NCMA111 LECTURE & LABORATORY – FINAL

COVERAGE
1. Geriatric Adaptation
2. Conducting Health History and Cultural Considerations
3. Documentation of Findings
4. Generation of Nursing Diagnosis
5. Diagnostic Procedures

GERIATIC ADAPTATION
Adapting interview techniques
- It is essential that the nurse adapt routine interviewing
techniques from the perspective that, regardless of the extent of
disability and illness being experienced by older adult, there is
always something positive that the older person is doing.
- Determine functional status- evaluate basic self-care abilities Examples of Questionnaire:
and ADLs,
• e.g., bathing, eating, grooming, and toileting instrumental
activities of daily living
• e.g., cooking, cleaning, laundry mobility-related activities
• e.g., shopping and transportation cognitive abilities
• e.g., money management, telephone use, decision making
affecting safety and social needs
Areas requiring special emphasis
• Function – (if they can still manage with their own or they have
to do that with the help of companion)
• Medications – (do they take medication on time; yun iba
tinetake nila as maintenance – habang buhay na nila tinetake
yon)
• Review of systems – (if the client is not functioning well or
experiencing limitation in their movements)
• Social history – (Ask client: if they can still go to the diff places
by their own, are they friendly with their neighborhood)
• Nutritional history – (Are they still allowed to eat certain food
like pork, beef, veggies or do they still eat 3 times a day or do
they still have good appetite)

Common Problems in Older Adult (SPICES)

• Skin impairment – (most of the older adult has low production
melanin in the body. So, there is a possibility to may acquire the
skin cancer. If they have diabetes, poor yun kanilang wound
healing)
• Poor nutrition – (loss of appetite, or they tend to eat vegetables
and not eating pork kasi nakaka-highblood. And make sure that
they are properly nourish, dapat umiinom more than 8 glasses a
day)
• Incontinence – (have problem urinating)
• Cognitive impairment – (if they have clear minds; nasusunod
ba nila un instruction na binibigay niyo)
• Evidence of falls or functional decline – (nagiging fragile na
yun bones nila, you have to keep the floor dry kasi baka madulas
sila)
• Sleep disturbance – (maybe it is cause by depression or other
problems)

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Katz Activities of Daily Living Geriatric Oral Health Assessment Index

- Assess 6 primary function of the older adult. - Maximum score – 60 points
- High score – 6 points (independent)

Lawton Scale for Instrumental Activities of Daily Living

(lADL)
- Assess the ability to perform tasks

Mini Nutritional Assessment tool (MNA)

- Identify geriatric patients age 65 and above who are
malnourished or at risk of malnutrition.

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Self- assessment: Geriatric Depression Scale

- For scoring, reverse the answers for No. 1,5, 7, 9, 15, 19, 21,
27, 29, and 30 then count the total number of yes
- Scoring: 0-10 = within normal range; 11 or higher = possible
indication of depression

Short Blessed Test

(Orientation-Memory-Concentration Test)
- A weighted six-item instrument originally designed to identify
dementia. This evaluates orientation, registration, and attention.

History Taking
• Have you noticed any changes in your ability to concentrate or
think clearly enough to keep up with your daily activities? If so,
about when did this begin and describe what you have noticed
• Do you believe that you have more problems with memory than
most? Do you believe that life is empty? Have you recently had
to drop many of your activities and interests?
• Are you concerned about changes in your memory? Are you
bothered by anger or inability to control your frustrations with
day-by-day living?
• Do you ever need to grab onto something because you feel like
you’re going to stumble or fall? Have you ever used anything
to steady yourself when you’re walking?
• Have you had any recent falls? What were you doing? Where
did it occur? What other kinds of feelings or symptoms did you
have when you fell (e.g., headache, confusion)?
• How has your energy level changed in the last few days or
weeks? How does it affect your daily activities such as cooking,
household chores, or activities outside the home (e.g., shopping,
social, church)? When is your energy at its lowest level? When
does it seem to be at its best?
• Do you ever experience shortness of breath? If so, is it related
to activity? (Specific questions about endurance, stair climbing,
or ADLs are necessary for quantifying the extent of the
problem.) Does it occur at rest or when lying down? How many
pillows do you use? Any pain with breathing?

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

• Have you experienced weight loss or changes in your health Hydration and Nutritional status
along with a chronic cough? - Evaluate hydration status as you would ask the nutritional status.
• Do you ever have any urine leakage or problems controlling - Look at their skin: does it look dry, smooth or moisturized skin
your urine flow? - Ask if the client can still drink up to 8 glasses or more a day.
• Do you have any problems with bowel elimination? - Check for the skin turgor
• Do you have pain, discomfort, aching, or soreness? If so, is the Normal findings:
discomfort worse with activity? Relieved by rest? Do you have  Stable weight
problems with grasping, reaching, or activities that use your  Stable mental status
hands, arms, back, or legs? Abnormal findings:
x Sudden weight loss; fever; dry, warm skin; furrowed,
Height and Weight, swollen, and red tongue; decreased urine output; lethargy;
- noting weight changes, changes in appetite, nausea and and weakness are all signs of dehydration.
vomiting, and problems with swallowing or chewing x An acute change in mental status (particularly confusion),
- “if possible, measure height with the person standing erect tachycardia, and hypotension may indicate severe
without shoes against a wall.” dehydration, which may be precipitated by certain
Body mass index medications such as diuretics, laxatives, tricyclic
- Formula: Weight (Kg) / Height (M)2 antidepressants, or lithium
- Example:
o Height = 173cm (1.73 m) Skin and Hair Assessment
o Weight = 73 kg Inspect and palpate for skin lesions
o Calculation: 73/ (1.73) x 2 = 24.41 - Wear gloves when palpating lesions. Note whether lesions are
flat or raised, palpable or non-palpable. Also note color, size,
and exudates, if any.
Normal Findings
 Despite decrease in total number of melanocytes,
hyperpigmentation occurs in sun-exposed skin (neck, face,
and arms).
 Although dermatologic lesions are common, many are
benign. Benign findings include:
o Venous lakes – reddish vascular lesions on ears or
other facial areas resulting from dilation of red blood
vessels
o Skin tags – acrochordons, flesh-colored pedunculated
lesions
o Seborrheic keratoses – tan, brown, or reddish, flat
lesions commonly found on fair- skinned persons in
sun-exposed areas.
o Cherry angiomas – small, round, red spots
o Senile purpura – vivid purple patches
o Lentigines – hyperpigmentation in exposed areas
• Underweight = <18.5 appear brown, pigmented, round, rectangular patches
• Normal = 18.5 ~ 24.9 often called liver spots; very common on aging skin.
• Overweight = 25.0 ~29.9 Abnormal Findings
• Obese = 30.0 ~ 34.9 x The combination of environmental exposure and
• Extremely obese = >35.0 diminished immunity increases risk of skin cancer and
• Note: sa may part na iniisquare, 2 decimals lang at hindi cutaneous infections such as ringworm, and candida
iroroundoff. Ganon din sa final answer “2 DECIMALS and infections of the mouth, vagina, and nail beds.
HINDI IROROUND OFF.” x This risk is increased by predisposing conditions such as
diabetes mellitus, malnutrition, and steroid or antibiotic use.
Normal Findings Inspect and palpate for Hair and Scalp
 Antral cells and intestinal villi atrophy, and gastric Normal Findings
production of hydrochloric acid decreases with age.  Loss of pigmentation causes graying of scalp, axillary, and
 The ability to smell and taste decreases with age, which can pubic hair
diminish appetite. Medications can also decrease sense of  Mild hair growth on upper lip of women may appear as a
smell and taste in older people. result of decreased estrogen to testosterone ratio.
Abnormal Findings  Toenails usually thicken while fingernails often become
thinner. Both usually become yellowish and dull.
x Indicators of malnutrition include poor wound healing,
bruising, dental deterioration, poor appetite and fluid intake, Abnormal Findings
weight loss. x Patchy or asymmetric hair loss is abnormal

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Head and Neck Assessment Observe the client swallowing food or fluids
- Inspect head and neck for symmetry and movement. Observe Normal Findings
facial expression  Mild decrease in swallowing ability (painumin ng tubig;
Normal Findings make sure you have to observe aspiration precautions)
 Atrophy of face and neck muscles Abnormal Findings
 Reduced ROM Shortening of the neck x Coughing, drooling, pocketing, or spitting out food after
 Shortening of neck due to vertebral degeneration and intake are all possible signs of dysphagia (difficulty
development of Buffalo Hump of top of cervical vertebrae swallowing).
Abnormal Findings x A drooping mouth, chronic congestion, or a weak or hoarse
x Asymmetry of mouth or eyes possibly from Bell’s palsy or voice (especially after eating or drinking) also suggests
cerebrovascular accident (CVA) dysphagia
x Marked limitation of movement or crepitation in back of • If swallowing difficulties are observed, complete a nutritional
neck from cervical arthritis assessment and refer the client for a barium swallow
x Involuntary facial or head movements from an examination
extrapyramidal disorder such as Parkinson’s disease or • Safety tip: help the client who reports dysphagia to lean slightly
some medications forward with the chin tucked in toward the neck when
x Reported episodic, unilateral, shock-like or burning pain of swallowing and offer food that has a pudding consistency to
the face or continuous pain, which may be postherpetic, tic minimize the risk of aspiration.
douloureux, or caused by a dental caries or abscess Test gag reflex.
- Depress the posterior third of the tongue, and note gag reflex.
Normal Findings
 Gag reflex may be slightly sluggish
Abnormal Findings
x Absence of gag reflex may be the result of a neurologic
disorder and indicates the need to be alert for signs of
aspiration pneumonia.

Nose and Sinuses Assessment

Inspection
- Inspect the nose for color and consistency. (use the nasal
speculum and pen light)
Mouth and Throat Assessment
Normal Findings
Inspect the gums and buccal mucosa
for color and consistency.  Nose and nasal passages are not inflamed, and skin and
Normal Findings mucous membranes are intact.
 Slight decrease in saliva production  Nose may seem more prominent on face because of loss of
Abnormal Findings subcutaneous fat. Nasal hairs are coarser.
x Saliva-depressing medications include antihistamines, Abnormal Findings
antipsychotics, and antihypertensives; any drug with x Edema, redness, swelling, or clear drainage, which may
anticholinergic side effects may promote dental caries and
indicate allergies or rhinitis
increase risk of pneumonia
- If the client is wearing dentures, inspect them for fit. Then ask - Evaluate the sense of smell. Have the client close the eyes and
the client to remove them for the rest of the oral examination. smell a common substance, such as mint, lemon, or soap.
Normal Findings Normal Findings
 Resorption of gum ridge commonly results in poorly fitting  Slightly diminished sense of smell and ability to detect
dentures. Tooth surfaces may be worn from prolonged use. odors.
Abnormal Findings Abnormal Findings
x Loose-fitting dentures or inability to close mouth
x Client cannot identify strong odor. This may cause a
completely may also be the result of a significant weight
gain or loss decrease in appetite and may be a safety concern
x Foul-smelling breath may indicate periodontal disease  Safety tip: alert clients with diminished smell to the
x Whitish or yellow-tinged patches in mouth or throat may importance of smoke alarms and routine inspections of
be candidiasis from use of steroid inhalers or antibiotics stoves and furnaces
Examine the tongue - Test nasal patency. Ask the client to breathe while blocking one
Observe symmetry and size. nostril at a time.
Normal Findings
Normal Findings
 Tongue pink and moist
Abnormal Findings  Client breathes with reasonable ease
x A swollen, red, and painful tongue may indicate vitamin B Abnormal Findings
or riboflavin deficiency x Client reports feeling of inadequate
breath intake, which may result from nasal polyps, a
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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

deviated septum, or allergic or infectious rhinitis or look dull or brownish. Location and extent of cloudiness
sinusitis determine degree to which a person’s vision is affected
Palpation  Age related abnormalities of the eyes:
- Palpate the frontal and maxillary • Glaucoma
sinuses for consistency and to elicit • Macular degeneration
possible pain. (use your thumb) • Retinal detachment
Normal Findings
• Diabetic retinopathy
 No lesion or pain upon palpation
Inspect the pupils
Abnormal Findings
- With penlight or similar device, test pupillary reaction to light
x Client reports pain, congestion, and dryness; inflammation
- Check for PERLA (Pupil, Equally, Round, reactive to Light and
is evident. Accommodation)
Normal Findings
Eyes and Vision Assessment  Overall decrease in the size of the pupil and ability to dilate
Inspect eyelids, eyelashes, and conjunctiva.
in dark and constrict in light may occur; results in poorer
- Observe eye and conjunctiva for dryness, redness, tearing, or
night vision and decreased tolerance to glare.
increased sensitivity to light and wind.
Abnormal Findings
Normal Findings
 Skin around the eyes becomes thin, and wrinkles appear x An irregularly shaped pupil may indicate removal of a
normally with age. cataract
 Stretched skin in eyelid may produce feeling of heaviness x Asymmetric pupillary reaction response may be due to a
and a tired feeling. In lower eyelid, “bags” form. neurologic condition
 Excessive stretching of lower eyelid may cause it to droop Test vision
- Ask the client to read from a newspaper or magazine.
downward, which keeps it from shutting completely and
- Use only room lighting for the initial reading use task lighting
can cause dryness, redness, or sensitivity to light and wind.
for a second reading.
 Eyes are described as irritated or having a “scratchy
- Ask about changes in vision, or differences in vision with left
sensation” versus right eye.
Abnormal Findings Normal Findings
x A turning in of the lower eyelid (entropion) is more  Impaired near vision is indicative of presbyopia
common and causes the eyelashes to touch the conjunctiva (farsightedness) a common finding in older adults.
and cornea.  Common are slight decrease in peripheral vision and
x Severe entropion may result in an ulcerous corneal difficulty differentiating blues from greens.
infection.  Tiny clumps of gel may develop within the eye. These are
x Abnormalities in blinking may result from Parkinson’s referred to as “floaters”
disease; dull or blank staring may be a sign of Abnormal Findings
hypothyroidism x A significant decrease in central vision, to the extent
Inspect the cornea and lens. needed for ADLs, may signal a cataract in one or both
- Also ask the client when he or she last had an eye and vision eyes
examination by an optometrist or ophthalmologist
x Macular (the macula is a thin membrane in the center of the
Normal Findings
retina) degeneration is suspected if the client has difficulty
 An arcus senilis, a cloudy or grayish ring around the iris,
in seeing with one eye. The disorder almost always
and decreased pigment in iris are normal age-related
becomes bilateral. Related findings include blurry words in
changes.
the center of the page or doorframes that don’t appear
 The lens loses elasticity – decreased ability to change shape
straight
(presbyopia).
x A noticeable loss of vision—including cloudiness,
 A loss of transparency in the crystalline lens in the eyes is
distortion of familiar objects, and occasionally blind spots
a natural part of aging process. Exposure to sunlight,
or floaters— is a common symptom of diabetic retinopathy.
smoking, and inherited tendencies increase risk.
New floaters, or an increase in frequency of floaters
 A thickening of the bulbar conjunctiva that grows over the
associated with flashes of light, may be a sign of retinal
cornea (called pterygium) may interfere with vision.
detachment
Abnormal Findings
 Cataracts most commonly affect people after age 55 and
result in a yellowish or brownish discoloration of the lens.
Common symptoms include painless blurring of vision,
glare and halos around lights, poor night vision, colors that

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Ears and Hearing Assessment  Increase reliance on diaphragmatic breathing and increased
Inspect the external ear. work of breathing.
- Observe shape, color, and hair growth. Also look for lesions or Abnormal Findings
drainage. x Respiratory rate exceeding 25 breaths/min along with
Normal Findings increased sputum production, confusion, loss of appetite
 Hairs may become coarser and thicker in external ear,
and hypotension may signal a pulmonary infection
especially in men.
x Respiratory rate of less than 16 breaths/min may be a sign
 Earlobes may elongate and pinna increases in length and
of neurologic impairment, which may lead to aspiration
width
pneumonia
Abnormal Findings
x Significant loss of aerobic capacity and dyspnea with
x Inflammation, drainage, or swelling may be from infection
exertion is usually due to disease, exposure over a lifetime
- Perform an otoscopic examination to determine quantity, color,
to pollutants, smoke, or severe or prolonged lack of
and consistency of cerumen.
exercise
Normal Findings
 Cerumen production decreases leading to dryness and Percuss lung tones as you would in a younger adult
Normal Findings
tendency toward accumulation
 Resonant, except in the presence of structural changes such
Abnormal Findings
as kyphosis or a slight barrel chest, when hyperresonance
x Hard, dark brown cerumen signals impaction of the
may occur.
auditory canal, which commonly causes a conductive
hearing loss Abnormal Findings
x Consolidation of infection will cause dullness to
x A darkened hole in the tympanic membrane or patches
percussion; alveolar retention of air, as occurs in
indicates perforation or scarring of the tympanic membrane
emphysema, results in hyperresonance
Perform the voice – whisper test
- This is a functional examination to detect obvious x Safety Tip: supine positioning, shallow breathing, and poor
(conversational) hearing loss. dental hygiene increase the risk of pulmonary infection.
- Instruct the clients to put a hand over one ear and to repeat the Auscultate lung sounds as you would in a younger adult
sentence you say. Stand approximately 2 feet away from the Normal Findings
client and whisper a sentence.  Vesicular sounds should be heard over all areas of air
- Clinical tip: assess hearing acuity before and after otoscopic exchange. However, because lung expansion may be
examination if cerumen is removed during the examination. If diminished, it may be necessary to emphasize taking deep
you are facing the client, hold your hand close to your mouth so breaths with the mouth open during exam. This may be
that the client cannot read your lips. very difficult for those with dementia.
Normal Findings Abnormal Findings
 The inability to hear high frequency sounds (presbycusis) x Breath sounds may be distant over areas affected by
or to discriminate a variety of simultaneous sounds and soft kyphosis or the barrel chest of aging
consonant sounds or background noises is due to x Rales and rhonchi are heard only with diseases, such as
degeneration of hair cells of inner ear. pulmonary edema, pneumonia, or restrictive disorders
Abnormal Findings x Diminished breath sounds, wheezes, crackles, rhonchi that
x Inability to hear the whispered sentence indicates a hearing do not clear with cough, and egophony are common signs
deficiency and the need to refer the client to an audiologist of consolidation caused by pneumonia
for testing.
x Clinical tip: raising one’s voice to someone with
presbycusis usually only makes it more difficult for them
to hear. Speaking more slowly will usually lower the
frequency and be ore therapeutic.

Thorax and Lungs Assessment

Inspect the shape of the thorax
- Note respiratory rate, rhythm, and quality of breathing
Normal Findings
 Decreased elasticity of alveoli causes lungs to recoil less
during expiration and loss of resilience that holds thorax in
a contracted position, loss of skeletal muscle strength and
abdomen, decreased vital capacity, increased residual
volume, and slight barrel chest.
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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Heart and Blood Vessels Assessment  Distal lower extremity pulses may be more difficult to feel
Measure blood pressure or even non-palpable. The dorsalis pedis pulse is absent in
1. Take blood pressure to detect actual or potential orthostatic up to 12% of the population
hypotension and, therefore, the risk for falling. Measure Abnormal Findings
pressure with the client in lying, sitting, and standing positions.
x Insufficient or absent pulses are a likely indication of
Also measure pulse rate
arterial insufficiency.
2. Have the client lie down for 5 minutes; take the pulse and blood
x Partially obstructed blood flow increases the risk of ulcers
pressure; at 1 minute, take blood pressure and pulse after client
is sitting and again at 1 minute after client stands. and infection.
3. Safety tip: if dizziness occurs, instruct client to sit a few minutes x Completely obstructed blood flow is a medical emergency
before attempting to stand up from a supine or reclining position requiring immediate intervention to prevent gangrene and
Normal Findings possible amputation
 Blood pressure increases as elasticity decreases in arteries Heart
with proportionately greater increase in systolic pressure, Inspect and palpate the precordium
resulting in widening of pulse pressure. Normal Findings
 An older adult’s baroreceptor response to positional  The precordium is still, not visible, and without thrills,
changes is slightly less efficient. A slight decrease in blood heaves, palpable pulsations (notes exception may be the
pressure may occur. apex of the heart if close to the surface.
Abnormal Findings Abnormal Findings
x Refer any client with blood pressure exceeding 160/90 mm x Heaves are felt with an enlarged right or left ventricular
Hg to the health care provider for follow-up aneurysm
x A greater than 20mmhg drop in systolic or 10mmhg drop x Thrills indicate aortic, mitral, or pulmonic stenosis and
in diastolic pressure, often associated with an increase in regurgitation that may originate from rheumatic fever
heart rate, indicates orthostatic hypotension x Pulsations suggest an aortic or ventricular aneurysm, right
ventricular enlargement, or mitral regurgitation
Exercise Tolerance Auscultate heart sounds
- Measure activity tolerance. Evaluate either by reviewing results Normal Findings
of stress testing or by observing the client’s ability to move from  A soft systolic murmur heard best at the base of the heart
a sitting to a standing position or to flex and extend fingers may result from calcification, stiffening and dilation of the
rapidly. aortic and mitral valve.
- Clinical tip: poor lower body strength, especially in the ankles, Abnormal Findings
may impair the ability of the frail older adult to rise from a chair
x Abnormal heart sounds are generally considered to be
to a standing position. Poor upper body strength, especially in
disease related only if there is additional evidence of
the shoulders, may impede the ability to push up from a bed or
chair or to extend and flex fingers. compromised cardiovascular function. However, any
previously undetected extra heart sound warrants further
Normal Findings
 The maximal heart rate with exercise is less than in a investigation
younger person. The heart rate will take longer to return to x S3 and S4 sounds may reflect the cardiac and fluid
its pre-exercise rate. overloads of congestive heart failure, aortic stenosis,
 Rise in pulse rate should be no greater than 10-20 beats/min. cardiomyopathy, or myocardial infarction
Pulse rate should return to the baseline rate within 2
minutes. Arteries and Veins Assessment
Auscultate carotid, abdominal, and femoral arteries
Abnormal Findings
Normal findings
x A rise in pulse greater than 20 beats/min and a rate that does
 No unusual sound should be heard.
not return to baseline within 2 minutes is an indicator of
Abnormal findings
exercise intolerance. Cardiac dysrhythmias as determined
x A bruit is abnormal; refer the client for further care because
by stress testing are also indicative of exercise intolerance.
of the high risk of CVA from a carotid embolism or an
Pulses
abdominal or femoral aneurysm
- Determine adequacy of blood flow by palpating the arterial
Evaluate arterial and venous sufficiency of extremities
pulses in all locations (carotid, brachial, radial, femoral,
- Elevate the legs above the level of the heart and observe color,
popliteal, posterior tibial, and dorsalis pedis) for strength and
temperature, size of the legs, and skin integrity
quality Normal Findings
Normal Findings  Hair loss with advanced age (cannot be used singly as an
 Proximal pulses may be easier to palpate due to loss of indicator of arterial insufficiency).
supporting surrounding tissue.
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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Abnormal Findings Normal Findings

x Leg pain associated with walking, burning or cramping,  Bowel sounds from 5 to 30 sounds/min are heard.
duskiness or mottling when the leg is in a dependent  A decrease in gastric emptying time occurs with aging and
position; paleness with elevation; cool, thin, shiny skin; may cause early satiety.
thickened, brittle nails; and diminished pulses are signs of  Intestinal motility is generally reduced from a general loss
arterial insufficiency of muscle tone.
Inspect and palpate veins while client is standing Abnormal Findings
Normal Findings x Absence of bowel sounds and vomiting of undigested food
 Prominent, bulging veins are common as are spider veins. is abnormal
 Varicose veins appear raised above the skin, often dark x Decreased motility is exacerbated by common pathologies
purple or blue, gnarled or cord like, and are considered such as Parkinson’s, stroke, and diabetes mellitus.
common unless symptoms appear (achy, heavy feeling in x Results in propensity for chronic constipation and
legs; burning, throbbing muscle cramping; itching around diverticula
veins; or especially skin ulcers around ankles). Determine absorption or retention problems in older adults
 Most of the time, varicose veins are hereditary. client receiving enteral feedings
Abnormal Findings Normal Findings
x Unilateral warmth, tenderness, and swelling may be  Less than 100 mL residual is a normal finding for
indications of thrombophlebitis intermittent feedings
Abnormal Findings
Breast Assessment
x More than 100 mL residual measure before a scheduled
Inspect and palpate breast and axillae
feeding is a sign of insufficient absorption and excessive
- When viewing axillae and contour of the breasts, assist a client
retention.
with arthritis to raise the rams over the head. Do this gently and
without force and only if it is not painful for the client. x Abdominal distention, diarrhea, fluid overload, aspiration
Normal Findings pneumonia, or fluid/ electrolyte imbalances may indicate
 Breast of elderly women are often described as pendulous excessive retention although mental status changes may be
due to the atrophy of breast tissue and supporting tissues the first or only sign
and the forward thrust of the client brought about by Inspect and percuss the abdomen
kyphosis. - Clinical tip: the loss of abdominal musculature that occurs with
Abnormal Findings aging may make it easier to palpate abdominal organs
x Pain upon palpation may indicate an infectious process or Normal Findings
cancer. Breast tenderness, pain, or swelling may be side  Liver, pancreas, and kidneys normally decrease in size, but
effects of hormone replacement therapy and an indication the decrease is not generally appreciable upon physical
that a lower dosage is needed. examination.
x Nipples that appear retracted and cannot be everted, or  Atrophy of intestinal villi is a common aging change.
any retraction of only one nipple may indicate breast Abnormal Findings
cancer x Anorexia, abdominal pain and distention, impaired protein
x Male breast enlargement (gynecomastia) may result from a digestion, and vitamin B12 malabsorption suggest
decrease in testosterone inflammatory gastritis or a peptic ulcer.
Inspect skin under breasts x Abdominal distention, cramping, diarrhea and increased
Normal Findings flatus are signs of lactose intolerance, which may occur for
 Skin under the breast is intact without lesions or rashes the first time in old age.
Abnormal Findings x Bruits over aorta suggest an aneurysm. If present, do not
x Macerated skin under the breasts may result from palpate because this could rupture the aneurysm.
perspiration or fungal infection (usually seen in an x Guarding upon palpation, rebound tenderness, or a friction
immunocompromised client). rub (sounds like pieces of sandpaper rubbing together)
often suggests peritonitis, which could be secondary to
Abdomen Assessment ruptured diverticuli, tumor, or infarct.
Assess GI motility and auscultate bowel sounds Palpate the Bladder
- Review fiber intake and laxative use. - Ask the client to empty bladder before the examination
- Clinical tip: risk of constipation is increased by diminished - If the bladder is palpable, percuss from symphysis pubis to
physical activity, decreased fluid intake, decreased fiber in diet, umbilicus.
and by ingestion of certain medications, such as iron or - If the client is incontinent, post, void residual content may also
narcotics. need to be measured.

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Normal Findings: empty bladder is not palpable or percussible  Sexual desire, pleasure is not necessarily diminished by
Abnormal Findings these structural changes, nor do women lose capacity for
x Full bladder sounds dull. orgasm with age.
x More than 100 mL drained from bladder is considered Abnormal Findings
abnormal for a postvoid residual. x Atrophic vaginitis symptoms can mimic malignancy,
x A distended bladder with an associated small volume urine vulvar dystrophies, UTIs, and other infections, such as
loss may indicate overflow incontinence Candida albicans, bacterial vaginosis, gonorrhea, or
chlamydia
Female Genitalia Assessment Test pelvic muscle tone
Inspect external genitalia - Ask the woman to squeeze muscles while the examiner’s finger
- Assist the client into the lithotomy position. (pag hindi kaya, is in the vagina.
dorsal recumbent position) - Assess perineal strength by turning fingers posterior to the
- Inspect the urethral meatus and vaginal opening. perineum while the woman squeezes muscles in the vaginal area
- Clinical tip: arthritis may make the lithotomy position
Normal Findings
particularly uncomfortable for the older woman, necessity
 The vaginal wall should constrict around the examiner’s
changes. If the client has breathing difficulties, elevating the
finger, and the perineum should feel smooth.
head to a semi-fowler’s position may help.
Normal Findings Abnormal Findings
 Many atrophic changes begin in women at menopause. x If the client has a cystocele, the examiner’s finger in the
Pubic hair is usually sparse, and labia are flattened. Clitoris vagina will feel pressure from the anterior surface of the
is decreased in size. vagina
 The size of the ovaries, uterus, and cervix also decreases. x In clients with uterine prolapse, protrusion of the cervix is
 No leakage of urine occurs. felt down through the vagina
Abnormal Findings x A bulging of the posterior vaginal wall and part of the
x Redness or swelling from the urethral meatus indicates a rectum may be felt with a rectocele
possible UTI
x Leakage of urine that occurs with coughing is a sign of Male Genitalia Assessment
Inspect the male genital area with the client in standing
stress incontinence and may be due to lax pelvic muscles
position if possible
from childbirth, surgery, obesity, cystocele, rectocele, or a
Normal Findings
prolapsed uterus
 The decline in testosterone brings about atrophic changes.
x Clinical tip: in noncommunicative clients, an excoriated Pubic hair is thinner.
perineum may be the result of incontinence, which  Scrotal skin is slightly darker than surrounding skin and is
warrants further investigation. smooth and flaccid in older man.
Test for prolapse  Penis and testicular size decreases, scrotum hangs lower.
- Ask the client to bear down while you observe the vaginal
Abnormal Findings
opening
x Scrotal edema may be present with portal vein obstruction
Normal Findings
or heart failure
 No prolapsed is evident.
x Lesions on the penis may be a sign of infection.
Abnormal Findings
x Associated symptoms of infection frequently include
x A protrusion into the vaginal opening may be a cystocele,
discharge, scrotal pain, and difficulty with urination
rectocele, or uterine prolapse, which is a common sequela
Observe and palpate for inguinal swelling or bulges suggestive
of relaxed pelvic musculature in older women
of hernia
Perform a pelvic examination
Normal Findings
- Put on disposable gloves and use a small speculum if the vaginal
 No swelling or bulges are present.
opening has narrowed with age. Use lubrication on the
speculum and hand because natural lubrication is decreased Abnormal Findings
x Masses or bulges are abnormal, and pain may be a sign of
Normal Findings
 Vagina narrows and shortens. testicular torsion. A mass may be due to a hydrocele,
 A loss of elastic tissue and vascularity in vagina results in spermatocele, or cancer
a thin, pale epithelium. Auscultate the scrotum
- if a mass is detected; otherwise palpate the right and left testicle
 Atrophic changes are intensified by infrequent intercourse.
using the thumb and first two fingers.
 Loss of elasticity and reduced vaginal lubrication from
- Inaauscultate lang siya kapag may inguinal hernia si client
diminishing levels of estrogen can cause dyspareunia
Normal Findings
(painful intercourse)
 No detectable sounds or masses are present.
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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Abnormal Findings Abnormal Findings

x Bowel sounds heard over the scrotum may suggest an x A hard, asymmetrically enlarged, and nodular prostate is
indirect inguinal hernia. suggestive of malignancy.
x Masses are abnormal, and the client should be referred to a x A tender and softer prostate is more common with
specialist for follow-up examination. prostatitis.
x Fever and painful urination are common with acute
Anus, Rectum, and Prostate Assessment prostatitis.
Inspect the anus and rectum x Obstructive symptoms are seen with both malignancy and
Normal Findings infection of the prostate.
 The anus is darker than the surrounding skin.
 Bluish, grapelike lumps at the anus are indicators of Musculoskeletal System Assessment
hemorrhoids. Observe the posture and balance
Abnormal Findings - when standing, especially the first 3-5 seconds.
x Lesions, swelling, inflammation, and bleeding are Normal Findings
abnormalities  Client stands reasonably straight with feet positioned fairly
x If hemorrhoids account for discomfort, the degree to which widely apart to form a firm base of support.
bleeding, swelling, or inflammation interferes with bowel  This stance compensates for diminished sense of
activity generally determines if treatment is warranted proprioception in lower extremities.
Palpate the anus and rectum  Body usually bends forward as well.
- Clinical tip: the left side-lying position with knees tucked up Abnormal Findings
toward the chest is the preferred one for comfort. Pillows may x A “humpback” curvature of the
be needed for positioning and client comfort. spine, called kyphosis, usually
Normal Findings results from osteoporosis.
 No masses, polyps, internal hemorrhoids, rectal prolapse, x The combination of osteoporosis,
or fecal impaction palpated. calcification of tendons and joints,
Abnormal Findings and muscle atrophy makes it difficult for the frail older
x Palpation of internal masses could indicate polyps, internal adult to extend the hips and knees fully when walking. This
hemorrhoids, rectal prolapse, cancer, or fecal impaction. impairs the ability to maintain balance early enough to
x Obliteration of the median sulcus is felt with prostatic prevent a fall
hyperplasia x Client cannot maintain balance without holding onto
something or someone. Postural instability increases the
risk of falling and immobility from the fear of falling.
Observe the gait by performing the
timed “get up and go” test.
1. Have the client rise from a straight-backed armchair, stand
momentarily, and walk about 3m toward a wall.
2. Ask the client to turn without touching the wall and walk back
to the chair, then turn around and sit down.
3. Using a watch or clock with a second hand, time how long it
takes the client to complete the test.
4. Score performance on a 1-5 scale:
o 1 = Normal
Palpate the prostate in the male client o 2 = Very slightly normal
Normal Findings o 3 = Mildly abnormal
 The prostate is normally soft or rubbery-firm and smooth, o 4 = Moderately abnormal
and the median sulcus is palpable. o 5 = Severely abnormal
 BPH (Benign Prostatic hyperplasia) almost always occurs Normal Findings
by age 85 as does a decrease in amount and viscosity of  Widening of pelvis and narrowing of shoulders.
seminal fluid.  Client walks steadily without swaying, stumbling or
 Sperm count may decrease by as much as 50%. hesitating during the walk. The client does not appear to be
 Orgasm may be briefer and time to obtain an erection may at risk of falling.
increase. These changes no not usually result in any loss of  Older adult clients without impairments in gaits or balance
libido or satisfaction. can complete the test within 10 seconds.

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Abnormal Findings Test ROM

x Shuffling gait, characterized by smaller steps and minimal - Ask client to touch each finger with the
lifting of the feet, increases the risk of tripping when thumb of the same hand, to turn wrists
walking on uneven or unsteady surfaces. up toward the ceiling and down toward
x Abnormal findings from the timed “Get Up and Go” test the floor, to push each finger against
include hesitancy, staggering, stumbling, and abnormal yours while you apply resistance, and to
movements of the trunk and arms. make a fist and release it.
x People who take more than 30 seconds to complete the test Normal Findings
 There is full ROM of each joints
tend to be dependent in some ADLs such as bathing,
and equal bilateral resistance.
getting in and out of bed, or climbing stairs
Abnormal Findings
x Limitations in ROM or strength may be due to degenerative
joint disease (DJD), rheumatoid arthritis, or a neurologic
disorder, which, if unilateral, suggests CVA
x Signs of pain such as grimacing, pulling back, or verbal
messages are indicators of the need to do a pain assessment
x Grating, popping, crepitus, and palpation of fluid are also
abnormalities. Crepitus and joint pain that is worse with
activity and relieved by rest in the absence of systemic
symptoms is often associated with DJD
Assess ROM and strength of shoulders and elbows
Normal Findings
Inspect the general contour of limbs, trunk, and joints
 The full ROM of reach joint and equal strength.
Palpate wrist and hand joints
Normal Findings Abnormal Findings
 Enlargement of the distal, interphalangeal joints of the x Tenderness, stiffness, and pain in the shoulders and elbows
fingers, called Heberden’s nodes, are indicators of (and hips), which is aggravated by movement, are common
degenerative joint disease (DJD), a common age-related signs associated with polymyalgia rheumatic (PMR)
condition involving joints in the hips, knees, and spine as
well as the fingers
Abnormal Findings
x With accumulated damage and loss of cartilage, bony
overgrowths protrude from the bone into the joint capsule,
causing deformities, limited mobility, and pain
x Hand deformities such as ulnar deviation, swan-neck
deformity, and boutonniere deformity are of concern Assess hip joint for strength and ROM
because of the limitations they impose on activities of daily Normal Findings
living and related pain  Intact flexion, extension, and internal and external rotation.
Abnormal Findings
x Hip pain that is worse with weight bearing and relieved
with rest may indicate DJD. There is usually also an
associated crepitation and decrease in ROM.
x Complaints of hip or thigh pain, external rotation and
adduction of the affected leg, and an inability to bear
weight are the most common signs of a hip fracture.
x Much fewer common signs may be mild discomfort and
minimal shortening of the leg
Inspect and palpate knees, ankles, and feet
- Also assess comfort level, particularly with movement (flexion,
extension, rotation).
Normal Findings
 The common problems associated with the aged foot, such
as soreness and aching, are most frequently due to
improperly fitting footwear.

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Abnormal Findings ADDITIONAL

x Great toe overriding or underlying the second toe may be Recording the Physical Examination
hallux valgus (bunion). Bunions are associated with pain (from Sir Vincent’s PPT)
and difficulty walking Mr. J is an older adult who appears healthy but overweight, with
good muscle bulk and tone. He is alert and interactive, with good
x Other abnormal findings may be enlargement of the medial
recall of his life history. He is accompanied by his son.
portion of the first metatarsal head and inflammation of the
• Vital Signs: Ht (without shoes) 5′ 10′′. Wt (dressed) 195 lbs.
bursae over the medial aspect of the joint BMI 28. BP 145/88 right arm, supine; 154/94 left arm,
Inspect muscle bulk and tone supine. Heart rate (HR) 98 and regular. Respiratory rate (RR)
Normal Findings 18. Temperature (oral) 98.6°F.
 Atrophy of the hand muscles may occur with normal aging. • Vision: Patient reports difficulty reading. Visual acuity 20/60
Abnormal Findings on Snellen chart.
x Muscle atrophy can result from rheumatoid arthritis, • Hearing: Cannot hear whispered voice in either ear. Cannot
hear 1,000 or 2,000 Hz with audio scope in either ear.
muscle disuse, malnutrition, motor neuron disease, or
• Leg Mobility: Able to walk 10 feet briskly, turn, walk back
diseases of the peripheral nervous system
to chair, and sit down in 9 seconds.
x Increased resistance to passive ROM is a classic sign of • Urinary Incontinence: Has lost urine and gotten wet on 20
Parkinson’s disease especially in clients with bradykinesia. separate days.
x Decreased resistance may also suggest peripheral nervous • Nutrition: Has lost 15 lbs. over the past 6 months without
system disease, cerebellar disease, or acute spinal cord trying.
injury • Memory: Can remember three items after 1 minute.
Depression: Does not often feel sad or depressed.
Neurologic System Assessment • Physical Disability: Can walk fast but cannot ride a bicycle.
Can do moderate but not heavy work around the house. Can
Observe for tremors and involuntary movements
go shopping for groceries or clothes. Can get to places out of
Normal Findings walking distance. Can bathe each day without difficulty. Can
 Resting tremors increase in the aged. In the absence of an dress, including buttoning and zipping, and can put on shoes.
identifiable disease process, they are not considered • Skin. Warm and moist. Nails without clubbing or cyanosis.
pathologic. Hair thinning at crown.
Abnormal Findings • Head, Eyes, Ears, Nose, Throat (HEENT). Scalp without
x The tremors of Parkinson’s may occur when the client is at lesions. Skull NC. Conjunctiva pink, sclera muddy. Pupils 2
rest. They usually diminish with voluntary movement. mm constricting to 1 mm, round, regular, equally reactive to
light and accommodation. Extraocular movements intact.
x They usually begin in the hand and may affect only one
Disc margins sharp, without hemorrhages or exudates. Mild
side of the body (especially early in the disease). arteriolar narrowing. TMs with good cone of light. Weber
x The tremors are accompanied by muscle rigidity. midline. AC ≥ BC. Nasal mucosa pink. No sinus tenderness.
Oral mucosa pink. Dentition fair. Caries present. Tongue
Sensory System Assessment midline, slight beefy redness. Pharynx without exudates.
Test sensation to pain, temperature, touch, position and • Neck. Supple. Trachea midline. Thyroid lobes slightly
vibration enlarged, no nodules.
Normal Findings • Lymph Nodes. No cervical, axillary, epitrochlear, or inguinal
 Touch and vibratory sensations may diminish normally lymph nodes.
with aging • Thorax and Lungs. Thorax symmetric. Kyphosis noted.
Lungs resonant with good excursion. Breath sounds vesicular.
Abnormal Findings
Diaphragms descend 4 cm bilaterally.
x unilateral sensory loss suggests a lesion in the spinal cord • Cardiovascular. JVP 6 cm above the left atrium. Carotid
or higher pathways; a symmetric sensory loss suggest a upstrokes brisk, with- out bruits. PMI tapping, in the 5th ICS,
neuropathy that may be associated with a condition such as 9 cm lateral to the midsternal line. II/VI harsh holosystolic
diabetes. murmur at the apex, radiating to the axilla. No S3, S4, or
Assess positional sense by using the Romberg test other murmurs.
- The exceptions to the test are clients who must use assistive • Abdomen. Scaphoid, with active bowel sounds. Soft,
devices such as walker. nontender. No masses or hepatosplenomegaly. Liver span 7
Normal Findings cm in right midclavicular line; edge smooth and palpable.
 There is minimal swaying without loss of balance. • Genitourinary. Circumcised male. No penile lesions. Testes
descended bilaterally, smooth without masses or tenderness.
Abnormal Findings
• Rectal. Good rectal sphincter tone. Rectal vault without
x Significant swaying with appearance of a potential fall. masses. Stool brown, negative for occult blood.
• Extremities. Warm and without edema. Calves supple.
Peripheral Vascular. Pulses 2+ and symmetric.

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

• Musculoskeletal. Mild degenerative changes at the knees, Biographic data

with quadriceps wasting. Good range of motion in all joints. - Collection of data that identifies the client
• Neurological. Oriented to person, place, and time. Cranial - Name, Address, Phone, Gender, Provider of history, Birth date,
nerves II–XII intact. Motor: Decreased quadriceps bulk. Tone Place of birth, Race, Educational level, Occupation, Significant
intact. Strength 4/5 throughout. RAMs, finger-to-nose intact. other
Gait with widened base. Sensation intact to pinprick, light - The client’s culture, ethnicity, and subculture may begin to be
touch, position, and vibration. Romberg negative. Reflexes determined by collecting data about date and place of birth,
2+ and symmetric, with plantar response down going. nationality, marital status, religious or spiritual practices,
primary and secondary languages spoken, written and read.
CONDUCTING HEALTH HISTORY AND - This information helps the nurse to examine special needs and
CULTURAL CONSIDERATION beliefs that may affect the client or family’s healthcare.
Health Reasons for seeking healthcare
- traditional meaning, was defined in terms of the presence or - Includes two questions:
absence of disease 1. What is your major health problem or concerns at this time?
- A state of being well and using every power the individual 2. How do you feel about having to see healthcare provider?
possesses to the fuller extent. Florence’s nightingale - These questions aid the healthcare provider to know the chief
- a state of complete physical, mental, and social well-being and complaint of the patient and may also draw out descriptions of
not merely the absence of disease or infirmity. WHO. previous experiences-both positive and negative-with other
- is a highly individual perception. healthcare providers.
- many factors affect individual definition of health. History of present health concern
- a person’s definition of health influences behavior related to - This section of health history takes into account several aspects
health and illness. of health problem and asks questions whose answer can provide
- By understanding client’s perception of health and illness, a detailed description of the concern.
nurses can provide more meaningful assistance to help them • Encourage the client to explain the health problem or
maintain, regain or attain a state of health. symptom in as much as detail as possible by focusing on
Health History Taking the onset, progression, and duration of the problem, signs
- Is to gather subjective data from patient and/or the patients and symptoms and related problems; and what the client
family so that the health care team and the patient can perceives as causing the problem.
collaboratively create a plan that will promote health, address
• Ask the client what makes the problem worse, what makes
acute health problems, and minimize chronic condition.
it better, which treatments have been tried, what effect the
• Health- a state of being free from illness or injury. problem has had on daily life, or lifestyle, what
• Chronic or Lingering- long time illness expectations are held about the recovery, and what is the
• Acute- short in duration but typically severe (acute client’s ability to provide healthcare
appendicitis dapat sabihin kung anong quadrant) Past health history
• Comprehensive record of the clients past and current - This portion of health history focuses on questions related to the
health- Ano, ilang beses, na uninom na gamot. client’s past, from the earliest beginnings to the present. These
Basic Components of Health History questions elicit data related to the client’s strengths and
• Chief complaint/concern (CC) weaknesses in her health history.
• History of Present Illness (HPI) - The data may also point to trends of unhealthy behaviors such
• Past Medical History (PMH)- existing illness, medication and as smoking or lack of physical activity. The information gained
allergies from these questions assists the nurse to identify risk factors that
• Family History (FH) stem from previous health problems.
• Social History (SH)- if alcoholic, nagpupuyat, smoker etc. - Risk factors may be to the client or to his significant others.
• Review of System (ROS)- dpat ireview client from head to toe. - Questions about the following are included: Birth, Growth,
Health History Development, Childhood diseases, Immunizations, Allergies,
- A comprehensive record of the client’s past and current health Previous health problems, Hospitalizations, Surgeries,
- This gathered during the initial assessment interview. Pregnancies, Births, Previous accidents, Injuries, Pain
- Sections Experiences, Emotional or psychiatric problems.
1. Biographic data Family Health History
2. Reasons for seeking healthcare - As more and more health problems that seem to run in families
3. History of present health concern and that are genetically based, the family health history assumes
4. Past health history greater importance.
5. Family health history - It is also helpful to see other health problems that may have
6. Review of body systems affected the client by virtue of having grown up in the family
7. Lifestyle and health practices and being exposed to these problems.
8. Developmental level - This portion should include:
• Maternal and paternal grandparents

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

• Aunts and uncles on both sides

• Parents
• Siblings
• Client’s children

Special Considerations During the Interview

1. Gerontologic
2. Cultural
3. Emotional
Communication During the Interview Gerontologic Variations in Communication
• check first hearing acuity, establish trust, assure of privacy,
avoid jargon words & medical terms, always show respect
• Do not to approach an interview with an elderly client assuming
that there is a health problem.
• First assess hearing acuity
- often misinterpreted as mental slowness or confusion
- If you detect hearing loss: speak slowly: face the client at
all times during the interview, do not yell at client.
• Establish and maintain trust, privacy, and partnership with the
older client.
• Assure your older adult clients that you are concerned, that you
see them as equal partners in health care, and that what is
discussed will be between you, their health care provider, and
them.
• Speak clearly and use straightforward language during the
interview with the older adult client.
• Ask questions in simple terms.
• Avoid medical jargon and modern slang.
• Do not talk down to client.
• Show respect.
• If the older client is mentally confused
- have a significant other (e.g., spouse, child, close friend)
present during the interview to provide or clarify the data

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Cultural Variations in Communication

• consider ethnic/culture
• Ethnic / cultural variations in communication and self-
disclosure styles may significantly affect the information
obtained
• If misunderstanding or difficulty in communicating is evident,
seek help from an expert
• Noted variations in communication styles include:
- Reluctance to reveal personal information to stranger for
various culturally based reasons
- Variation in willingness to openly express emotional
distress or pain
- Variation in meaning conveyed by language.
- Variation in use and meaning of nonverbal communication:
eye contact, stance, gestures, demeanor.
- Variation in disease / illness perception: Culture-specific
syndromes or disorders are accepted by some groups.
- Variation in past, present or future time orientation.
- Variation in the family’s role in the decision-making
process: A person other than the client or the client’s parent
may be the major decision maker regarding appointments,
treatments, or follow-up care for the client.
Emotional Variations in Communication
• Not every client you encounter will be calm, friendly, and eager
to participate in the interview process
• Clients’ emotions vary for a number of reasons
- They may be scared or anxious
- Angry that they are sick or about having to have an
examination
- Depressed about their health or other life events
- Some helpful ways to deal with various clients with
problematic emotions and behaviors:
Interacting with clients with various emotional states
- when interacting with an anxious client (uneasiness)
- when interacting with an angry client (mad, annoyed)
- when interacting with a depressed client (unhappy or sad)
- when interacting with a manipulative client (controlling of
the situation)
- when interacting with a seductive client (attractive)
- when discussing sensitive issues like sexuality, dying, What are general values of Filipino nurses?
spirituality Work Ethic
- As a group Filipino nurses are well linked because they are
hardworking. They place high value on responsibility and
seldom complain.
Spirituality
- Filipino nurses are very religious people.
- There is a deep faith in God that is reflected in the expression
of “bahala na”- it is up to God or leave it to God.
Sensitivity
- Filipinos are generally sensitive and equally sensitive to the
feelings of others so they try to find a ways to say things
diplomatically
Interpersonal Relationships
- Filipinos are generally quiet. Very conservative families do not
allow their younger members to join conversation of adults
w/out an invitation.

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Respect and Reverence Advantages

- One’s position in society professional achievements and age • Bayanihan refer to spirit of communal unity and
carry a lot of weight in the Philippine society cooperation.
- Physicians lawyers priests engineers teachers and nurses are • Pakikipagdamayan helping each other.
among the well-respected professionals in the Philippines • Pagpapahalaga sa kapwa mutual respect
Modesty • Utang na loob debt of gratitude
- Filipino nurses find it uncomfortable to accept even a well- Disadvantages
deserved compliment. • Doing thigs you wouldn’t normally do
- Filipino nurses are less likely to use I to express what they have • The fear of being rejected.
achieved.
Language Culture care
- Respect is integrated in the Filipino language. Reference to the - Professional nursing care that is culturally sensitive, culturally
elderly is the use of the third person. appropriate and culturally competent.
Close Family Ties - Culture care nursing is critical to meeting the complex nursing
- Filipino nurses have strong family ties they end to eat the same care needs of a given person, family and community.
food and mingle with individuals of the same ethnic background • Culture sensitive – implies that the nurse possesses some
hence the old health beliefs and practices. basic knowledge of and constructive attitudes toward the
health traditions observed among the diverse cultural
Health beliefs groups found in the setting in which they are practicing
- Are conviction of truth abouth health something that is accepted
• Culture appropriate – implies that the nurse applies the
considered to be true or held as an opinion
underlying background knowledge that must be possessed
- It is not limited to any specific ethnic group geographical area
to provide a given client with the best possible health care
language religious belief manner of clothing sexual orientation
• Culturally competent – Implies that within the delivered
and socioeconomic status (fisher 1996)
care the nurse understands and attends to the total context
Culture
of the client’s situation and uses a complex combination of
- Is defined as the totality of socially transmitted pattern of
knowledge attitude and skills.
thought values meanings and beliefs (Purnell 2005)
Concepts related to Cultural Care Nursing
• Subculture – usually composed of people who have a distinct
identity and yet are related to a larger cultural group. Ex.
Occupational groups (nurses, doctors etc.) societal groups
(feminist, activist etc.)
• Diversity – refers to the fact or state of being different. Many
factors account for diversity: race, gender, sexual orientation,
culture, ethnicity, socioeconomic status, educational attainment
etc.
• Bicultural – used to describe a person who crosses 2 cultures,
lifestyle, and values.
• Acculturation – Changes of one’s cultural patterns to those of
the host society.
• Assimilation – the process by which an individual develops a
new cultural identity.
What are the negative values of Filipinos affecting health?
Manana habit or procrastination • Race – the classification of people according to shared biologic
- Is one of the most negative traits of the Filipinos. characteristics, genetic markers, or feature.
- It means mamaya na in Filipino or to do a certain thing in a later • Prejudice – a negative belief or preference that is generalized
time. about a group and that leads to prejudgment.
Ningas kugon • Stereotyping – Is assuming that all members of a culture or
- Is a tendency among individuals to start a new venture or task ethnic group are alike.
with too much enthusiasm and effort but after some time will • Discrimination – the differential treatment of individuals or
take a pause or will suddenly stop working until such time that groups based on categories such as race, ethnicity, gender,
they lose interest in the venture or task. social class or exceptionality, occurs when a person acts on
Pakikisama prejudice and denies another person one or more of the
- Refers to an interpersonal relationship where people are fundamental rights.
friendly with each other.
- To be with someone and to get along with each other indicates
basic human friendliness and affinity.

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

DOCUMENTATION OF FINDINGS - Information from records may assist health care

Documentation planners to identify agency needs, such as over
- Documentation within a client’s medical record is a vital aspect utilized and underutilized hospital services.
of nursing care or practice - Records can be used to establish the costs of various
- It is anything written or printed on which you rely as record or services and to identify those services that cost the
proof of patient actions and activities. agency money and those that generate revenue.
- Remember: “if it is not documented, NOT DONE” Who reads nursing records?
- “The approach to record keeping that the courts of law tends to • Nurses
adopt is that if it is not recorded, it has not been done” • Patients
• Relatives
Record/ Chart
• Doctors
- It is a formal, legal document that provides evidence of a
• Members of the health care team
client’s care and can be written or computer based.
Nursing Process
- It is a tool you can use to communicate data graphically.
- A systematic approach to nursing which comprises a series of
- A thing constituting a piece of evidence about the past,
steps which most commonly, are referred to as assessing,
especially an account kept in writing or some other permanent
planning, implementing and evaluation
form.
- Assessment- Diagnosis- Planning- Intervention- Evaluation
Purpose of Record/ Chart
Nursing Documentation
- The patient record is a valuable source of data for all members
- The nursing documentation must be accurate, comprehensive,
of the health care team.
and flexible.
- Client records are kept for a number of purposes including:
- Information in the client records provides a detailed account of
1. Communication
the level of quality of nursing care delivered to clients.
- The record serves as the vehicle by which different
- Accurate and effective documentation ensures continuity of
health professionals who interact with a client
care, saves time and prevent duplication or error in the patient
communicate with each other.
care.
- This prevents fragmentation, repetition, and delays in
- Importance of Nursing Documentation
client care.
2. Planning client care → Record keeping is an integral part of nursing and practice.
- Each health professional uses data from the client’s It is a tool of professional practice and one that should
record to plan care for that client. help the care process. It is not separate from this process
- Nurses use baseline and ongoing data to evaluate the and it is not an optional extra to be fitted in if
effectiveness of the using care plan. circumstances allow.
- The physicians plan treatment after seeing the Documenting Data
laboratory reports of patient. - It is another crucial part of the first step in the nursing process
3. Auditing health agencies - Categories of information on the forms are designed to ensure
- An audit is a review of client records for quality that the nurse gathers pertinent information needed to meet the
assurance purposes. standards and guidelines of the specific institutions mentioned
4. Research previously and to develop a plan of care for the client
- The information contained in a record can be a Purpose of documentation
valuable source of data for research. 1. Primary reason for documentation of assessment data is to
- The treatment plans for a number of clients with the promote effective communication among multidisciplinary
same health problems can yield information helpful health team members to facilitate safe and efficient client care
in treating other clients. 2. Provides the health care team with a database that becomes the
5. Education foundation for care of the client
- Students in health disciplines often use client records 3. Helps to identify health problems, formulate nursing diagnoses,
as educational tools. and plan immediate and ongoing interventions.
- A record can frequently provide a comprehensive 4. The use of electronic health records (EHRs) also increases the
view of the client, the illness and effective treatment likelihood that clients received life-saving treatments and may
strategies. lower the risk of hospital acquired infections.
6. Reimbursement Things to Consider on Documentation
- Documentation also helps a facility receive • Legal record of patient encounter
reimbursement from the government. • May be used by many professionals.
- For a patient to obtain payment through Medicare or • Document in a professional and legally acceptable manner
insurance agencies the client’s clinical record must • Follow institution’s system:
contain the correct diagnosis and reveal that the - Ensure accuracy.
appropriate care has been given. - Ensure correct patient record or chart.
7. Legal documentation - Record information immediately upon completion of
- The client’s record is a legal document and is usually patient encounter
admissible in court as evidence. - Avoid distractions while documenting.
8. Health care analysis - Date and time each entry

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Guidelines for Documentation • It serves as an information sheet of the medications and

• Keep confidential all documented information in the client procedures rendered to the patient.
record • Legal evidence for cross-examination whenever
• Document legibly or print neatly in non-erasable ink complaints or malpractice claims have been sighted out.
• Use correct grammar and spelling • It serves as the evidence of continuity of care.
• Avoid wordiness that creates redundancy • It serves as a research material for retrospective study.
• Use phrases instead of sentences to record data Types of Charting
• Record data findings, not how they were obtained 1. Narrative Charting
• Write entries objectively without making premature judgments - Traditional form of charting
or diagnoses - Source-oriented record
• Record the client’s understanding and perception of problems - Advantage is that it provides organized section for each
• Avoid recording the word “normal” for normal findings member of the healthcare team
• Record complete information and details for all client - Disadvantage in using this type of recording is that the
symptoms or experiences information is scattered throughout the chart
- Example:
• Include additional assessment content when applicable
• Treatment Chart
• Support objective data with specific observations obtained
during the physical examination • Admission sheet
Assessment Specific Documentation Guidelines • Initial Nursing Assessment
• Record pertinent positive and negative assessment data • Graphic Record
• Document any parts of the assessment that are omitted or 2. Problem-Oriented Record
refused by patient - Give focus on the problems that patients face
• Avoid using judgmental language - Each medical personnel can contribute and collaborate on
• Avoid evaluative statements; cite specific statements or actions the plan of care
you observe - Advantage seen in this type of charting is collaboration
• State time intervals precisely among medical personnel
- The disadvantage here is that it takes complete and on time
• Use specific measurements
assessment of problem lists
• Draw pictures when appropriate
3. Soapier Formats
• Refer to findings using anatomic landmarks
- It is usually used since it gives a quick look at the
• Use the face of a clock to describe findings that are in a circular
observation of each nurse as well as the nursing action on
pattern
each observation.
• Document any change in patient’s condition during a visit or - S – Subjective data includes the patient’s complaints or
from previous visits perception of the present problem sited.
• Describe what you observed, not what you did - O – Objective data includes the nurse’s observation using
his or her clinical eye
Examples of Vague Versus Clear and Concise Documentation - A – Assessment includes the inference made by the nurse
of Data from the two types of data. This is the part wherein the
Vague problem is stated. The nursing problem is stated in a form
Clear and Concise Documentation
Documentation of nursing diagnoses using the NANDA.
- P – Plan this includes the nursing actions to be made in
Memory intact Recent and remote memory intact order to solve the stated problem. This part can be revised
Temperature: 37.2OC; PR 66; RR 18; - I – Intervention –This is the part wherein specific nursing
Vital signs good actions are stated
BP 120/80
- E – Evaluation –This is the part wherein the nurse evaluates
Skin color normal Skin pink with consistent pigmentation the reaction of the patient or progress of the problem being
solved.
Appetite good Reports no change in appetite - R- Revision – This is the section that states the changes
made in order to further resolve the problem
Swelling of Pitting edema 3+ of both ankles that lasts Example:
ankles 10 seconds Case: A patient with hypersensitivity reaction secondary to food
Voids a lot Polyuria, urinary output = 3000 mL/day intake.
• S - “My skin is so itchy, especially on the skinfolds.”
Charting • O - Skin appears to be flushed with bumps. Irritation noted
- the common term used in the field of nursing when it comes to on the armpit and inner thighs.
documentation • A - Altered comfort secondary to food intake
- Purpose of Charting • P - Inform the patient not to scratch the skin.
• It is a permanent record of patient’s information. • I - Instructed not to scratch the skin
• Tracks the progress of the patient’s condition during the - Cut the fingernails short
hospitalization as well as the status upon discharge. - Applied cold compress
- Referred to the physician

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

• E - “I feel more comfortable and I do not have the urge to - Do not identify charts by room number only; check the
scratch my skin.” client’s name.
• R - Give antihistamine (Antamin) 1mg/mL as deep 7. Sequence
intramuscular injection to left deltoid muscle. - Document events in the order in which they occur;
4. Focus Charting (FDAR) - For example, record assessments, then the nursing
- This type of charting involves Data, Action and Response interventions, and then the client’s responses
category. 8. Appropriate
- This is a client-focused charting - Record only information that pertains to the client’s health
- Since it the client being talked about most of the problems and care.
documentation, this is a form of holistic perspective of - Any other personal information that the client conveys is
client’s needs. inappropriate for the record
- Example: 9. Complete
• F – Nursing Dx, Client Concern, S&S, Event - Record all assessments, dependent and independent
• D - Facial grimacing, graded the nape pain as 7 in the nursing interventions, client problems, client comments
scale of 1 to 10 with 10 as severe pain and responses to interventions and tests, progress toward
• A - Given Norgesic Forte per orem as now dose. goals, and communication with other members of the
health team.
• R - Rated pain as 2 and able to walk on her own
10. Concise
Guidelines / Principles of Recording
- Recordings need to be brief as well as complete to save
1. Factual
time in communication.
- A factual record contains descriptive, objective
- Repeated usage of the client’s name and the word client are
information about what a nurse sees, hears, feels, and
omitted.
smells.
11. Legal Prudence
- Avoid vague terms such as appears, seems, or apparently
- Accurate, complete documentation should give legal
because these words suggest that you are stating an opinion,
protection to the nurse, the client’s other caregivers, the
do not accurately communicate facts
health care facility, and the client
2. Timing
- Document the date and time of each recording.
Legal Matters of Nursing Record's
- This is essential not only for legal reasons but also for client
- Nursing records can be used:
safety.
1. In court of law by the Health Service Commissioner – To
- Record the time in the conventional manner (e.g., 9:00 AM
investigate a patient complaint
or 3:15 PM)
2. In case of complaint of professional misconduct.
3. Legibility
- All entries must be legible and easy to read to prevent
interpretation errors.
- Hand printing or easily understood handwriting is usually
permissible.
4. Permanence
- All entries on the client’s record are made in dark ink so
that the record is permanent and changes can be identified.
- Dark ink reproduces well in duplication processes.
- Follow the agency’s policies about the type of pen and ink
used for recording.
5. Accepted Terminology
- Use only the standard and recognized abbreviations.
- Ambiguity occurs when an abbreviation can stand for more
than one term leading to misinterpretation.
6. Correct Signature
- Each recording on the nursing notes is signed by the nurse
making it.
- The signature includes the name and title; for example,
“S. B. CAJAYON MAN, RN”
5. Spelling
- Use correct spelling while documenting.
- Correct spelling is essential for accuracy in recording.
- Avoid spelling mistakes If unsure how to spell a word, look
it up in a dictionary or other resource.
6. Accuracy
- The client’s name and identifying information should be
stamped or written on each page of the clinical record.
- Before making any entry, check that it is the correct chart.
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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

ADDITIONAL: (FROM COURSE UNIT 13) GENERATION OF NURSING DIAGNOSIS

SBAR Diagnostic Reasoning Process
- Situation, background, assessment, recommendation - Diagnostic reasoning is a form of critical thinking.
- A model of communication - Before you begin analyzing data, make sure you have
- One of the most common handover mnemonic models used in accurately performed the steps of the assessment phase of the
health care nursing process.
- Improve quality and patient safety outcomes when used by
- If you are confident of your work during the assessment phase,
health team members to communicate or hand-off client
you are ready to analyze your data.
information
- This phase consists of the following essential components:
• Grouping and organizing data.
• Validating data and comparing the data with norms.
• Clustering data to make inferences.
• Generating possible hypotheses regarding the client’s
problems.
• Formulating a professional clinical judgment.
• Validating the judgment with the client.
7 distinct steps to provide a clear, concise explanation of how to
perform data analysis.
Step One — Identify Abnormal Data and Strengths
- Identifying abnormal findings and client strengths
- Compare collected assessment data with findings in reliable
charts and reference resources.
- The nurse should have a basic knowledge of risk factors for
the client.
- Analyze both subjective and objective data when identifying
strengths and abnormal findings.
Step Two — Cluster Data
- The nurse looks at the identified abnormal findings and
strengths for cues that are related.
- Clustering of both abnormal cues and strength cues
- During clustering of the data, nurses may find that certain cues
are pointing toward a problem but that more data are needed to
support the determination of that problem, so the nurse would
perform additional assessment.
Step Three — Draw Inferences
Write down hunches about each cue cluster.
- For example, based on the cue cluster presented in step
Some Examples of Documentation:
https://olfu.instructure.com/courses/67023/files/6878860?module_item_id=6020794 two—rash on face, neck, chest, and back; patchy alopecia;
-nasa canvas po yan – module week 15 (nasa drive lang din natin) “so ugly”—you would write down what you think these
data are saying and determine whether it is something that
the nurse can treat independently. Your hunch about this
data cluster might be: “Changes in physical appearance are
affecting self-perception.” This is something for which the
nurse would intervene and treat independently. Therefore,
the nurse would move to step four: analysis of data to
formulate a nursing diagnosis.
Attempt to generate collaborative problems as necessary.
- May suggest the need for both medical and nursing
interventions to resolve the problem.
Referral of identified problems for which the nurse cannot prescribe
definitive treatment.
- For example, a diabetic client who is having trouble
understanding the exchange diet. Although the nurse has
knowledge in this area, referral to a dietitian can provide
the client with updated materials and allow the nurse more
time to deal with client problems within the nursing domain.

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

- Another important reason for referral is the identification - Risk nursing diagnosis
or suspicion of a medical problem based on the subjective • Indicates the client does not currently have the problem but
and objective data collected. In such cases, referral to the is at high risk for developing it (e.g., risk for impaired skin
client’s physician, nurse practitioner, or another specialist integrity related to immobility, poor nutrition, and
is necessary. incontinence)
- Actual nursing diagnosis
• Indicates that the client is currently experiencing the stated
problem or has a dysfunctional pattern (e.g., impaired skin
integrity: reddened area on right buttocks).
- Syndrome diagnosis
• When a cluster of nursing diagnoses is related in a way that
they occur together
Comparison of Health Promotion, Risk, and Actual Nursing
Diagnosis

Step Five — Check for Defining Characteristics

- The nurse checks for defining characteristics for the data
clusters and hypothesized diagnoses in order to choose the most
accurate diagnoses.
- Delete those diagnosis that are not valid or accurate for the
client.
• This step is often difficult because diagnostic labels overlap,
making it hard to identify the most appropriate diagnosis.
For example, the diagnostic categories of impaired gas
exchange, ineffective airway clearance, and ineffective
breathing patterns all reflect respiratory problems, but each
is used to describe a very different human response pattern
and set of defining characteristics.
- Reference texts such as North American Nursing Diagnosis
Association (NANDA) Nursing Diagnoses: Definitions and
Classifications 2015–2017 can assist the nurse in determining
when and when not to use each nursing diagnostic category
(NANDA, 2014). It assists with ruling out invalid diagnoses and
selecting valid diagnoses.
Step Six — Confirm or Rule Out Diagnoses
- Rule out a particular diagnosis if the cue cluster does not meet
the defining characteristics.
Step Four — Propose Possible Nursing Diagnoses - Verify diagnosis with client and other health care professionals
- The nursing diagnoses may be wellness, or health promotion, if the cue cluster does meet the defining characteristics.
diagnoses; risk diagnoses; or actual diagnoses, and syndrome - Often nursing diagnosis terminology is difficult for the client to
diagnoses (NANDA, 2014). understand.
- Wellness diagnosis, or health promotion nursing diagnosis • For example, you would not tell the client that you believe
• Indicates that the client (individual, family, community) that he has impaired nutrition: less than body requirements.
has the motivation to increase well-being and enhance Instead, you might say that you believe that current
health behaviors. nutritional intake is not adequate to promote healing of
• The nurse supports the client’s movement toward greater body tissues. Then you would ask the client if this seemed
health and wellness by identifying “readiness for” the to be an accurate statement of the problem. It is essential
diagnostic label (e.g., readiness for enhanced sleep) that the client understand the problem so that treatment can
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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

be properly implemented. If the client is not in a coherent Wellness or Health Promotion Nursing Diagnosis
state of mind to help validate the problem, consult with - Health promotion diagnoses represent those situations in which
family members or significant others, or even other health the client does not have a problem but is at a point at which he
care professionals. or she can attain a higher level of health.
- Validation is also important with the client who has a - This type of diagnosis is often worded readiness for enhanced.
collaborative problem or who requires a referral. - Indicates an opportunity to make greater, to increase quality of,
- Collaborate with the client regarding referrals to determine or to attain the most desired level of function.
what is needed to resolve the problem and to discuss possible - When documenting these diagnoses, it is best to use the
resources to help the client. following format:
Step Seven—Document Conclusions • Readiness for + diagnostic label + r/t + etiology + AMB +
- Document all of your professional judgments and the data that symptoms (defining characteristics)
support those judgments. - Example: Readiness for enhanced immunization status
- Nursing diagnoses are often documented and worded in r/t mother’s expressed desire to resume recommended
different formats. immunization schedule for 3-year-old child AMB
- The most useful formats for actual, wellness, health promotion, mother’s description of recommended immunization
risk, and actual syndrome nursing diagnoses schedule and importance of following it to prevent
infections
Actual Nursing Diagnosis
- The most useful format for an actual nursing diagnosis is: Risk Nursing Diagnosis
- NANDA label (for problem) + related to (r/t) + etiology + as - Describes a situation in which an actual diagnosis will most
manifested by (AMB) + defining characteristics. likely occur if the nurse does not intervene
- Example: Fatigue r/t an increase in job demands and personal - In this case, the client does not have any symptoms or defining
stress AMB client’s statements of feeling exhausted all of the characteristics that are manifested, thus a shorter statement is
time and inability to perform usual work and home sufficient:
responsibilities (e.g., cooking, cleaning). • Risk for + diagnostic label + r/t + etiology
- Provides all of the necessary information and provides the - Example: Risk for Infection r/t presence of dirty knife
reader with the clearest and most accurate description of the wound, leukopenia, and lack of client knowledge of how
client’s problem. adequately to care for the wound.

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

DIAGNOSTIC PROCEDURES • Airway obstruction (possibly from mucus plugs or a tumor)

Diagnostic Tests • Bronchiole obstruction caused by asthma or emphysema.
• Laboratory tests • Partially blocked alveoli or pulmonary capillaries
• Used for basic screening as part of wellness check. • Damaged alveoli
• Used to help confirm diagnosis, monitor an illness, and provide • Alveoli that are filled with fluid because of disease,
valuable information about the client’s response to treatment. hemorrhage, or near drowning.
Phases of Diagnostic Testing
Pretest Blood Urea Nitrogen
- Client preparation - The blood urea nitrogen (BUN) test is used to measure the
- A thorough assessment and data collection (biological, nitrogen fraction of urea, the chief end product of protein
psychological, sociological, cultural, and spiritual) assist the metabolism.
nurse in determining communication and teaching strategies. - To check if the kidney is still in good condition. It measures the
- Informed consent nitrogen in the body which is the end product of urea.
- Ensuring client’s safety - Urea is made up when there is breakdown in the protein.
- Examples: MRI, CT scan, Chest Xray, CBC - Most of the time blood para makita kung gaano kadami un urea.
Intratest Purpose
- (during the procedure itself) • To evaluate kidney function and aid in the diagnosis of renal
- Specimen collection and performing or assisting with certain disease
diagnostic testing. • To aid in the assessment of hydration
- The nurses use standard precaution, sterile technique, provides Reference Value
emotional and physical support while monitoring the client. • BUN: 8 to 20 mg/ dL (SI, 2.9-7.5 mmol /L)
- The nurses ensure correct labelling, storage, and transportation • Elderly patients: slightly higher, possibly to 69 mg/ dL (SI, 25.8
of specimen to avoid invalid test result. mmol /L)
Post Test Abnormal Findings
- On nursing care of the client and follow up activities and - Elevated Levels
observation. • Renal disease (greater than 100 mg indicates serious
- The nurse compares the previous and current test result and impairment of renal function)
report to appropriate health team members. • Reduced renal blood flow (due to dehydration, for
Nursing Diagnosis Appropriate for Client’s Who Will Undergo example)
Diagnostic Testing • Urinary tract obstruction
• Anxiety or Fear related to possible diagnosis of acute or chronic • Increased protein catabolism (such as with burns)
illness pending conclusion of diagnostic testing.
• Impaired Physical Mobility related to prescribed bed rest and Blood Chemistry Test
restricted movement of involved extremity after testing - Measures certain amount of chemicals using blood (checking
• Deficient Knowledge (state diagnostic test) related to glucose, sodium, albumin)
misperceptions received from others regarding process for test - include determining certain enzymes that may be present
(including lactic dehydrogenase [LDH], creatine kinase [CK],
Arterial Blood Gas aspartate aminotransferase [AST], and alanine
- ABG analysis measures blood pH and arterial oxygen (PaO2) aminotransferase [ALT]), serum glucose, hormones such as
and carbon dioxide (PaCO2) partial pressures thyroid hormone, and other substances such as cholesterol and
- Being ordered to assist the client if they have adequate triglycerides.
oxygenation and ventilation in their body. - a common laboratory test is the glycosylated hemoglobin or
Purpose hemoglobin A1C (HbA1C) test
• To evaluate the efficiency of pulmonary gas exchange
• To assess the integrity of the ventilatory control system
• To determine the acid base level of the blood
• To monitor respiratory therapy
Reference value
• PaO2: 80 to 100 mm Hg (SI, 10.6-13.3 kPa)
• PaCO2: 35 to 45 mm Hg (SI, 4.7-5.3 kPa)
• pH: 7.35 to 7.45 (SI, 7.35-7.45)
• O2CT: 15% to 23% (SI, 0.15-0.23)
• SaO2: 94% to 100% (SI, 0.94-1)
• HCO3 22 to 25 mEq/L (SI, 22-25 mmol/L)
Abnormal finding
- Decreased PaO2, O2CT, and SaO2 Levels, and Increased
PaCO2 Level
• Respiratory muscle weakness or paralysis
• Respiratory center inhibition (from head injury, brain
tumor, or drug abuse)

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Capillary Blood Glucose Test Abnormal Findings

- a procedure that measures the amount of sugar, or glucose, in • Deviation of the trachea from midline, indicating possible
your blood. Your doctor may order this test to help diagnose tension pneumothorax or pleural effusion.
diabetes. • Right sided hypertrophy of the heart, indicating cor-pulmonale
- People with diabetes can also use this test to manage their or heart failure.
condition. • Tortuous aortic knob, indicating atherosclerosis.
Purpose • Gross widening of the mediastinum, suggesting neoplasm or
• Assist in the diagnosis of diabetes. aortic aneurysm.
• Assist in the management of glucose levels in an individuals. • Break or misalignment of bones, indicating fracture.
• Determine insulin requirements. • Visible bronchi, indicating bronchial pneumonia.
• Identify hypoglycemia. • Flattening of the diaphragm, indicating emphysema or asthma.
Reference value • Irregular, patchy infiltrates in the lung fields, indicating
Normal values: pneumonia.
• 0- 50 years - < 140 dL or < 7.8 mmol /L (SI units)
• 50-60 years - < 150 dL. 60 years and older -< 160 mg/ Dl Colonoscopy
- Uses a flexible fiber optic video endoscope to permit visual
examination of the large intestine’s lining.
Abnormal findings - If there us obstruction in intestines (make sure na nakita nyo
• A glucose level that is higher than normal may mean you have kung ano un instruction ni doc sa chart)
pre-diabetes or diabetes. - (minsan nag oorder si doc ng laxative para dumumi ng dumumi
• A 2-hour value between 140and 200 mg/ dL (7.8 and 11.1 mmol si client or hindi na sila pinapakain before midnight)
/L) is called impaired glucose tolerance. - (pag hindi effective un laxative, ang ginagamit ay enema)
Enema is the introduction of a solution into the intestine or into
Chest Radiography the rectum on your client. (how will you know if the enema is
- chest radiography, X rays or electromagnetic waves penetrate effective- if the return flow is clear)
the chest and cause an image to form on specially sensitized Purpose
film. • To detect or evaluate inflammatory and ulcerative bowel
- Lung problem disease.
Purpose • To locate the origin of lower GI bleeding
• To detect cardiopulmonary disorders, such as emphysema, • To help diagnose colonic strictures and benign or malignant
pneumonia, atelectasis, pneumothorax, pulmonary bullae, lesions.
pleurisy, cardiomegaly, heart failure, and tumors. • To evaluate the colon postoperatively for recurrence of polyps
• To detect mediastinal abnormalities, such as tumors, and and malignant lesions.
cardiac disease, such as heart failure. Normal Findings
• To determine the correct placement of pulmonary catheters, • Light pink-orange mucosa of the large intestine beyond the
endotracheal tubes, and other chest tubes. sigmoid colon that’s marked by semilunar folds and deep
• To determine the location and size of lesions or foreign bodies tubular pits.
• To help assess pulmonary status. • Visible blood vessels beneath the intestinal mucosa, which
• To evaluate the patient’s response to interventions. glisten from mucus secretion.
Normal Findings Abnormal Findings
• Translucent and tube-like trachea visible midline in the anterior - Elevated Levels
mediastinal cavity • Proctitis, granulomatous or ulcerative colitis, Crohn’s
• Heart in the anterior left mediastinal cavity, appearing solid disease, and malignant or benign lesions.
because of its blood content. • Diverticular disease or the site of lower GI bleeding
• Aortic knob visible as water density
• Mediastinum (mediastinal shadow) visible as the space between Complete Blood Count
the lungs, appearing shadowy and widened at the hilum. - To evaluate numerous conditions involving red blood cells
• Ribs visible as a thoracic cavity encasement. (RBCs), white blood cells (WBCs), and platelets. This test is
• Spine with visible midline in the posterior chest, clearest on a also used to indicate inflammation, infection, and response to
lateral view. Purpose
• Clavicles visible in the upper thorax, appearing intact and • Detect hematological disorder, tumor, leukemia, or
equidistant in properly centered films. immunological abnormality.
• Hila (lung roots appearing as small, white, bilateral branching • Determine the presence of hereditary hematological
densities) visible above the heart where pulmonary vessels, abnormality.
bronchi, and lymph nodes join the lungs. • Evaluate known or suspected anemia and related treatment.
• Translucent, tube like mainstem bronchus visible as part of the • Monitor blood loss and response to blood replacement.
hila Normal Findings
• Hemidiaphragm rounded and visible with right side to ¾” (1-2 Red Blood Cells:
cm) higher than the left side. - men: 4.32-5.72 million cells/ mcL
- women: 3.90-5.03 million cells/ mcL

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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Hemoglobin
- Men: 135-175 grams/L
- Women: 120-155 grams/L
Hematocrit
- Men: 38.8-50.0 percent
- Women: 34.9-44.5 percent
White Blood Cells
- 3,500 to 10,500 cells/ mcL
Platelet Count:
- 150,000 to 450,000/ mcL
Abnormal Findings
• Iron or other vitamin and
mineral deficiencies
• Bleeding disorders
• Heart disease
• Autoimmune disorders
• Bone marrow problems Cancer
• Infection or inflammation
• Reaction to medication

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Computed tomography (CT) Scan Abnormal Findings

- combines radiologic and computer technology to produce cross • Myocardial infarction (MI), right or left ventricular hypertrophy,
sectional images of various layers of tissue. arrhythmias, right or left bundle-branch block, ischemia,
Purpose conduction defects or pericarditis, electrolyte abnormalities
• To determine the existence and extent of primary bone tumors, (such as hypokalemia), and abnormalities caused by
skeletal metastases, soft tissue tumors, injuries to ligaments or cardioactive drugs.
tendons, and fractures • Abnormal waveforms during angina episodes or during
• To diagnose joint abnormalities that are difficult to detect by exercise.
other methods.
Normal Findings
• No pathology in the bones or joints
• Crisp images of the structure with blurred or eliminated details
of surrounding structures.
Abnormal Findings
• Primary bone tumors, soft tissue tumors, and skeletal metastasis
(differentiation of tissues)
• Bone fracture
• Other bone abnormalities (based on characteristics of tissues
and organs)
• Joint abnormalities
Creatinine
- Serum creatinine levels provide a more sensitive measure of
renal damage than do blood urea nitrogen levels. Creatinine is
a nonprotein end product of creatine metabolism that appears in Metabolic Screening Test
serum in amounts proportional to the body’s muscle mass. - Routinely screened for congenital metabolic conditions for
- If the client has damage kidney (combined with PUN) newborn.
Purpose - Conditions that are frequently screened for include sickle cell
- To assess glomerular filtration. disease and galactocemia.
- To screen for renal damage. - Screening involves collecting peripheral venous blood (via a
Normal Findings heel stick) on prepared blotting paper and sending the specimen
Reference Values to the state laboratory for analysis.
• Females: 0.6 to 0.9 mg/ dL (SI, 53- 97 µ mol /L) - Discovered abnormalities allow the provider and parents to plan
• Males: 0.8 to 1.2 mg/ dL (SI, 62- 115 µ mol /L) early care. Example: special diets for children with PKU) that
• Critical Values Less than 0.4 mg/ dL (SI, 35 µ mol /L) or can prevent long term complications.
2.8 mg/ dL (SI, 247 µ mol /L) - It should be done 24-48 hours after the delivery of the baby.
Abnormal Findings (heel part ng baby)
• Plasma creatinine of 2 mg/ dL indicates that renal disease has - After makuha tong test, dinadala sa newborns screening facility
seriously damaged 50% or more of the nephrons.
• Gigantism and acromegaly Magnetic resonance imaging (MRI)
- Has the ability to “see through” bone and to delineate fluid filled
Electrocardiography (ECG) soft tissue in great detail and produce images of organs and
- A common test for evaluating cardiac status, and it graphically vessels in motion.
records the electric current (electrical potential) generated by - It would take 15-90 mins depende sa area na i-eexamine ninyo
the heart. - It is not recommended if your client is claustrophobic
Purpose
• To help diagnose the cause of chest pain or other possible
cardiac pain.
• To determine the functional capacity of the heart after surgery
or a myocardial infarction (MI)
Normal Findings (Lead II)
• P wave that doesn’t exceed 2.5 mm (0.25 mV) in height or last
longer than 0.12 second.
• PR interval (includes the P wave plus the PR segment)
persisting for 0.12 to 0.2 second for heart rates above 60
beats/minute.
• QT interval that varies with the heart rate and lasts 0.4 to 0.52
second for heart rates above 60 beats/minute.
• Voltage of the R wave in leads V1 through V6 that doesn’t
exceed 27 mm.
• Total QRS complex lasting 0.06 to 0.1 second.
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Normal findings
• Color: clear, straw colored to dark yellow urine
• Odor: slightly aromatic Specific gravity: 1.005 to 1.035 pH: 4.5
to 8.0
• Red blood cells (RBCs) RBCs): 0 to 2 per High power field
• White blood cells (WBCs) or epithelial cells: 0 to 5 per high
power field
• Casts: none except one to two hyaline casts per low power field
• Crystals: present
Abnormal findings
Color
• Orange- (concentrated urine, bilirubin, phenazopyridine
Pyridium, carrots)
• Green - (Pseudomonas, indican, chlorophyll)
Odor
• Fruity (diabetes mellitus, starvation, dehydration, fetid
urine, urinary tract infections [Escherichia coli])
• Musty - (phenylketonuria)
• Fishy or cabbagelike tyrosinemia
Appearance
• Turbid (renal infection)
Specific Gravity
• Low specific gravity (characteristic of diabetes insipidus,
acute tubular necrosis, and pyelonephritis)
• Fixed specific gravity (doesn’t changes despite fluid
intake), indicating chronic glomerulonephritis and severe
renal damage.
• High specific gravity, indicating nephrotic syndrome,
Stool Examination dehydration, acute glomerulonephritis, heart failure, liver
- Frequently used to diagnose the cause of prolonged diarrhea and failure and shock.
to detect several types of intestinal parasites. pH
Purpose Normal Findings Abnormal Findings • Alkaline, possibly resulting from Fanconi’s syndrome,
• Entamoeba upper urinary tract infection caused by urea splitting
histolytica (confirms bacteria (Proteus and Pseudomonas), and metabolic or
To confirm or amebiasis) respiratory acidosis.
rule out
• Giardia lamblia • Acidic, suggesting renal tuberculosis, pyrexia,
intestinal No parasites or
(confirms giardiasis) phenylketonuria, alkaptonuria, or acidosis.
parasitic ova in stools
• Helminth ova or Casts
infection and
larvae • Hyaline: renal parenchymal disease, inflammation, or
disease.
• Hookworms trauma to the glomerular capillary membrane
• Diphyllobothrium • Course and fine: acute or chronic renal failure,
latum pyelonephritis, or chronic lead intoxication
• Fatty and waxy: chronic renal failure, nephrotic syndrome,
Urinalysis or diabetes mellitus
- Evaluates the physical characteristics of urine; determines Crystals
specific gravity and pH; detects and measures protein, glucose, • Calcium oxalate (hypercalcemia, ethylene glycol
and ketone bodies; and examines sediment for blood cells, casts, ingestion)
and crystals. • Cystine crystals (inborn error of metabolism)
- To check if there is urinary tract infection (mataas un infection),
kidney disease, diabetes (mataas un glucose level) or if your Types of Urine Specimen
client is pregnant. (mataas un human chorionic gonadotropin or Clean Voided Urine Specimen
HCG hormone level) - A clean voided specimen is usually adequate for routine
- Pag ichecheck kung may UTI or diabetes, i-instruct natin si examination.
client na umuhi muna ng konti and then pigilan nya saglit, yung - Routine urine examination is usually done on the first
susunod na ihi ilalagay na sa specimen bottle, 5-10ml) voided specimen in the morning because it tends to have a
Purpose higher, more uniform concentration and a more acidic pH
• To screen the patient’s urine for renal or urinary tract disease. than specimens later in the day.
• To help detect metabolic or systemic disease unrelated to renal - 10 mL of urine is sufficient.
disorders.
• To detect the presence of drugs
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 HEALTH ASSESSMENT LECTURE & LABORATORY: 1ST YEAR 2ND SEMESTER FINAL

Clean-Catch or Midstream Urine Specimen • Help send messages from cell to cell, nerve to nerve and organ
- Clean-catch or midstream voided specimens are collected to organ.
when a urine culture is ordered to identify microorganisms Normal findings
causing a urinary tract infection. • Potassium: 3.5 to 5.3 mEq /l
- Care is taken to ensure that the specimen is as free as • Sodium: 135 145mEq/L
possible from contamination by microorganisms around • Magnesium: 1.5 2.5mEq/L
the urinary meatus. • Calcium: 4.5 5.5 mEq /L or 8.5 10.5 mg/dl
- Clean-catch specimens are collected in a sterile specimen • Chloride: 95 105 mEqL
container with a lid. Abnormal findings
Timed Urine Specimen
• Hypo and hyperkalemia
- collection of all urine produced and voided over a specific
• Hypo and hypernatremia
period of time, ranging from 1 to 2 hours to 24 hours.
• Hypo and hypermagnesemia
- generally, either are refrigerated or contain a preservative
to prevent bacterial growth or decomposition of urine • Hypo and hypercalcemia
components.
- Purposes: Throat Culture
- Used primarily to isolate and identify pathogens, thus allowing
• To assess the ability of the kidney to concentrate and
early treatment of pharyngitis and prevention of rheumatic heart
dilute urine.
disease and glomerulonephritis.
• To determine disorders of glucose metabolism, for
To obtain a throat culture specimen, the nurse follows these steps:
example, diabetes mellitus.
1. Nurse applies clean gloves, then inserts the swab into the
• To determine levels of specific constituents, for oropharynx and runs the swab along the tonsils and areas
example, albumin, amylase, creatinine, urobilinogen, on the pharynx that are reddened or contain exudate.
or certain hormones (e.g., estriol or corticosteroids), in 2. The gag reflex, active in some clients, may be decreased by
the urine. having the client sit upright if health permits, open the
Indwelling Catheter Specimen mouth, extend the tongue, and say “ah,” and by taking the
- Sterile urine specimens obtained from closed drainage systems specimen quickly.
by inserting a sterile needle attached to a syringe through a 3. The sitting position and extension of the tongue help
drainage port in the tubing. expose the pharynx; saying “ah” relaxes the throat muscles
and helps minimize contraction of the constrictor muscle of
Sputum Test the pharynx (the gag reflex)
- A test to detect and identify bacteria or fungi that infect the 4. If the posterior pharynx cannot be seen, use a light and
lungs or breathing passages. depress the tongue with a tongue blade
• Mucoid – containing or resembling mucous. Purpose
• Purulent - containing pus. • To isolate and identify group A beta-hemolytic streptococci.
• Mucopurulent – containing pus and mucous. • To screen asymptomatic carriers of pathogens, especially
• Frothy – visible froth. Neisseria meningitides.
• Viscous – thick and sticky. Normal findings
• Blood-stained – visible blood present. • Nonhemolytic and alpha hemolytic streptococci
Purpose • Neisseria species
• To detect clinical signs of lung infection • Staphylococci Diphtheroid
• To detect signs of systemic infection • Some Haemophilus species
• To detect pyrexia of unknown origin • Pneumococci
Normal findings • Yeasts
• Color: clear sputum • Enteric gram-negative rods
Abnormal findings • Spirochetes
• Pneumonia • Veillonella species
• Pulmonary tuberculosis • Micrococcus species
• Diphtheria Abnormal findings
• Chronic obstructive pulmonary disease • Group A beta hemolytic streptococci (Streptococcus pyogenes)
(scarlet fever and pharyngitis)
Serum Electrolytes Test • Candida albicans (thrush)
- A blood test that measures levels of the body's main • Corynebacterium diphtheriae (diphtheria)
electrolytes: sodium, potassium, magnesium, chloride, and
• Bordetella pertussis (whooping cough)
calcium.
• N. gonorrhoeae
- Swab – kukuha ka lang at ichecheck; culture – kukuha ng
specimen then nilalagay sa disk, pinapahid doon un specimen • Neisseria meningitidis
Purpose • Mycoplasma and Chlamydia
• Helps to conduct electricity and energy. Yung Geria and Diagnostic procedures galing sa ppt ni mam jho. Tas
• Help control body fluids. documentation kay mam Sharon. Ung health history kay mam suva. Then nursing
• Maintain homeostasis in the body. diagnosis, sa module ko lang kinuha (course unit)
Last day na guyssss. Goooodluckkk!!!!! – Aki
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