Arba Minch University

College of Medicine and Health

Sciences
Department of
Midwifery

Antenatal Care, Obstetrics,

Gynecologic History
&
Physical
Examination

Gordon’s Functional
Health
Patterns Assessment,
Nursing
Process & NANDA
Approved

Prepared by Gebremichael Reta Mengistu (BSc.)

 Nursing Diagnoses 2015-
2017

By Gebremichael Reta Mengistu

June 2018
Arba Minch, Ethiopia

Prepared by Gebremichael Reta Mengistu (BSc.)

 Antenatal Care History and
Physical
Examination
History
1. Identification
 Name Religion 
 Age Occupation 
 Sex 
Educational Status
 Address 
Date of visit
Medical Registration
 Marital status  Number
 OPD, Ward, Bed or
 Ethnicity Unit
2. Source of referral: Self, Health center, Health post/HEWs, etc.
3. Source of history: Herself, husband, etc.
4. Mode of arrival: Public transport, Ambulance
5. Pervious history of visit/admission with case: If Yes with
case/No
6. Chief complaints: Patients may have come for routine antenatal
care follow up or may come with one or more specific complaints.
Note the duration of each complaint.
7. History of present pregnancy: Get information on the
following points:

Gravidity: all forms of pregnancy whether it is term, live births, still
birth, abortion, ectopic pregnancy or molar pregnancy.

Parity: fetus delivered after 28 weeks of gestation for Ethiopia and
United kingdom and greater than or equal to 20 weeks – according to
WHO

Abortion: Loss of pregnancy before 28 weeks of gestation for
Ethiopia and UK and less than 20 weeks according to WHO

Last normal menstrual period (LNMP)

Expected date of delivery (EDD)- which could be calculated by:
1- Ethiopian calendars
 LNMP+ 9 months +10 days if pagume is not
passed
 LNMP+ 9 months + 5/4 days if
pagume is passed 2- Naegale’s rule (using European
calendar)
 LNMP- 3 months + 7 days

Gestational age: Calculate gestational age in completed weeks and
days by using LNMP.

Date of quickening: the first time the mother felt fetal movement
 In primigravida it is around 18-20 weeks and in
multigravida at 16-18 weeks of gestational age.
 Used to date pregnancy if LNMP is unknown

Presence of ANC elsewhere, place and number of visits

Elaboration of chief complaints

Sign and symptoms of pregnancy(if early)

Prepared by Gebremichael Reta Mengistu (BSc.)

 
Danger symptoms of pregnancy: vaginal bleeding, severe
headache, blurring of vision, epigastric or severe abdominal
pain, profuse vaginal discharge, absence or reduction of fetal
movement, fever and persistent vomiting.

Prepared by Gebremichael Reta Mengistu (BSc.)

 
Pregnancy facts: planned or unplanned pregnancy, wanted
or unwanted, supported or unsupported

Any client concern or complaints

Ask positive and negative statement according to the patient complaints
8. Past obstetric history
The following should be asked for all previous pregnancies in
chronologic order:

Date, month and year of gestation for example first delivery in June 2017

Length of gestation - abortion (< 28 weeks), preterm (<37
completed weeks), term (>37 completed to 42 completed
weeks), post term (greater than 42 completed weeks)

Onset of labor (spontaneous or induced)

Fetal presentation

Duration of labor

Mode of delivery (spontaneous vaginal, instrumental, caesarian
section, destructive delivery)

Place of delivery

Fetal outcome (alive or dead, sex of the newborn, weight of the
newborn, malformations, current condition)

Complications which can recur or have an impact on current pregnancy

Complications/health problems during previous pregnancy: Pre-term
labor, APH, pre-eclampsia, PROM, uterine rupture, PPH, infections,
early neonatal deaths, etc.
9. Past

gynecology history
Family planning methods - use , type , duration and side effects

Sexual history- assess risk of sexually transmitted infections and HIV/AIDS

Gynecology operations- Female genital mutilation , laparatomy,
dilatation and curettage ,evacuation and curettage, manual vacuum
aspiration

Menstrual history ( age of menarche, interval of period 21-36 days,
amount of flow 10 –80 ml, duration of flow 1-8 days, normally dark
red and non-clotting).
10. Past medical and surgical history

History of diabetes mellitus, hypertension, hypo or hyper
thyroidism which may the affect pregnancy or get aggravated
by pregnancy

Blood transfusion important in hemolytic disease of new born

Drugs risk of teratogenicity or allergic reactions

Maternal infection – TORCH Syndrome.
11. Personal, family and social history
 Childhood development
 Educational status
 Habits like alcohol , smoking and elicit drugs
 Occupation- exposure to radiation, anesthesia- halothane,
chemical factory and others
 Income- low socio-economic status associated with obstetric
problems like preeclampsia ,preterm labor
 Family history- diabetes mellitus, hypertension, multiple
pregnancy, genetic disorders

Prepared by Gebremichael Reta Mengistu (BSc.)

 12. Review of Systems/Functional inquiry
 General condition
 HEENT
 Check all systems
Physical examination
1. General appearance
2. Vital signs and anthropometric measurements
 Blood pressure: positions include left lateral with 300 tilt to
the left to avoid supine hypotensive syndrome or sitting
position in ambulatory patient.
 Pulse rate: increases 10-15 beats/minute in pregnancy
 Respiratory rate: increases 1-4 breath /minute in pregnancy
 Temperature
 Weight: pregnancy and pre-pregnancy weight. Increment of
more than 1kg/week is abnormal
 Height: less than 150 centimeters could be constitutional
but may be a risk factor. Strikingly short for every society is
risk factor.
3. HEENT

Emphasis on conjunctiva, sclera, teeth and buccal mucus
membrane to see pallor, jaundice, edema, mucosal congestion and
dental carries.
4. Lympho glandular System
 Thyroid gland for hyper or hypo thyroidism signs.
 Breast for nipple refraction, pigmentation, lumps, discharge,
colour change
5. Respiratory and cardiovascular system
Steps in examination are essentially same as non-pregnant
patient. Note that the following are normal findings in
pregnancy.

Decreased diaphragmatic excursion due to diaphragm elevation by gravid
uterus

PMI deviation to left is possible in pregnancy

S3 gallop may be heard

Functional systolic murmur may be heard
6. Abdomen
i. Inspection( 5s)-size, shape, scar, striae and skin
 Linea nigra- midline hyper pigmentation due to melanocyte
stimulating hormone
 Striae gravidarum – purplish in new striae and white in old
striae. In both cases is due to distension, which causes
stretching.
 Umbilicus may be inverted, flat or everted
 Surgical or non-surgical scar
 Distended veins, flank fullness, fetal movement
ii. Palpation
 Superficial palpation – checks for rigidity, tenderness,
superficial mass and characterize it, abdominal wall defects.
 Deep palpation – palpate for mass, organomegally and
characterize the mass
 Obstetric palpation or Leopold’s maneuver
A. The first Leopold maneuver or fundal palpation
Prepared by Gebremichael Reta Mengistu (BSc.)
 3

Prepared by Gebremichael Reta Mengistu (BSc.)

 I. Fundal height measurement: first correct for asymmetry
before measurement. Then use one of the following
methods:
1- Finger method – one finger above umbilicus is equal
to two weeks and below umbilicus one finger is
equal to one week. Uterus felt at symphysis
corresponds to 12 weeks. At the umbilicus it is 20
weeks and at xiphysternum it is 38 weeks.
2- Tape measurement: symphysis to funded height in
centimeter with tape meter between 18-34 weeks is
accurate to within two weeks of actual gestational
age.
II. Determine what occupies the fundus. If soft, irregular
bulky mass is found it is the breech. If hard round
ballotable mass is found, it is the head.
B. The second Leopold maneuver or lateral palpation
I. Determines the lie of the fetus which could be
longitudinal, transverse or
oblique lie. .
II.In longitudinal lie it determines on which side of the
abdomen is the fetal back. The back of the fetus is linear,
rigid and smooth in outline. The extremities are felt as
small irregular and bulky masses. The fetal heart beat is
best heard on back side.
C.The third Leopold maneuver or Pelvic palpation
I. Determines what part of the fetus occupies the lower
uterine pole which is also called the presentation. The
possibilities are the head (cephalic presentation), the
breech (breech presentation), and the shoulder (shoulder
presentation).
II. In cephalic presentations it determines the descent by
using rule of fifth which measures the distance between
upper border of the symphysis to anterior shoulder.
5/5 is floating head, 4/5 is fixed head, 2/5 denotes engaged
head.
III. In conjunction of the findings of the second maneuver
it determines the attitude of the fetus (relation of head to
the trunk). In extended attitude the cephalic prominence
is on the same side of the back. In flexed attitude the
cephalic prominence is on the opposite side of the back. In
military attitude the cephalic prominence is felt on both
sides at the same level.
D. The fourth Leopold maneuver or Pawlik grip
It is the only maneuver that is done with one hand. It
assesses presentation of the fetus.
iii. Percussion
 Shifting and flank dullness
 Fluid thrill
iv. Auscultation

Prepared by Gebremichael Reta Mengistu (BSc.)

  Fetal heart beat is first heard in the back side at16-18 weeks
in multiparas and 18-20 weeks in primigravida. In complete
breech it is heard above umbilicus. In cephalic presentations
it is below umbilicus. In occipito posterior it is heard in the
flanks. .
7. Genitourinary system
 Costovertebral and suprapubic tenderness
 Pelvic examination- to be done two times in pregnancy except
in cases of complications and if labor is suspected

Prepared by Gebremichael Reta Mengistu (BSc.)

 I. First trimester (early) – To diagnose pregnancy, for
dating of the pregnancy by measuring uterine size and to
diagnose pelvic problems II. Late in pregnancy greater
than 37 weeks
A. To diagnose contracted pelvis (refer
chapter on) B. To assess Bishop Score (refer
to chapter on induction)
III. In labor assess cervical dilatation and effacement,
status of the membranes and color of liquor, presenting
part, station of presenting part and position, molding,
caput, clinical pelvimetry.
8. Integumentary system
 Hyper pigmentation on breast, lower and mid line abdomen
genitalia are normally seen in pregnancy
 Vascular Changes- Spider angiomata and palmar erythema
9. Extremities
 Check for edema, dilated vessels and calf tenderness.
Dependent edema (pretibial and pedal), seen in 80% of normal
pregnancies. Pathological edema (non -dependent) involves the
face, fingers or the whole body.
10. Central nervous system
 As non-pregnant
Laboratory Examination:

Hct/Hgb

Blood group and Rh

U/A for: proteinuria, glucose, ketone, infection

Serology examination for syphilis, HBSAg

PTIC

Other investigation as indicated

Prepared by Gebremichael Reta Mengistu (BSc.)

 5

Prepared by Gebremichael Reta Mengistu (BSc.)

 Obstetrics History &
Physical Examination
History
1. Identification
 Name  Religion
 Age  Occupation
 Sex  Educational Status
 Address  Date of admission
Medical Registration
 Marital status  Number
 Ethnicity  Ward and bed number
2. Source of Referral: Self, Health center, Health post, etc.
3. Source of History: Herself, husband, etc.
4. Mode of Arrival: Public transport, Ambulance
5. Pervious History of Admission with Case: If Yes with
case/No
6. Chief complaints: Patients may have come for routine antenatal
care follow up or may come with one or more specific complaints.
Note the duration of each complaint.
7. History of present pregnancy: Get information on the
following points
 Gravidity: all forms of pregnancy whether it is term, live
births, still birth, abortion, ectopic pregnancy or molar
pregnancy.
 Parity: fetus delivered after 28 weeks of gestation for
Ethiopia and United kingdom and greater than or equal to 20
weeks – according to WHO
 Abortion
 Last normal menstrual period (LNMP)
 Expected date of delivery (EDD) which could be calculated
by
1. Naegale’s rule (using European calendar)
 LNMP- 3 months + 7 days
2. Ethiopian calendars
 LNMP+ 9 months +10 days if pagume is not passed
 LNMP+ 9 months + 5/4 if pagume is passed
 Calculate gestational age in completed weeks and days by
using LNMP
 If the mother doesn’t know her LNMP use developmental
milestones for pregnancy:
a. Date of quickening: the first time the mother felt fetal movement
- In primigravida it is around 18-20 weeks and in
multigravida at 16-18 weeks of gestational age.
+20wk
b. The date when first HCG test positive+36wk
c. Ultrasound result up to 20 week +19wk
Prepared by Gebremichael Reta Mengistu (BSc.)
 d. Doppler ultrasound of FHR at 10 wk+29wk
e. Fetal heart rate from 18-20wk up to 36 wk
 Presence of antenatal care elsewhere: Place and Number of
visits.
 Elaboration of chief complaints

Prepared by Gebremichael Reta Mengistu (BSc.)

  Danger symptoms of pregnancy: vaginal bleeding, severe
headache, blurring of vision, epigastric or severe abdominal
pain, profuse vaginal discharge, absence or reduction of fetal
movement, fever, persistent vomiting.
 Common complaints in pregnancy (like nausea, vomiting,
weakness etc.
 Pregnancy - unplanned , unwanted and unsupported
 Ask positive and negative statement according to the patient
complaints
8. Past obstetric history
The following should be asked for all previous pregnancies in
chronologic order

Date, month and year of gestation for example first delivery in July 2017

Length of gestation - abortion (< 28 weeks), preterm (<37
completed weeks), term (>37 completed to 42 completed
weeks), post term (greater than 42 completed weeks)

Significant antenatal medical problems like hypertension, ante
partum hemorrhage, diabetes

Onset of labor (spontaneous or induced)

Fetal presentation

Duration of labor

Mode of delivery (spontaneous vaginal, instrumental, caesarian
section, destructive delivery)

Place of delivery

Fetal outcome (alive or dead, sex of the newborn, weight of the
newborn, malformations, current condition)

Post- partum complications: postpartum hemorrhage, postpartum psychosis,
etc.
9. Past gynecology history
 Family planning methods - use , type , duration and side
effects
 Sexual history- assess risk of sexually transmitted infections
and HIV/AIDS
 Gynecology operations- Female genital mutilation,
laparotomy, dilatation and curettage ,evacuation and
curettage, manual vacuum aspiration
 Menstrual history ( age of menarche, interval of period 21-36
days, amount of flow 10 –80 ml, duration of flow 1-8 days,
normally dark red and non-clotting).
10. Past medical and surgical history

History of diabetes mellitus, hypertension, hypo or hyper
thyroidism which may the affect pregnancy or get aggravated
by pregnancy

Blood transfusion important in hemolytic disease of new born

Drugs risk of teratogenicity or allergic reactions

Maternal infection – TORCH Syndrome.
11. Personal, family and social history

Childhood development

Educational status

Habits like alcohol , smoking and elicit drugs

Occupation- exposure to radiation, anesthesia- halothane, chemical
factory and others

Income- low socio-economic status associated with obstetric
problems like preeclampsia ,preterm labor

Prepared by Gebremichael Reta Mengistu (BSc.)

 7

Prepared by Gebremichael Reta Mengistu (BSc.)

 
Family history- diabetes mellitus, hypertension, multiple
pregnancy, genetic disorders
12. Review of Systems/Functional inquiry
 General condition
 HEENT
 Check all systems
Physical examination
Examination must be done in a private room in the presence of a chaperone.
Proper explanation must be offered to the patient before during and after
the examination. Bladder should be emptied and the patient properly
positioned on the couch. Warm hands and instruments must be used.
Adequate light, appropriate gloves and swabs should be prepared. Always
keep eye contact throughout the examination.
1. General appearance
2. Vital signs and anthropometric measurements
 Blood pressure: positions include left lateral with 300 tilt to
the left to avoid supine hypotensive syndrome or sitting
position in ambulatory patient.
 Pulse rate: increases 10-15 beats/minute in pregnancy
 Respiratory rate: increases 1-4 breath /minute in pregnancy
 Temperature
 Weight: pregnancy and pre-pregnancy weight. Increment of
more than 1kg/week is abnormal
 Height: less than 150 centimeters could be constitutional
but may be a risk factor. Strikingly short for every society is
risk factor.
3. HEENT
 Emphasis on conjunctiva, sclera, teeth and buccal mucus
membrane to see pallor, jaundice, edema, mucosal congestion and
dental carries.
4. Lymphoglandular System
 Thyroid gland for hyper or hypo thyroidism signs.
 Breast for nipple refraction, pigmentation, lumps, discharge,
colour change
5. Respiratory and cardiovascular system
Steps in examination are essentially same as non-pregnant
patient. Note that the following are normal findings in
pregnancy.
 Decreased diaphragmatic excursion due to diaphragm
elevation by gravid uterus
 PMI deviation to left is possible in pregnancy
 S3 gallop may be heard
 Functional systolic murmur may be heard
6. Abdomen
A. Inspection (5s)
 Linea nigra- midline hyper pigmentation due to melanocyte
stimulating hormone

Prepared by Gebremichael Reta Mengistu (BSc.)

  Striae gravidarum – purplish in new striae and white in old
striae. In both cases is due to distension, which causes
stretching.
 Umbilicus may be inverted, flat or everted
 Surgical or non-surgical scar

Prepared by Gebremichael Reta Mengistu (BSc.)

  Distended veins, flank fullness, fetal movement
B. Palpation
 Superficial palpation – checks for rigidity, tenderness,
superficial mass and characterize it, abdominal wall defects.
 Deep palpation – palpate for mass, organomegally and
characterize the mass
 Obstetric palpation or Leopold’s maneuver
a. The first Leopold maneuver or fundal palpation
I. Fundal height measurement: first correct for asymmetry
before measurement. Then use one of the following
methods:
3- Finger method – one finger above umbilicus is equal
to two weeks and below umbilicus one finger is
equal to one week. Uterus felt at symphysis
corresponds to 12 weeks. At the umbilicus it is 20
weeks and at xiphysternum it is 38 weeks.
4- Tape measurement: symphysis to funded height in
centimeter with tape meter between 18-34 weeks is
accurate to within two weeks of actual gestational
age.
II. Determine what occupies the fundus. If soft, irregular
bulky mass is found it is the breech. If hard round
ballotable mass is found, it is the head.
b. The second Leopold maneuver or lateral palpation
I. Determines the lie of the fetus which could be
longitudinal, transverse or
oblique lie. .
II.In longitudinal lie it determines on which side of the
abdomen is the fetal back. The back of the fetus is linear,
rigid and smooth in outline. The extremities are felt as
small irregular and bulky masses. The fetal heart beat is
best heard on back side.
c.The third Leopold maneuver or Pelvic palpation
I. Determines what part of the fetus occupies the lower
uterine pole which is also called the presentation. The
possibilities are the head (cephalic presentation), the
breech (breech presentation), and the shoulder (shoulder
presentation).
II. In cephalic presentations it determines the descent by
using rule of fifth which measures the distance between
upper border of the symphysis to anterior shoulder.
5/5 is floating head, 4/5 is fixed head, 2/5 denotes engaged
head.
III. In conjunction of the findings of the second maneuver
it determines the attitude of the fetus (relation of head to
the trunk). In extended attitude the cephalic prominence
is on the same side of the back. In flexed attitude the
cephalic prominence is on the opposite side of the back. In
military attitude the cephalic prominence is felt on both
sides at the same level.
Prepared by Gebremichael Reta Mengistu (BSc.)
 d.The fourth Leopold maneuver or Pawlik grip
It is the only maneuver that is done with one hand. It
assesses presentation of the fetus.
C. Percussion
 Shifting and flank dullness
 Fluid thrill
D. Auscultation

Prepared by Gebremichael Reta Mengistu (BSc.)

  Fetal heart beat is first heard in the back side at16-18 weeks
in multiparas and 18-20 weeks in primigravida. In complete
breech it is heard above umbilicus. In cephalic presentations
it is below umbilicus .IN occipito posterior it is heard in the
flanks. .
7. Genitourinary system
 Costovertebral and suprapubic tenderness
 Pelvic examination- to be done two times in pregnancy except
in cases of complications and if labor is suspected
I. First trimester (early) – To diagnose pregnancy, for
dating of the pregnancy by measuring uterine size and to
diagnose pelvic problems
II. Late in pregnancy greater than 37 weeks
A. To diagnose contracted pelvis (refer chapter on)
- B. To assess Bishop score- (refer to chapter on
induction)
III. In labor assess cervical dilatation and effacement,
status of the membranes and color of liquor, presenting
part, station of presenting part and position, molding,
caput, clinical pelvimetry.
8. Intgumentary system
 Hyper pigmentation on breast, lower and mid line abdomen
genitalia are normally seen in pregnancy
 Vascular Changes- Spider angiomata and palmar erythema
9. Extremities
 Check for edema, dilated vessels and calf tenderness.
Dependent edema (pretibial and pedal), seen in 80% of normal
pregnancies. Pathological edema (non-dependent) involves the
face, fingers or the whole body.
10. Central nervous system
 As non- pregnant
Laboratory Investigation

Prepared by Gebremichael Reta Mengistu (BSc.)

 10

Prepared by Gebremichael Reta Mengistu (BSc.)

Gynecology History and
Physical Examination
History
1. Identification
 As obstetric history
2. Source of Referral: Self, Health center, Health post, etc.
3. Source of History: Herself, husband
4. Mode of Arrival: Public transport, Ambulance
5. Pervious History of Admission with Case: If Yes with
case/No
6. Chief complaints: Patient comes with the following
gynecologic complaints. The
common complaints are cessation of menses, vaginal bleeding and
discharge, lower abdominal pain or deep pelvic pain, pain during
intercourse (dysparunia), pain during menstruation (dysmenorrhea),
protruding mass out of the introitus, genital ulcer, urinary
incontinence and others.
7. History of present illness
 Gravidity, parity and abortion
 Detail of each complaint (localization, duration, date and time of
onset, aggravating and relieving factors, sequence of symptoms,
evolution with time, effect on life style, relation to menstrual
cycle and others)
 LMP should be included details of menstrual history if pertinent
to the complaints
 Negative and positive statements pertinent to the presenting
complaint
 Treatment received
8. Menstrual history

Age of menarche

Interval between period

Duration of flow

Amount & character of flow

Dysmenorrhea , premenstrual symptoms

Age of menopause
9. Past gynecologic history
 As obstetric history
10. Past obstetric history
 As obstetric history
11. Past medical and surgical history
 As obstetric history
12. Personal social family, history
 As obstetric history
13. Review of systems/Functional inquiry
 As obstetrics history

Prepared by Gebremichael Reta Mengistu (BSc.)

 11

Prepared by Gebremichael Reta Mengistu (BSc.)

Physical examination
Preparation for examination is similar to obstetric examination. In addition
slides, applicator, test tube, gloves, speculum and fixative are needed.
1. General appearance
2. Vital signs
 Blood pressure, pulse rate, respiratory rate, temperature
3. HEENT
 As non-pregnant
4. Lymphoglandular system

Lymph nodes- to see for metastatic cancer check mainly
supraclavicular and axillary nodes.

Thyroid gland- hypo and hyper thyroidism affects reproductive function

Breast examination- inspection and palpation
5. Chest and cardiovascular system
 As non-pregnant
6. Abdomen
 As non-pregnant (Inspection, auscultation, palpation and
percussion)
7. Genitourinary system
 Costovertebral and suprapubic tenderness
 Pelvic examination
I. Examination of external genitalia:
Pubic hair- diamond shaped in male and inverted triangle
in female.

II. Speculum Examination

Vagina- note color (normally pink), vaginal septum, rugae
folds, fornices, discharge, scar, laceration
Cervix – note color (normally pink) pink, cervical os (pin-
pointed in nulliparous and slit-like in multiparous), dilatation,
effacement and
bleeding, mass
III. Digital vaginal & bimanual pelvic
examination Vagina- mass and
tenderness
Cervix- Closed normally, moves 2- 4cm without discomfort,
smooth surface and like tip of nose inconsistency.
Uterus- normally non-tender, mobile, 9 cm in length, pear
shaped smooth
and firm.
Adnexa (tubes, ovaries, parametrium and broad ligaments): normally adenexal structure
not palpable except in thin women with soft abdomen,
description of masses.
Rectal and recto vaginal
IV. examination
Rectal examination- In virgin and
children
Rectovaginal examination- For uterosacr ligam
Prepared by Gebremichael Reta Mengistu (BSc.)
 rectovaginal and al ent
nodularity or malignant infiltration
To differentiate rectocele from
enterocele

12

Prepared by Gebremichael Reta Mengistu (BSc.)

 8. Intgumentary
 As non-pregnant
9. Extremities
 As non-pregnant
10. Central nervous system
 As non- pregnant
Laboratory Investigation

13

Prepared by Gebremichael Reta Mengistu (BSc.)

 Gordon’s Functional Health
Patterns
Assessment
Identification
 Name 
Religion
 Age 
Occupation
 Sex 
Educational Status
 Address 
Date of admission
Medical Registration
 Marital status  Number
 Ethnicity  Ward and bed number
Chief complaints: One or more specific complaints and duration of
each complaint+ some pertinent positive symptoms
Medical Diagnosis:
1. Health Perception -Health Management Pattern
History/Subjective date
a. How has general health been?
b. Any colds in past year? When appropriate: absences from
work/school?
c. Most important things you do to keep healthy? Think these things
make a difference to health? (Include family folk remedies when
appropriate.) Use of cigarettes, alcohol, drugs? Perform self-exams?
i.e. Breast self-examination.
d. Accidents (home, work, school, driving)?
e. In past, been easy to find ways to follow suggestions from
physicians or nurses?
f. When appropriate: what do you think caused this illness? Actions
taken when symptoms perceived? Results of action?
g. When appropriate: things important to you in your health care?
How can we be most
helpful? How often do you
exercise? Examination/Objective
date: general health appearance
2. Nutritional-Metabolic Pattern
History/Subjective date
a. Typical daily food intake? (Describe.) Supplements (vitamins, type
of snacks)?
b. Typical daily fluid intake? (Describe.)
c. Weight loss or gain? (Amount) Height loss or gain? (Amount)
d. Appetite?
e. Food or eating: Discomfort? Swallowing? Diet restrictions?
f. Heal well or poorly?
g. Skin problems: Lesions? Dryness?
h. Dental problems?
Examination/Objective date
Prepared by Gebremichael Reta Mengistu (BSc.)
 a. Skin: Bony prominences? Lesions? Color changes? Moistness?
b. Oral mucous membranes: Color? Moistness? Lesions?
c. Teeth: General appearance and alignment? Dentures? Cavities?
Missing teeth?
d. Actual weight, height.
e. Temperature.

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 f. Intravenous feeding–parenteral feeding (specify)?
3. Elimination Pattern
History/Subjective data
a. Bowel elimination pattern? (Describe) Frequency? Character?
Discomfort? Problem in control? Laxatives?
b. Urinary elimination pattern? (Describe.) Frequency? Problem in
control?
c. Excessive perspiration? Odor problems?
d. Body cavity drainage, suction, and so on? (Specify.)
Examination/Objective data: when indicated: examine excreta or drain-
age color and consistency.
4. Activity-Exercise Pattern
History/Subjective data
a. Sufficient energy for desired or required activities?
b. Exercise pattern? Type? Regularity?
c. Spare-time (leisure) activities? Child: play activities?
d. Perceived ability (code for level) for:
Feeding _________________________ Dressing _________________________
Cooking _________________________ Bathing _________________________
Grooming _______________________ Shopping ________________________
Toileting ________________________ General
mobility______________________
Bed mobility______________________ Home maintenance
__________________
Functional Level Codes: Level 0: full self-care
• Level I: requires use of equipment or device
• Level II: requires assistance or supervision from another person
• Level III: requires assistance or supervision from another
person and equipment or device
• Level IV: is dependent and does not participate
Examination/Objective data
a. Demonstrated ability (code listed above) for:
Feeding_________________________ Dressing________________________
Cooking___________________________Bathing_________________________
Grooming________________________
Shopping__________________________
Toileting________________________ General mobility___________________
b. Gait_____________________________ Posture__________________________
Absent body part?
__________________(Specify)_________________________
c. Range of motion
(joints)________________Muscle________________Firmness_____________
____
d. Hand grip ___________________Can pick up a pencil?
________________________
e. Pulse (rate) _______________________ (rhythm) ______________________
Breath sounds___________________
f. Respirations (rate) __________________ (rhythm)
______________________ Breath sounds____________________
g. Blood pressure ______________________
Prepared by Gebremichael Reta Mengistu (BSc.)
 h. General appearance (grooming, hygiene, and energy level)
5. SLEEP-REST PATTERN
History/Subjective data
a. Generally rested and ready for daily activities after sleep?
b. Sleep onset problems? Aids? Dreams (nightmares)? Early
awakening?

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 c. Rest-relaxation periods?
Examination/Objective data
a. When appropriate: Observe sleep pattern.
6. Cognitive-Perceptual Pattern
History/Subjective data
a. Hearing difficulty? Hearing aid?
b. Vision? Wear glasses? Last checked? When last changed?
c. Any change in memory lately?
d. Important decision easy or difficult to make?
e. Easiest way for you to learn things? Any difficulty?
f. Any discomfort? Pain? When appropriate: How do you manage it?
Examination/Objective data
a. Orientation?
b. Hears whisper?
c. Reads newsprint?
d. Grasps ideas and questions (abstract, concrete)?
e. Language spoken.
f. Vocabulary level. Attention span.
7. Self-Perception-Self- Concept Pattern
History/Subjective data
a. How describe self? Most of the time, feel good (not so good) about
self?
b. Changes in body or things you can’t do? Problem to you?
c. Changes in way you feel about self or body (since ill- ness started)?
d. Things frequently make you angry? Annoyed? Fearful? Anxious?
e. Ever feel you lose hope?
Examination/Objective data
a. Eye contact. Attention span (distraction)
b. Voice and speech pattern. Body posture
c. Nervous (5) or relaxed (1); rate from 1 to 5.
d. Assertive (5) or passive (1); rate from 1 to 5.
8. Roles-Relationships Pattern
History/Subjective data
a. Live alone? Family? Family structure (diagram)?
b. Any family problems you have difficulty handling (nu- clear or
extended)?
c. Family or others depend on you for things? How managing?
d. When appropriate: How family or others feel about ill- ness or
hospitalization?
e. When appropriate: Problems with children? Difficulty handling?
f. Belong to social groups? Close friends? Feel lonely (frequency)?
g. Things generally go well at work? (School?)
h. When appropriate: Income sufficient for needs?
i. Feel part of (or isolated in) neighborhood where living?
Examination/Objective data
a. Interaction with family member(s) or others (if present).
9. Sexuality-Reproductive Pattern
History/Subjective data

Prepared by Gebremichael Reta Mengistu (BSc.)

 a. When appropriate to age and situations: Sexual relationships
satisfying? Changes? Problems?

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 b. When appropriate: Use of contraceptives? Problems?
c. Female: When menstruation started? Last menstrual period?
Menstrual problems? Para?
Gravida?
Examination/Objective data
a. None unless problem identified or pelvic examination is part of full
physical assessment.
10. Coping-Stress Tolerance Pattern
History/Subjective data
a. Any big changes in your life in the last year or two? Crisis?
b. Who’s most helpful in talking things over? Available to you now?
c. Tense or relaxed most of the time? When tense, what helps?
d. Use any medicines, drugs, alcohol?
e. When (if) have big problems (any problems) in your life, how do you
handle them?
f. Most of the time is this (are these) way(s) successful?
Examination/Objective data: None.
11. Values-Beliefs Pattern
History/Subjective data
a. Generally get things you want from life? Important plans for the
future?
b. Religion important in life? When appropriate: Does this help when
difficulties arise?
c. When appropriate: Will being here interfere with any religious
practices?
Examination/Objective: None.
12. Other concerns (This is not part of functional health pattern but
it is very important and it must be asked after completing the 11
approaches)
a. Any other things we haven’t talked about that you would like to
mention?
b. Any questions?

Prepared by Gebremichael Reta Mengistu (BSc.)

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Prepared by Gebremichael Reta Mengistu (BSc.)

 Nursing Process
Identificat
ion
 Name 
Religion
 Age 
Occupation
 Sex 
Educational Status
 Address 
Date of admission
Medical Registration
 Marital status  Number
 Ethnicity  Ward and bed number
Chief complaints: One or more specific complaints and duration of each
complaint+ some pertinent positive symptoms
Medical Diagnosis:
1. Assessment (what data is collected?)
Subjective data:
a. Information from the client’s point of view. OR
b. Symptoms or covert data
Objective data:
a. Signs or overt cues are observable and measurable (quantitative)
data that are obtained through observation. OR
b. Standard assessment techniques performed during the physical
examination, and laboratory and diagnostic testing.
2. Nursing Diagnosis (what is the problem?)
a. Clinical judgment about individual, family or community response
to actual or potential health problem.
b. Parts of Nursing Diagnosis:*Problem; statement that describe the
health problem of the patient clearly & concisely.*Etiology; The
reason (etiology) that identifies the physiological, psychological,
social, spiritual & environmental factors related to the problem.
*Defining characteristics of manifestations (signs or
symptoms).
c. Components of a nursing diagnosis: Two statement nursing
diagnosis (the first component is problem statement or diagnostic
label which is listed in NANDA and the second component is
etiology or reason which connected by Related to (RT) by problem)
and three statement (Problem RT Etiology AEB by manifestation or
sign and symptoms).
d. Types of nursing diagnosis: Actual Nursing Diagnosis; represent
a problem that has been validated by the presence of its
characteristics. Risk Nursing Diagnosis; it’s a clinical judgment
that an individual, family, or community is more vulnerable (able) to
develop the problem. Possible Nursing Diagnosis; are statements
describing a suspected problem. Wellness Diagnosis; it’s a clinical
judgment about individual, group, or community in transition from
specific level of wellness to a higher level. Syndrome nursing
Diagnosis; a cluster of an actual or risk nursing diagnosis
suspected to be present according to certain events.
Prepared by Gebremichael Reta Mengistu (BSc.)
3. Outcome Identification: (was originally a part of the planning
phase, but has recently been
added as a new step in the complete process).
a. Establish client’s goals and outcome criteria.
b. It must be SMART

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4. Planning (how to manage the problem)
a. Establish/Set priorities
b. Plan nursing interventions (plan to action)
c. Write a Nursing Care Plan/documentation
5. Implementation (putting plan into action)
6. Rationale (Scientific reason of the implementations)
7. Evaluation (did the plan work)

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 NANDA Approved
Nursing Diagnoses
2015-2017
Indicates new diagnosis for 2015-2017—25 total
Indicates revised diagnosis for 2015-
2017- 14 total
(Retired Diagnoses at bottom of list—
7 total)
1 3
. Activity Intolerance 8. Constipation, Perceived
2 3
. Activity Intolerance, Risk for 9. Constipation, Risk for
3 40. Constipation, Chronic
. Activity Planning, Ineffective Functional
4 Activity Planning, Risk for 4 Constipation, Risk for Chronic
. Ineffective 1. Functional
5 Adaptive Capacity, Decreased 4
. Intracranial 2. Contamination
6 4
. Airway Clearance, Ineffective 3. Contamination, Risk for
7 4
. Allergy Response, Risk for 4. Coping, Compromised Family
8 4
. Anxiety 5. Coping, Defensive
9 4
. Aspiration, Risk for 6. Coping, Disabled Family
1 4
0. Attachment, Risk for Impaired 7. Coping, Ineffective
1 4
1. Autonomic Dysreflexia 8. Coping, Ineffective Community
1 4 Coping, Readiness for
2. Autonomic Dysreflexia, Risk for 9. Enhanced
1 5 Coping, Readiness for
3. Behavior, Disorganized Infant 0. Enhanced
1
4. Behavior, Readiness for Enhanced Community
5 Coping, Readiness for
Organized Infant 1. Enhanced Family
1 Behavior, Risk for Disorganized 5
5. Infant 2. Death Anxiety
1 5 Decision-Making, Readiness for
6. Bleeding, Risk for 3. Enhanced
1 Blood Glucose Level, Risk for 5
7. Unstable 4. Decisional Conflict
1 5
8. Body Image, Disturbed 5. Denial, Ineffective
1 Body Temperature, Risk for 5
9. Imbalanced 6. Dentition, Impaired
Prepared by Gebremichael Reta Mengistu (BSc.)
2 Breastfeeding, Readiness for 5
0. enhanced 7. Development, Risk for Delayed
2 Breastfeeding, 5
1. Ineffective 8. Diarrhea
2 5
2. Breastfeeding, Interrupted 9. Disuse Syndrome, Risk for
2 Breast Milk, 6
3. Insufficient 0. Diversional Activity, Deficient
2 6
4. Breathing Pattern, Ineffective 1. Dry Eye, Risk for
2 6
5. Cardiac Output, Decreased 2. Electrolyte Imbalance, Risk for
26. Cardiac Output, Risk for 6
Decreased 3. Elimination, Impaired Urinary
27. Cardiovascular Function, Risk 6 Elimination, Readiness for
for 4. Enhanced
Impaired Urinary
2 65. Emancipated Decision
8. Childbearing Process, Ineffective Making,
2 Childbearing Process, Readiness
9. for Impaired
66. Emancipated Decision
Enhanced Making,
3 Childbearing Process, Risk for
0. Ineffective Readiness for Enhanced
3 67. Emancipated Decision
1. Comfort, Impaired Making, Risk
3
2. Comfort, Readiness for Enhanced for Impaired
3 Communication, Readiness for
3. Enhanced 68. Emotional Control, Labile
3 6
4. Confusion, Acute 9. Falls, Risk for
3 7
5. Confusion, Chronic 0. Family Processes, Dysfunctional
3 7
6. Confusion, Risk for Acute 1. Family Processes, Interrupted
3 7 Family Processes, Readiness for
7. Constipation 2. Enhanced

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73. Fatigue 104. Hypothermia, Risk for
74. Fear Perioperative
75. Feeding Pattern, Ineffective 105. Impulse Control, Ineffective
Infant 106. Incontinence, Functional
76. Fluid Balance, Readiness for Urinary
Enhanced 107. Incontinence, Overflow
77. Fluid Volume, Deficient Urinary
78. Fluid Volume, Excess 108. Incontinence, Reflex Urinary
79. Fluid Volume, Risk for 109. Incontinence, Risk for Urge
Deficient Urinary
80. Fluid Volume, Risk for 110. Incontinence, Stress Urinary
Imbalanced 111. Incontinence, Urge Urinary
81. Frail Elderly Syndrome 112. Incontinence, Bowel
82. Frail Elderly Syndrome, 113. Infection, Risk for
Risk for 114. Injury, Risk for
83. Gas Exchange, Impaired 115. Injury, Risk for Corneal
84. Gastrointestinal Motility, 116. Injury, Risk for Perioperative-
Dysfunctional Positioning
85. Gastrointestinal 117. Injury, Risk for Thermal
Motility, Risk for
Dysfunctional
86. Gastrointestinal
Perfusion, Risk for Ineffective
87. Grieving
88. Grieving, Complicated
89. Grieving, Risk for
Complicated
90. Growth, Risk for
Disproportionate
91. Health, Deficient Community
92. Health Behavior, Risk-Prone
93. Health Maintenance,
Ineffective
94. Health Management,
Ineffective
95. Health Management,
Readiness for Enhanced
96. Health Management,
Ineffective Family
97. Home Maintenance,
Impaired
98. Hope, Readiness for
Enhanced
99. Hopelessness
100. Human Dignity, Risk for
Compromised
101. Hyperthermia
102. Hypothermia
103. Hypothermia, Risk for

Prepared by Gebremichael Reta Mengistu (BSc.)

118. Injury, Risk for Urinary 141. Oral Mucous Membrane,
Tract Impaired
119. Insomnia 142. Oral Mucous
120. Jaundice, Neonatal Membrane, Risk for
121. Jaundice, Risk for Neonatal Impaired
122. Knowledge, Deficient 143. Other-Directed Violence,
123. Knowledge, Readiness for Risk for
Enhanced 144. Overweight
124. Latex Allergy Response 145. Overweight, Risk for
125. Latex Allergy Response, Risk 146. Pain, Acute
for 147. Pain, Chronic
126. Lifestyle, Sedentary 148. Pain, Labor
127. Liver Function, Risk for 149. Pain Syndrome, Chronic
Impaired 150. Parenting, Impaired
128. Loneliness, Risk for 151. Parenting, Readiness for
129. Maternal/Fetal Dyad, Risk for Enhanced
Disturbed 152. Parenting, Risk for Impaired
130. Memory, Impaired 153. Peripheral Neurovascular
131. Mobility, Impaired Bed Dysfunction, Risk for
132. Mobility, Impaired Physical 154. Personal Identity, Disturbed
133. Mobility, Impaired 155. Personal Identity, Risk for
Wheelchair Disturbed
134. Mood Regulation, 156. Poisoning, Risk for
Impaired 157. Post-Trauma Syndrome
135. Moral Distress 158. Post-Trauma Syndrome, Risk
136. Nausea for
137. Noncompliance 159. Power, Readiness for
138. Nutrition, Imbalanced: Enhanced
Less than Body Requirements 160. Powerlessness
139. Nutrition, Readiness for 161. Powerlessness, Risk for
Enhanced 162. Pressure Ulcer, Risk for
140. Obesity

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163. Protection, Ineffective 195. Self-Neglect
164. Rape-Trauma Syndrome 196. Sexual Dysfunction
165. Reaction to Iodinated 197. Sexuality Pattern, Ineffective
Contrast Media, Risk for 198. Shock, Risk for
166. Relationship, Ineffective 199. Sitting, Impaired
167. Relationship, Risk for 200. Skin Integrity, Impaired
Ineffective 201. Skin Integrity, Risk for Impaired
168. Relationship, Readiness 202. Sleep, Readiness for Enhanced
for Enhanced 203. Sleep Deprivation
169. Religiosity, Impaired 204. Sleep Pattern, Disturbed
170. Religiosity, Readiness for 205. Social Interaction, Impaired
Enhanced 206. Social Isolation
171. Religiosity, Risk for 207. Sorrow, Chronic
Impaired
172. Relocation Stress
Syndrome
173. Relocation Stress
Syndrome, Risk for
174. Renal Perfusion, Risk for
Ineffective
175. Resilience, Impaired
176. Resilience, Readiness for
Enhanced
177. Resilience, Risk for
Impaired
178. Role Conflict, Parental
179. Role Performance,
Ineffective
180. Role Strain, Caregiver
181. Role Strain, Risk for
Caregiver
182. Self-Care, Readiness for
Enhanced
183. Self-Care Deficit, Bathing
184. Self-Care Deficit, Dressing
185. Self-Care Deficit, Feeding
186. Self-Care Deficit, Toileting
187. Self-Concept, Readiness for
Enhanced
188. Self-Directed Violence,
Risk For
189. Self-Esteem, Chronic Low
190. Self-Esteem, Risk for
Chronic Low
191. Self-Esteem, Situational
Low
192. Self-Esteem, Risk for
Situational Low
193. Self-Mutilation
194. Self-Mutilation, Risk for
208. Spiritual Distress 233. Verbal Communication,
209. Spiritual Distress, Impaired
Risk for 234. Walking, Impaired
210. Spiritual Well- 235. Wandering
Being, Readiness for
Enhanced
Retired Diagnoses
Energy Field, Disturbed
211. Spontaneous
Failure to Thrive, Adult
Ventilation, Impaired
Immunization Status, Readiness
212. Standing,
for Enhanced Nutrition,
Impaired
Imbalanced: More than Body
213. Stress Overload
Requirements
214. Sudden Infant Death
Nutrition, Risk for Imbalanced:
Syndrome, Risk for
More than Body Requirements
215. Suffocation, Risk for
Environmental Interpretation
216. Suicide, Risk for
Syndrome, Impaired
217. Surgical Recovery,
Growth and Development, Delayed
Delayed
218. Surgical Recovery,
Risk for Delayed
219. Swallowing,
Impaired
220. Thermoregulation,
Ineffective 22
221. Tissue Integrity,
Impaired
222. Tissue Integrity,
Risk for Impaired
223. Tissue Perfusion,
Ineffective Peripheral
224. Tissue Perfusion,
Risk for Ineffective
Peripheral
225. Tissue Perfusion,
Risk for Decreased
Cardiac
226. Tissue Perfusion,
Risk for Ineffective
Cerebral
227. Transfer Ability,
Impaired
228. Trauma, Risk for
229. Vascular Trauma,
Risk for
230. Unilateral Neglect
231. Urinary Retention
232. Ventilatory
Weaning Response,
Dysfunctional