1. Monitor V.S
2. Assess skin color and temperature
3. Monitor WBC, Hct and other pertinent lab records
4. Provide adequate foods and fluids.
5. Promote rest
6. Monitor I & O
7. Provide TSB
8. Provide dry clothing and linens
9. Give antipyretic as ordered by MD
Heat – producing & Heat – losing Mechanisms
 Heat production: most body heat is produced by the oxidation of foods; the
rate at which it is produced is called METABOLIC RATE.
Heat Loss:
 Radiation
 Conduction
 Convection
 Evaporation
Pre – optic area of the Hypothalamus
 Temperature regulator; thermostat
 Receives input from temp receptors in the skin & mucous membranes
(peripheral thermoreceptors) & internal structures (central thermoreceptors)
* If blood temp increases, neurons of the pre – optic area fire nerve if it decreases.

Heat Promoting Centers

1. Vasoconstriction
 =Less blood flow from the internal organs to the skin= less heat
transfer from the internal organs to the skin= increases internal
body temperature
2. Sympathetic Stimulation
 = stimulation of sympathetic nerves leading to the adrenal
medulla = secretes epinephrine & norepinephrine = Increases
cellular metabolism = increases heat production
3. Skeletal Muscles
 = stimulation of part of the brain that increases muscle tone
(stretch reflex + contraction of muscles = SHIVERING) = heat
production
4. Thyroxine
 = increases metabolism = increase in body temperature
Body Temperature Abnormalities
1. Fever/hyperthermia/hyperpyrexia
 An abnormally high temp mainly results from infection from
bacteria (& their toxins) & viruses. (Stimulates prostaglandin
secretion)
 Other causes: heart attacks, tumors, tissue destruction by x – ray,
surgery or trauma & rxns to vaccines.
2. Heat cramps and Heat exhaustion
 Due to fluid & electrolyte loss
3. Heat Stroke
4. Hypothermia
The Thermometer
 A glass clinical thermometer is most commonly used to measure body
temperature.
It has 2 parts:
 Bulb– contains mercury which expands when exposed to heat & rise in the
stem
 Stem – is calibrated in degrees of Celcius or Fahrenheit
Pulse
 This is a wave of blood created by contraction of the left ventricle of the
heart. The heart is a pulsating pump, and the blood enters the arteries with
each heartbeat, causing pressure pulses or pulse waves. Generally, the
pulse wave represents the stroke volume and the compliance of the arteries.
  Stroke volume is the amount of blood that enters the arteries with each
contraction in a healthy adult.
 Compliance of the arteries is their ability to contract and expand. When a
person’s arteries lose their distensibility, greater pressure is required to
pump the blood into the arteries.
 Peripheral pulse is the pulse located in the periphery of the body, for
example in the foot, hand and neck. Apical pulse is a central pulse. It is
located at the apex of the heart.
Normal Pulse rate
 1 year 80-140 beats/min
 2 years 80- 130 beats/min
 6 years 75- 120 beats/min
 10 years 60-90 beats/min
 Adult 60-100 beats/min
 Tachycardia – pulse rate of above 100 beats/min
 Bradycardia– pulse rate below 60 beats/min
 Irregular – uneven time interval between beats.
What you need:
1. Watch with second hand
2. Stethoscope (for apical pulse)
3. Doppler ultrasound blood flow detector if necessary
Obtaining Radial Pulse
1. Wash your hand and tell your client that you are going to take his pulse
2. Place the client in sitting or supine position with his arm on his side or across
his chest
3. Gently press your index, middle, and ring fingers on the radial artery, inside
the patient’s wrist.
4. Excessive pressure may obstruct blood flow distal to the pulse site
5. Counting for a full minute provides a more accurate picture of irregularities
Obtaining Pulse Using Doppler device
1. Apply small amount of transmission gel to the ultrasound probe
2. Position the probe on the skin directly over a selected artery
3. Set the volume to the lowest setting
4. To obtain best signals, put gel between the skin and the probe and tilt the
probe 45 degrees from the artery.
5. After you have measure the pulse rate, clean the probe with soft cloth
soaked in antiseptic. Do not immerse the probe
Factors Affecting Pulse Rate
1. Age
 As age increases, the pulse rate gradually decreases
2. Sex
 After puberty, the average male’s pulse rate is slightly lower than
the female’s.
3. Exercise
  Pulse rate usually increases with activity
4. Fever
The pulse rate increases in response to the lowered blood
pressure that results from peripheral vasodilation associated with
elevated body temperature, and because of the increased
metabolic rate.
5. Medications
 Some medications decrease the pulse rate, and others increase
it.
6. Hemorrhage
 Loss of blood from the vascular system normally increases pulse
rate.
7. Stress
 In response to stress, sympathetic nervous stimulation increases
the overall activity of the heart. Stress increases the rate as well
as the force of the heartbeat.
8. Position changes
 When a person assumes a sitting or standing position, blood
usually pools in dependent vessels of the venous system. Pooling
results in a transient decrease in the venous blood return to the
heart and a subsequent reduction in blood pressure reduction in
blood pressure and increase in the heart rate.
Characteristics of Normal Pulse
1. Rate
 This is the number of pulse beats per minute (70 – 80 beats/min
in the adult). An excessively fast heart rate (100 beats/min) is
referred to as tachycardia. A heart rate in the adult of 60
beats/minute or less is called bradycardia.
2. Pulse rhythm
 This is the pattern of the beats and the intervals between the
beats. Equal time elapses between beats of a normal pulse. A
pulse with an irregular rhythm is referred to as a dysrhythmia or
arrhythmia. It may consist of random, irregular beats or a
predictable pattern of irregular beats.
3. Pulse volume
 This is also called the pulse strength or amplitude. It refers to the
force of blood with each beat. It can range from absent to
bounding. A normal pulse can be felt with moderate pressure of
the fingers and can be obliterated with greater pressure. A
forceful or full blood volume that is obliterated only with difficulty is
called a full or bounding pulse. A pulse that is readily obliterated
with pressure from the fingers is referred to as weak, feeble, or
thready. A pulse volume is usually measured on a scale 0 to 3.
Pulse sites
1. Temporal, where the temporal artery passes over the temporal bone of the
head. The site is superior and lateral to the eye.
2. Carotid, at the side of the neck below the lobe of the ear, where the carotid
artery runs between the trachea and the sternocleidomastoid muscle.
3. Apical, at the apex of the heart.
4. Brachial, at the inner aspect of the biceps muscle of the arm (especially in
infants) or medially in the antecubital space (elbow crease).
5. Radial, where the radial artery runs along the radial bone, on the thumb site
of the inner aspect of the wrist.
6. Femoral, where the femoral artery passes alongside the inguinal ligament.
7. Popliteal, where the popliteal artery passes behind the knee. This point is
difficult to find, but it can be palpated if the client flexes the knee slightly.
8. Poserior tibial, on the medial surface of the ankle where the posterior tibial
artery passes behind the medial malleolus.
9. Pedal (dorsalis pedis), where the dorsalis pedis artery passes over the
bones of the foot. This artery can be palpated by feeling the dorsum of the
foot on the imaginary line drawn from the middle of the ankle to the space
between the big and second toes.
Respiration
 Is the exchange of oxygen and carbon dioxide between the atmosphere and
the body
Assessing Respiration
 Rate – Normal 14-20/ min in adult
 The best time to assess respiration is immediately after taking client’s pulse
 Count respiration for 60 second
 As you count the respiration, assess and record breath sound as stridor,
wheezing, or stertor.
 Respiratory rates of less than 10 or more than 40 are usually considered
abnormal and should be reported immediately to the physician.
 Resting respirations should be assessed when the client is at rest because
exercise affects respirations, and increase their rate and depth as well.
Respiration may also need to be assessed after exercise to identify the
client’s tolerance to activity. Before assessing a client’s respirations, a nurse
should be aware of:
 The client’s normal breathing pattern.
 The influence of the client’s health problems on respirations.
 Any medications or therapies that might affect respirations.
 The relationship of the client’s respirations to cardiovascular
function.
Characteristics of Normal Respiration
1. Respiratory rate
 This is described in breaths per minute. A healthy adult normally
takes between 15 and 20 breaths per minute. Breathing that is
normal in rate is eupnea. Abnormally slow respirations are
referred to as bradypnea, and abnormally fast respirations are
called tachypnea or polypnea.
2. Depth
 This can be established by watching the movement of the chest.
It is generally described as normal, deep, or shallow.
3. Respiratory rhythm or pattern
 This refers to the regularity of the expirations and the inspirations.
Normally, respirations are evenly spaced. Respiratory rhythm can
be described as regular or irregular.
4. Respiratory quality or character
 This refers to those aspects of breathing that are different from
normal, effortless breathing. It includes:

 Amount of effort a client must exert to breathe.
Usually, breathing does not require noticeable effort.

 The sound of breathing. Normal breathing is silent, but
a number of abnormal sounds such as a wheeze are
obvious to the nurse’s ear.
Blood Pressure
 This is the force exerted by the blood against a vessel wall. Arterial blood
pressure is a measure of the pressure exerted by the blood as it flows
through the arties. There are two blood pressure measures:
1. Systolic pressure. This is the pressure of the blood because of contraction of
the ventricles, which is the height of the blood wave.
2. Diastolic pressure. This is the pressure when the ventricles are at rest. It is
the lower pressure present at all times within the arteries.
 Pulse pressure is the difference between the diastolic and systolic pressures.
 Blood pressure is measured in millimeters of mercury (mm Hg) and recorded
as a fraction. The systolic pressure is written over the diastolic pressure. The
average blood pressure of a healthy adult is 120/80 mm Hg. A number of
conditions are reflected by changes in blood pressure. The most common is
hypertension, an abnormally high blood pressure. Hypotension is an
abnormally low blood pressure below 100min Hg systolic.
        Adult – 90- 132 systolic
60- 85 diastolic
 Elderly– 140-160 systolic
70-90 diastolic
1. Ensure that the client is rested
2. Use appropriate size of BP cuff.
3. If too tight and narrow- false high BP
4. If too lose and wide-false low BP
5. Position the patient on sitting or supine position
6. Position the arm at the level of the heart, if the artery is below the heart level,
you may get a false high reading
7. Use the bell of the stethoscope since the blood pressure is a low frequency
sound.
8. If the client is crying or anxious, delay measuring his blood pressure to avoid
false-high BP
Electronic Vital Sign Monitor
1. An electronic vital signs monitor allows you to continually tract a patient’s
vital sign without having to reapply a blood pressure cuff each time.
2. Example: Dinamap VS monitor 8100
3. Lightweight, battery operated and can be attached to an IV pole
4. Before using the device, check the client7s pulse and BP manually using the
same arm you’ll using for the monitor cuff.
5. Compare the result with the initial reading from the monitor. If the results
differ call the supply department or the manufacturer’s representative.
Physiology of Arterial Blood Pressure
1. Pumping action of the heart
 Cardiac output is the volume of blood pumped into the arteries by
the heart. When the pumping action of the heart is weak, less
blood is pumped into arteries, and the blood pressure decreases.
When the heart’s pumping action is strong and the volume of
 blood pumped into the circulation increases, the blood pressure
increases. Cardiac output increases with fever and exercise.
2. Peripheral Vascular Resistance
 This can increase blood pressure. The diastolic pressure is
especially affected. The following are factors that create
resistance in the arterial system:

 Size of the arterioles and capillaries. This determines
in great part the peripheral resistance to the blood in
the body pressure, whereas decreased
vasoconstriction lowers the blood pressure.

 Compliance of the arteries. The arteries contain
smooth muscles that permit them to contract, thus
decreasing their compliance (distensibility). The major
factor reducing arterial compliance is pathologic
change affecting the arterial walls. The elastic and
muscular tissues of the arteries are replaced with
fibrous tissues. The condition, most common in
middle-aged and elderly adults, is known as
arteriosclerosis.

 Viscosity of the blood.
2. Blood volume
 When the blood volume decreases, the blood pressure decreases
because of decreased fluid in the arteries. Conversely, when the
volume increase, the blood pressure increases because of the
greater fluid volume within the circulatory system.
2. Blood viscosity
 This is a physical property that results from friction of molecules in
a fluid. The blood pressure is higher when the blood is highly
viscous, that is, when the proportion of RBC’s to the blood plasma
is high. This ratio is referred to as the hematocrit is more than 60
to 65%
Factors Affecting Blood Pressure
1. Age. Newborn have a mean systolic pressure of 78mmHg. The pressure
rises with age. The pressure rises with age, reaching a peak at the onset of
puberty, and then tends to decline somewhat.
2. Exercise. Physical activity increase both the cardiac output and hence the
blood pressure. Thus, a rest of 20 to 30 minutes is indicated before the blood
pressure can be readily assessed.
3. Stress. Stimulation of the sympathetic nervous system increase cardiac
output and vasoconstriction of the arterioles, thus increasing the blood
pressure.
4. Race. African – American males over 35 years have higher blood pressure
than European – American males of the same age.
 5. Obesity. Pressure is generally higher in some overweight and obese people
than in people of normal weight.
6. Sex. After puberty, females usually have lower blood pressures than males
of the same age; this difference is thought to be due to hormonal variations.
After menopause, women generally have higher blood pressures than
before.
7. Medications. Many medications may increase or decrease the blood
pressure; nurses should be aware of the specific medications a client is
receiving and consider their possible impact when interpreting blood
pressure readings.
8. Diurnal variations. Pressure is usually lowest early in the morning, when the
metabolic rate is lowest, then rises throughout the day and peaks in the late
afternoon or early evening.
9. Disease process. Any conditions affecting the cardiac output, viscosity, and
or compliance of the arteries have a direct effect on the blood pressure.

 
Effect
Error

Bladder cuff too narrow Erroneously high

Bladder cuff too wide Erroneously high

Arm unsupported Erroneously high

Insufficient rest before the assessment Erroneously high

repeating assessment too quickly Erroneously high

Cuff wrapped too loosely or unevenly Erroneously high

Deflating cuff too quickly Erroneously low systolic and high diastolic reading

Deflating cuff too slowly Erroneously high diastolic reading

Failure to use the same arm consistently Inconsistent measurements

Arm above level of the heart Erroneously low

Assessing immediately after a meal or while

client smokes Erroneously high

Erroneously low systolic pressure and erroneously

Failure to identify auscultatory gap pressure low diastolic

Common Errors in Blood Pressure Assessment

 Auscultatory gap is the temporary disappearance of sounds normally heard over the
brachial artery when the cuff pressure is high and the reappearance of the sounds at a
lower level.

Provide excellent clues to the physiological functioning of the body.

 Alterations in body fxn are reflected in the body temp, pulse, respirations and
blood pressure.
 These data provide part of the baseline info from which plan of care is
developed.
  Any change from normal is considered to be an indication of the person’s
state of health.
 Also called Cardinal Signs.

Pain
How to Assess Pain
1. You must consider both the patient’s description and your observations on
his behavioral responses.
2. First, ask the client to rank his pain on a scale of 0-10, with 0 denoting lack of
pain and 10 denoting the worst pain imaginable.
3. Ask:
a. Where is the pain located?
b. How long does the pain last?
c. How often does it occur?
d. Can you describe the pain?
e. What makes the pain worse?
4. Observe the patient’s behavioral response to pain (body language, moaning,
grimacing, withdrawal, crying,restlessness muscle twitching and  immobility)
5. Also note physiological response, which may be sympathetic or
parasympathetic
Managing Pain
1. Giving medication as per MD’s order
2. Giving emotional support
3. Performing comfort measures
4. Use cognitive therapy

Pain
  According to the International Association for the Study of
Pain, pain is an unpleasant, subjective sensory and emotional
experience associated with actual or potential tissue damage,
or described in terms of such damage.
Pain Theories
Specific Theory
1. Proposes that body’s neurons & pathways for pain transmission are
specific, similar to other senses like taste
2. Free nerve endings in the skin act as pain receptors, accept input &
transmit impulses along highly specific nerve fibers
3. Does not account for differences in pain perception or psychologic
variables among individuals.
Pattern Theory
1. Identifies 2 major types of pain fibers; rapidly & slowly conducting
2. Stimulation of these fibers forms a pattern; impulses ascend to the
brain to be interpreted as painful
3. Does not account for differences in pain perception or psychologic
variables among individuals.
Gate Control Theory
1. Pain impulses can be modulated by a transmission blocking action
within the CNS.
2. Large-diameter cutaneous pain fibers can be stimulated (e.g.
rubbing or scratching an area) and may inhibit smaller diameter
fibers to prevent transmission of the impulse (“close the gate”).
Current Developments in Pain Theory
Indicate that pain mechanisms & responses are far more complex than
believed to be in the past.

1. Pain may modulate at different points in the nervous system.

 First-order neurons at the tissue level
 Second-order neurons in the spinal cord that process
nociceptor information
 Third-order tracts & pathways in the spinal cord & brain
that relay/process this information
 2. The role of the pain experience in the development of new
nociceptors and/or reducing the threshold of current nociceptor is
also being investigate
Types of Pain
Acute Pain
1. Usually temporary, sudden in onset, localized, lasts for 6 months;
results from tissue injury associated with trauma, surgery, or
inflammation.
Types of Acute Pain
 Somatic: arises from nerve receptors in the skin or close to body’s
surface; may be sharp & well-localized or dull & diffuse; often
accompanied by nausea & vomiting
 Visceral: arises from body’s organs; dull & poorly localized because
of minimal noriceptors; accompanied by nausea & vomiting,
hypotension & restlessness
 Referred pain: pain that is perceived in an area distant from the site
of stimuli (e.g. pain in a shoulder following abdominal laparoscopic
procedure).
2. Acute pain initiates the “fight-or-flight” response of the Autonomic Nervous
System and is characterized by the following symptoms:

 Tachycardia
 Rapid, shallow respirations
 Increased BP
 Sweating
 Pallor
 Dilated pupils
 Fear & Anxiety
Chronic Pain
1. Prolonged, lasting longer than 6 months, often not attributed to a
definite cause, often unresponsive to medical treatment. Some
people may go to a mild-drug dosage to help them with the pain and
to give them a sense of relief through websites
like, https://www.payspi.org.
Types of Chronic Pain
  Neuropathic: painful condition that results from damage to peripheral
nerves caused by infection or disease; post-therapeutic neuralgia
(shingles) is an example
 Phantom: pain syndrome that occurs following surgical or traumatic
amputation of a limb.
 The client is aware that the body part is missing
 Pain may result of stimulation of severed nerves at the
site of amputation
 Sensation may be experienced as an itching, pressure, or
as stabbing or burning in nature
 It can be triggered by stressors (fatigue, illness, emotions,
weather)
 This experience is limited for most clients because the
brain adapts to amputated limb; however, some clients
experience abnormal sensation or pain over longer
periods
 This type of pain requires treatment just as any other type
of pain does.
 Psychogenic: pain that is experienced in the absence of a diagnosed
physiologic cause or event; the client’s emotional needs may prompt
pain sensation.
Some chronic pain can be helped and decreased by using CBD tincture that
can be found at sites like octavia wellness. Also consider pg group if you’re
interested in some marijunana instead to work on reducing the pain.
2. Depression is a common associated symptom for the client experiencing
chronic pain; feelings of despair & hopelessness along with fatigue are
expected findings.

Pain Assessment
Tools/Instruments Used
1. A Verbal Report using an intensity scale is a fast, easy & reliable
method allowing the client to state pain intensity & in turn, promotes
consisted communication among the nurse, client & other
healthcare professionals about the client’s pain status; the 2 most
 common scales used are “0 to 5” or “0 to 10”. With 0 specifying no
pain & the highest number specifying the worst pain
2. A Visual Analog Scale is a horizontal pain-intensity scale with word
modifiers at both ends of the scale, such as “no pain” at one end
and “worst pain” at the other, clients are asked to point or mark
along the line to convey the degree of pain being experienced
3. A Graphic Rating Scale is similar to the visual analog scale but adds a
numerical scale with the word modifiers, usually the numbers “0 to
10” are added to the scale.
4. Faces Pain Scale children, clients who do not speak English & clients
with communication impairments may have difficulty using a
numerical pain intensity scale; the FACES pain scale may be used
for children as young as 3 years old; this scale provides facial
expressions (happy face reflects no pain, crying face represents
worst pain)
5. Physiologic Indicators of Pain may be the only means a nurse can use
to assess pain for a non-communicating client, facial & vocal
expression may be the initial manifestations of pain; expressions
may include rapid eye blinking, biting of the lip, moaning, crying,
screaming, either closed or clenched eyes, or stiff unmoving body
position
A B C D E method of pain assessment
1. This acronym was developed for cancer pain; however, it is very
appropriate for clients with any type of pain, regardless of the
underlying disease.
2. A = Ask about pain
3. B = Believe the client & family reports pain
4. C = Choose pain control options appropriate for the client
5. D = Deliver interventions in a timely, logical &coordinated fashion
6. E = Empower clients & families
P Q R S T assessment for pain reception
1. This method is especially helpful when approaching a new pain
problem
2. P = What precipitated the pain?
3. Q = What are the quality & quantity of the pain?
4. R = What is the region of the pain?
 5. S = What is the severity of the pain?
6. T = What is the timing of the pain?
Pain History
1. Location – when clients report “pain all over”, this generally refers to
total pain or existential distress (unless there is an underlying
physiologic reason for pain all over the body, such as myalgias);
assess the client’s emotional state for depression, fear, anxiety or
hopelessness.
2. Intensity – It is important to quantify pain using a standard pain
intensity scale. When clients cannot conceptualize pain using a
number, simple word categorizes can be useful (e.g. no pain, mild,
moderate, severe).
3. Quality- Nociceptive pain are usually related to damage to bones,
soft tissues, or internal organs; nociceptive pain includes somatic &
visceral pains.
 Somatic pain is aching, throbbing pain; example arthritis
 Visceral pain is squeezing, cramping pain; example: pain
associated with ulcerative colitis
4. Pattern – pain may be always present for a client; this is often
termed baseline pain. Additional pain may occur intermittently that
is of rapid onset & greater intensity than the baseline pain; known as
breakthrough pain. People at end-of-life often have both types of
pain. Cultural beliefs regarding the meaning of pain should be
examined