NCMA: HEALTH ASSESSMENT

The Nursing Process

• History of present health concern
• Is a systematic, rational method of planning, and • Past health history
providing quality and individualized nursing care. • Family history
• Series of phases describing the practice of • Lifestyle and health practice
nursing
• GOSH approach for efficient and effective Types of Assessment
provision of nursing care.
Initial comprehensive assessment
Goal oriented o First time to see the patient
Organized o Completing data base
Systematic Time-lapsed reassessment
Humanistic care o Ongoing process
o Data about specific problem that has been
Purposes of the Nursing Process identified
Focused or problem-oriented assessment
• To identify a client’s health status and o Life threatening situation
actual/present and potential/possible health o Rapid identification and intervention of
problems or needs. client’s need
• To establish plans to meet identified needs Time lapsed
• Deliver specific nursing interventions to meet o After initial assessment
those needs. o Compare current status to baseline data
(next to IC assessment)
Characteristics of the Nursing Process
Steps of assessment
According to Kozier • Collection of data
• Cyclic and dynamic • Organizing data
• Client centered • Validation of data
• Universally applicable • Documentation of data
• Focus on problem solving
• Interpersonal collaborative Sources of data
• Used to critical thinking o Primary
o Secondary
According to Udan
• Goal oriented Types of data
• Organized
• Systematic
SUBJECTIVE OBJECTIVE
• Humanistic
• Efficient and effective nursing care Data elicited and Data directly/indirectly
Description verified by the observed through
client measurement
5 steps of the Nursing Process - Client - Observation and physical
- Client record assessment
1. Assessment - Other health findings of the health
2. Diagnosis care professionals
Sources professionals - Documentation of the
3. Planning
assessment made in the
4. Intervention client record
5. Evaluation - Observation made by the
family or significant others
Assessment Methods used Client interview Observation and physical
to obtain data examination
Interview and IPPA (inspection, palpation,
• Collection, organization, validation and Skills needed therapeutic percussion, and auscultation)
documentation of data. The most important step. to obtain data communication
• Begins during the first meeting of the nurse and skills
the client - “I can’t - Heart rate of 110bpm
• Continuous process carried out during all phases breathe” - UTZ reveals the client is
Examples - “I have a pregnant for 18weeks
of the nursing process. Identifies the patient’s stomach pain” - X-ray film reveals PTB
strengths and limitations. - “I can’t sleep”

4 sections of Assessment

Eloisa BSN 1-Y2-5 1

Diagnosis o Physiological complication that nurses
monitor to detect their onset or changes in
• A statement or conclusion regarding the nature of status.
phenomena
• Analyzing subjective and objective data to make • Referral
a professional judgement o Occurs after assessing the client as a whole.
• Provides basis for the selection of nursing
intervention Types of Nursing Diagnosis

Nursing Diagnosis DESCRIPTION EXAMPLE

Wellness Describes human
• Clinical judgement about individuals, family, or Diagnosis response to level
community responses to actual and potential of Readiness for
health problems and life process. wellness in an enhanced spiritual
individual, family, well-being
or
Diagnostic divisions (NANDA) community that Enhanced family
have a readiness coping
o ACTIVITY/REST for
® activity intolerance, fatigue, sleep pattern enhancement
disturbance Actual Diagnosis Problem is present
Ineffective
o CIRCULATION breathing pattern
(+) signs and
® decreased cardiac output, Altered tissue symptoms
Anxiety
perfusion
o EGO INTEGRITY Risk Diagnosis Problem does not
exist, but the
impaired adjustment, ineffective individual present of risk
coping, rape trauma factors indicate a Risk for infection
syndrome problem is likely to
o ELIMINATION develop unless
® bowel incontinence, diarrhea, constipation nurses intervene
o FOOD/FLUID Possible Health problem is Possible social
Diagnosis incomplete or isolation related to
® effective breastfeeding, ineffective
unclear unknown etiology
breastfeeding, fluid volume deficit
Syndrome Chronis pain
o HYGIENE Associated with a syndrome; Post
Diagnosis
® self care deficit cluster of other trauma syndrome;
o NUEROSENSORY diagnosis Frail elderly
® altered thought process syndrome
o PAIN/COMFORT
® acute pain, Chronic pain
o RESPIRATION Qualifiers
® ineffective airway clearance, impaired gas
exchange words that have been added to NANDA labels to
o SAFETY give additional meaning
® altered health maintenance, high risk for o Deficient
infection, high risk for injury o Impaired
o SEXUALITY o Decreased
® sexual dysfunction, altered sexuality o Ineffective
patterns o Compromised
o SOCIAL INTERACTION
® altered role performance, altered parenting, Component of Nursing Diagnosis
Ineffective family coping
o TEACHING / LEARNING One-part statement
® knowledge deficit, altered growth and o consist of NANDA label only
development ® rape trauma syndrome
® readiness for enhanced spiritual well being
After Assessing the Subjective and Objective Data
Two-part statement
• Nursing Diagnosis o Problem + Etiology
• Collaborative problem ® Constipation related to prolonged laxative
use

Eloisa BSN 1-Y2-5 2

 ® Anxiety related to change in health status ¯
® Ineffective breathing pattern related to Selecting nursing interventions
tracheobronchial obstruction ¯
Individualized nursing care plan

Three-part statement Planning should be:

o Problem + Etiology + Signs and symptoms Specific
® Acute pain related to surgical trauma and Measurable
inflammation as evidenced by grimacing and Attainable
verbal reports of pain Realistic
Time-bound
Related factor (Etiology)
Etiological cause or causative factor for diagnosis Implementation

Defining characteristics (Signs and Symptoms) • Also called “Intervention”

Observable assessment cues such as patient • Putting the nursing care plan into action
behavior, physical signs • Purpose: to carry out planned nursing
interventions to help the client attain goals and
NURSING DIAGNOSIS MEDICAL DIAGNOSIS achieve optimal health.
Is a statement of nursing • Any treatment based on clinical judgement and
judgement that made by knowledge that a nurse performs to enhance
It is made by the physician
nurse, by their education, patience outcomes.
experience and expertise
• The “doing” phase
It describes the human
Refers to the disease
response to an illness or
process Implementation process
health problem
A client’s medical
It may change as the client diagnosis remains the Determine
Reassessing Implementing
response to change same for as long as the nursing nurse’s need of
disease is present the client interventions assistance
Ineffective breath pattern Asthma
Activity intolerance Cerebrovascular accident
Disturbed body image Amputation
Acute pain Appendicitis
Documenting Supervising
nursing activities nursing activities

Planning

• Deliberative, systematic phase of nursing process Approach

that involves decision making and problem
solving • Direct Care
• Involves setting goals and outcomes o Direct intervention
• Individualized plan of care for patient once o Interventions are treatments performed
diagnosis have been prioritized. through interaction with patient.
® Ex. Medication administration, VS checking,
insertion of IFC
Client assessment Formulating • Indirect care
Nurse refers data and diagnostic
statements client’s goal o Intervention are treatments performed away
from a patient but on behalf of the group of /
patient.
® Ex. Safety and Infection control,
Nursing care plan Designing Prevent, reduce or delegating nurse care
(NCP) the blue print eliminate the client’s
of nursing process interventions health problems
Types

Planning process • Dependent

o Actions that require an order from a health
Establish client’s goal care provider
¯ • Collaborative
Setting priorities o Interdependent interventions

Eloisa BSN 1-Y2-5 3

 o Therapies that require the combined • To monitor clients at risk for alteration in health
knowledge, skills, and expertise of multiple
health care providers Normal Vital Signs

Evaluation • Temperature
® 36.5 – 37.2 °C
• Assessing client’s response to nursing progress • Adult PR
toward health care and effectiveness of nursing ® 60 – 100 bpm
care plan • Respiration
• Final step of the nursing process ® 16 -20
• Crucial to determine if the patient’s condition
improved or worsen after application of the first When to assess vital signs
four steps of nursing process.
• Upon admission
Types of evaluation • A change in health status
• Pre and Post Op / Procedure
• Ongoing evaluation – continuous • Pre and Post medication administration
• Initial evaluation – specific intervals • Before and after any nursing intervention that
• Terminal evaluation – evaluation at discharge could affect the vital signs
o Activity, talking, chewing a gum and anxiety
Types of outcome affect pulse, respiration, blood pressure.
o Allow 5 minutes rest before taking VS
• The goal was completely met
• Partially met
• Completely met

The nurse must take note:

• The steps of the nursing process are interrelated

forming a continuous circle of thought and action
that is both dynamic and cyclic.
• The nurse must be able to apply some basic
abilities on the knowledge of science and theory.
• Creativity and adaptability are very important.

Temperature
Methods in taking Vital signs
• Normal temperature is 36.5 - 37.7 °C
• Also known as “Cardinal signs”
• Balance between the heat produced by the body
• The “taking of vital signs” refers to measurement and heat lost from the body
of the client’s body temperature (T), pulse (P) • The degree (°) or intensity of internal het of a
and respiratory (R) rates, and blood pressure person’s body
(BP)
• The first step in the physical examination; Two kinds of temperature:
common, non-invasive physical assessment
procedure done to clients. • Surface temperature
• Usually when a vital sign is abnormal, something o Fluctuates in response to environment
is wrong in at least one of the body systems • Core temperature
• Clinical measurements that provide data that o Temperature of deep tissue of the body.
reflect the status of several body system o Remains relatively constant.
including cardiovascular, peripheral vascular, › Temperature is lowest in the morning (4am -
neurologic and respiratory systems. 6am), highest during the evening. (8pm to
• 5th vital sign - pain midnight)
Purpose:

• To obtain baseline data

• To detect or monitor change in client’s health
status

Eloisa BSN 1-Y2-5 4

Hypothalamus Types of thermometers

• Is a small region located at the base of the brain 1. Glass thermometers

that plays a vitals role such as releasing of o No longer an instrument of choice
hormones 2. Electronic / digital thermometer
• Temperature regulatory center found in the brain o Heat sensitive probe, read in seconds
3. Tympanic thermometer
Factors that influence body temperature: o Sensor probe shaped like an otoscope in
external opening of ear canal
• Age
o Infants and older clients are greatly Alterations in body temperature
influenced by environment
• Diurnal variations • Pyrexia / Hyperthermia / Febrile
o Temperature normally changes throughout o Body temperature above the usual range
the day (fluctuating temperature – a change • Hyperpyrexia
in rate or magnitude) o A response to prolonged exposure to cold or
• Exercise need for oxygen in the body
o Strenuous activity = high temperature • Hypothermia
• Hormones o A response to prolonged exposure to cold or
o Women need for oxygen of the body, hypoglycemia,
® progesterone increases hypothyroidism, starvation
temperature (.3 - .6 °C )
• Stress Types of Fever
o Stimulates sympathetic nervous system =
increase metabolic activity • Intermittent fever
• Environment o Alternates at regular interval where
o Room temperature may affect assessment temperature is elevated for several hours or
• Environment periods of fever and followed by an interval of
• Ovulation normal temperature
® Malaria or other infectious disease
Terminologies: • Remittent fever
o Wide range of temperature fluctuations all of
• Febrile or Hyperthermia which are above normal (pyrexia) throughout
o temperature is above normal or the patient the day over 24-hour period
has fever, may be seen in viral or bacterial ® May be associated with viral upper respiratory
infections, malignancies, trauma, blood and tract or caused by drugs
immune disorders. • Relapsing fever
• Afebrile o Short periods of high fever (40ºC) with
o Temperature is normal or without fever periods of 1 or 2 days of normal temperature
• Hypothermia o Recurrent fever
o (lower than 36.5) may be seen in prolonged ® May be caused by bacterial infections
exposure to cold, hypoglycemia, • Constant fever
hypothyroidism or starvation o Fluctuates minimally but always remain
• Thyroid hormone above normal
o regulation of metabolism (BMR) o Temperature does not touch the baseline and
o Increased Thyroxine output increases remain above normal throughout the day
metabolism (Chemical Thermogenesis)
o Thyroid hormones affects blood vessels to Signs and symptoms of fever
determine body temperature
o Affect protein synthesis 1. Sweating
o Hyperthyroidism (overactive thyroid) can 2. Chills, shivering, or shaking
cause a person to feel too hot 3. Hot or flushed skin
o Hypothyroidism (underactive thyroid) can 4. Headache
cause a person to feel too cold 5. Body aches
6. Fatigue and weakness
7. Loss of appetite
8. Increased heart rate
9. Dehydration

Eloisa BSN 1-Y2-5 5

Site for temperature measurement • Defervescence
o Occurs when the cause of fever is suddenly
SITE ADVANTAGE DISADVANTAGE removed, patient’s body temperature returns
• Thermometers break if
bitten
to normal
Oral
• Inaccurate if the client o The hypothalamus attempts to normalize the
Accessible & convenient • ingested hot or cold food,
(36.5-37.5⁰C)
fluid or smoked
temperature resulting in a sudden
• Could injured the mouth vasodilation
following oral surgery o This event is known as crisis, the flush
• Inconvenient and more
unpleasant for clients defervesce stage of pyrexia
• Difficult for client who ® Flushed skin
cannot turn to the side
Rectal
Reliable measurement • Could injure the rectum ® Sweating
(37-38.1⁰C)
following rectal surgery ® Decreased shivering
• Presence of stool may
interfere with thermometer ® Possible dehydration
placement.
• The thermometer must be
Axillary Safe left in place a long time to Nursing interventions during Fever
(35.8-37⁰C) Non-invasive obtain an accurate
measurement
• Can be uncomfortable • Take your temperature and assess symptoms
and involves risk of injuring • Stay in bed and rest
the measurement if the
Readily accessible probe is inserted too far. • Keep hydrated or increase fluid intake
Tympanic
(36.8-37.9)
Reflects core temperature
Very fast
• Repeated measurements; • Stay cool or manage stress
may vary, right and left
measurements may • Tepid sponge bath / use of cold compress
•
differ.
Expensive
• Take over the counter medication or take
• Requires electronic medication as prescribed
equipment that may be
expensive or unavailable
Safe and non-invasive variation in technique
Temporal
Very fast needed if the client has
perspiration on the
Blood pressure
forehead.
• Blood pressure is the measure of pressure
exerted as blood flows through the artery.
Clinical onset of fever • May vary, position of the body and the arm
• BP in a normal person who is standing is usually
• Onset / Chill higher due to gravity
o set point increases from normal to higher • BP in normal reclining is slightly lower due to
than normal decrease in resistance
o Core temperature needs time to adjust thus • It is measured in terms of millimeters of mercury
the body will compensate by heat (mm Hg) and written in fraction form.
production response o Systolic pressure
® ↑ Heart rate ® Pressure of blood as result of contraction
® ↑ RR (respiratory rate) of the ventricles
® Shivering o Diastolic
® Cold, pallid skin ® Lower pressure as result of ventricular
® Cyanotic nail beds relaxation
® “Gooseflesh”
® Cessation of sweating Terminologies:
• Course / Plateau • Pulse pressure
o after the core temperature has reach a new o The difference between systolic and diastolic
set point, the person neither feels warm nor pressure
cold • Stroke volume
® Absence of Chills o The volume of blood ejected with each
® Skin that feels warm heartbeat
® Photosensitivity
® Glassy eyed appearance Factors contributing to blood pressure
® ↑ PR and RR (pulse & respiratory rate)
® ↑ Thirst • Pumping action of the heart
® Dehydration o if the heart is weak = ↓blood pumped into
® Drowsiness, restlessness, delirium arteries
® Loss of appetite • Cardiac output
® Malaise

Eloisa BSN 1-Y2-5 6

 o The more blood the heart pumps, the Do not take B/P in:
greater the pressure in blood vessels
• Circulating blood volume • Arm with cast
o An increase in volume will increase BP • Arm with arteriovenous (AV) fistula
o ↓blood = low BP because of ↓ fluid in • Arm on the side of a mastectomy i.e. rt
arteries mastectomy, rt arm
• Peripheral vascular resistance
o vasoconstriction = ↑ BP Factors that influence blood pressure
o vasodilation = ↓BP
• Blood viscosity • Age
o measurement of thickness and stickiness of • Exercise
blood • Stress
o proportion of RBC to plasma is high • Race
(hematocrit) • Obesity
o 60-65% - (RBC increased) • Sex
o common to patients with polycythemia • Medication
(thickening of blood) • Caffeine or nicotine intake
• Elasticity of vessel walls • Extreme emotions/pain
o An increase stiffness such as • Diurnal Variation
atherosclerosis, will increase BP
Factors affecting blood pressure
Alterations in blood pressure
• Lower during sleep
• Hypertension • Lower with blood loss
o Abnormally high blood pressure over • Position changes BP
140/90, • Anything that causing vessels to dilate or constrict
o confirmed by a minimum of 2 consecutive • Medication
visits.
o Primary Hypertension. Classification of blood pressure (mmHg)
o Secondary Hypertension
• Hypotension CATEGORY SYSTOLIC DIASTOLIC
o Abnormally low blood pressure below 100
Normal < 120 > 80
mmHg systolic.
Prehypertension 120-139 80-89
o Between 85-100 mmHg systolic.
Hypertension –
• Orthostatic hypotension 140-159 90-99
stage 1
o Is a sudden drop in blood pressure when
Hypertension –
you stand from seated or lying down > 160 > 100
stage 2
position.

Cuff Common errors

• Inflatable rubber bladder, tube connects to the

manometer, another to the bulb, important to
have correct cuff size (judge by circumference of
the arm not age)
• Support arm at heart level, palm turned upward -
above heart causes false low reading
o Cuff too wide – false low reading
o Cuff too narrow – false high reading
o Cuff too loose – false high reading

Korotkoff sounds

• Series of sounds created as blood flows through

an artery after it has been occluded with a cuff
then cuff pressure is gradually released.

Eloisa BSN 1-Y2-5 7

Pulse Pulse points

• Wave of blood created by contraction of the left

ventricle of the heart.
• Regulated by ANS (Autonomic Nervous System)
• A normal pulse rate for adults is between 60 and
100 beats per minute, average 80 bpm
• an indirect measurement of cardiac output
obtained by counting the number of apical or
peripheral pulse waves over a pulse point.

• Assess: rate, rhythm, strength

o can assess by using palpation & auscultation.
• Pulse deficit
o the difference between the radial pulse and
the apical pulse – indicates a decrease in
peripheral perfusion from some heart
conditions

Factors affecting pulse rate

• Age 1. Temporal
• Gender o Located in front of the ear and lateral to
• Exercise and Fever eyebrow
• Medications 2. Carotid
• Hemorrhage o Located beside the larynx
• Stress 3. Brachial
• Position changes o Located in the medial antecubital fossa
(hollow in front of the elbow)
Two types of pulse 4. Radial
o Located on the thumb side of the forearm at
• Central or Apical pulse wrist
o It is located on the apex of the heart on the 5. Femoral
left side of the chest that is monitored using o located halfway between the anterior
a stethoscope. superior iliac spine and the symphysis pubis,
o The apex is usually found at the 5th below the inguinal ligament.
intercostal space just inside the midclavicular 6. Popliteal
line o Located behind the knee in the popliteal
fossa with the patient’s knee flexed
• Peripheral 7. Dorsalis pedis
o Pulses that can be felt on the periphery of the o located on the dorsum of the foot with the
body by palpating an artery over a bony foot plantar flexed. Palpate for this pulse
prominence. halfway between the middle of the pt.’s ankle
and the space between the great toe and the
Pulse rate (beats per minute) second toe.
8. Posterior tibial
o Located on the inner side of the ankle slightly
below

Rhythm

• Patterns of beats and interval between the beats

(regular / irregular)
• Dysrhythmia or arrhythmia
o may be a random, irregular beats or
predictable pattern of irregular beats
o Apical pulse, ECG

Eloisa BSN 1-Y2-5 8

Pulse volume Respiration

• The act of breathing or ventilation

• Normal breathing is slightly observable, even
effortless, quiet, automatic, and regular. It can be
assessed by observing chest wall expansion and
bilateral symmetrical movement of the thorax
• Inspiration / Inhalation
o Intake of air into the lungs (breathing in)
• Expiration / Exhalation
o Breathing out of gases into the atmosphere
(breathing out)
› I&E is automatic & controlled by the
medulla oblongata (respiratory center of
Artery wall elasticity brain)
› Normal breathing is active & passive n
• An artery is straight, smooth, soft, and pliable/
Women breathe thoracically, while men &
elastic.
young children breathe diaphramatically
• An elastic artery contains collagen and elastin ***usually
filaments which gives it the ability to stretch in › Asses after taking pulse, while still holding
response to each pulse.
hand, so patient is unaware you are
• It reflects expansibility and deformities counting respirations
• Ventilation
Presence / Absence of bilateral equality o Movement of air in and out of the lungs
• Symmetrical
• Absence of bilateral equality will also affect blood o Sides of the chest normally rise & fall together
pressure
• Asymmetrical
• Each time the heart beats, pressure is created that o Rise & fall are not together
pressure may indicates cardiovascular disorder • External respiration
o Interchange of O2 and CO2 between the
Terminologies: alveoli and the pulmonary blood
• Internal respiration
• Rate – N – 60-100, average 8- bpm o Interchange of O2 and CO2 between the
o Bradycardia – less than 60 bpm circulating blood (pulmonary blood) and body
o Tachycardia – greater than 100 bpm tissues
• Rhythm – pattern of the beats (reg / irreg)
• Strength or size – or amplitude, the volume of Two types of breathing
blood pushed against the wall of an artery during
the ventricular contraction • Costal (thoracic)
o Bounding / full – strong pulse, volume higher o Involves the movement of the chest
than normal o External intercoastal muscles
o Thready / weak – diminished strength, lacks o Accessory muscles
fullness o Chest upward then outward at midpoint
o Imperceptible – cannot be felt or heard
• Diaphragmatic (abdominal)
0----------------- 1+ --------------------2+--------------- 3+ -----------------4+
Absent Weak NORMAL. Full Bounding o Involves movement of the abdomen.
o Contraction and relaxation of the diaphragm
Assessing the pulse rate o Breath-in, diaphragm contracts – lungs
expands, creating a partial vacuum, allows air
1. The nurse should begin the assessment by to be drawn in (inhalation)
speaking with the client about the normal pulse o Breath-out, diaphragm RELAXES –
rate. abdominal muscles contract and expel air
2. Palpate a peripheral pulse by placing the first two that contains carbon dioxide
fingers on the pulse point with moderate pressure. o Tidal volume = 500ml of air
3. Count the rate for a full minute, noting the o Diaphragmatic breathing is the most efficient
regularity (rhythm). because of the greater expansion and
ventilation

Eloisa BSN 1-Y2-5 9

Normal breathing is accomplished by Depths of respiration

1. The downward and upward movement of the 1. Normal

diaphragm to lengthen or shorten the chest cavity 2. Deep
2. The elevation and depression of the ribs to 3. Shallow
increase and decrease the anteroposterior
diameter of the chest cavity Abnormal patterns

Sites • Hyperventilation
o Increased amount of air in the lungs
1. Chest wall characterized by prolonged deep breaths.
2. Thorax o It is a condition in which you start to breathe
3. Nose and mouth very fast
Symptoms:
Rate ® Dizziness, shortness of breath, bloating, dry
mouth, weakness, confusion, sleep
• Describes as breaths per minute. disturbances, numbness and tingling or your
o Eupnea – normal arms, muscle spasms, chest pain and
o Bradypnea – slow respiration palpitations
o Tachypnea – fast / rapid respiration
o Apnea – absence of breathing • Hypoventilation
o Decreased in amount of air in lungs caused
Cycle /minute or breathes/minute by shallow breaths (hypopnea) or too slow
(bradypnea) or may be caused by diminished
lung function
Symptoms:
® Bluish discoloration of the skin caused by
lacked of oxygen, fatigue, drowsiness,
headaches, swelling of ankles, waking up
many times at night or waking up from sleep
unrested

Sounds

Rhythm • Stridor
o Shrill harsh sound during inspiration –
• Cheyne-stokes laryngeal obstruction
o Characterized by a gradual increase in • Stertor
breathing then decrease followed by apnea o Snoring or sonorous respiration – partial
o Very deep, very shallow with apnea obstruction of upper airway
• Kussmauls • Wheeze
o A rapid, deep, labored breathing associated o High pitched musical squeak on expiration –
with acidosis particularly diabetes. narrowed/partially obstructed airway
• Biots (asthma)
o Is characterized by regular deep inspirations • Bubbling
followed by regular or irregular periods of o Gurgling sounds – moist secretions
apnea. (productive cough)

Effort of respiration Chest movement

• Orthopnea • Intercostal Retractions

o Refers to a need to sit up/upright position in o Upper airway (trachea) or small airways
order to breath (bronchioles) are blocked as a result,
• Dyspnea intercostal muscles are sucked inward
o Describes difficult & labored breathing between the ribs
o Reduced air pressure inside chest a sign of a
® Atelectasis – Partial or complete collapse of blocked airway
alveoli of lungs (insufficient O2) • Substernal Retractions
o Beneath the breastbone

Eloisa BSN 1-Y2-5 10

 o Indrawing of the abdomen just below the
sternum (breastbone) • Client in bed – 45-degree angle to bed
o Belly breathing • Initial admission – overbed table between
• Suprasternal Retractions • Standing and looking down at a client can be
o Above the clavicles intimidating

Secretions Distance

• Hemoptysis • Neither too small or too far

o Coughing up of blood / blood-stained mucus • 2 to 3 feet during interview
• Productive cough • Also varies in ethnicity
o Wet cough, produces mucus (type of phlegm) o 8-12 inches – Arab
• Non-Productive cough o 24 inches – Britain
o Dry cough, does not produce sputum o 18 inches – US
(phlegm) o 36 inches – Japan

Nursing Health History and Interview Process Language

Health history • Convert medical terminology into common

English usage
• A comprehensive record of the client’s past and • Interpreters / translators if nurse don’t speak the
current health. same language or dialect
• This is gathered during the initial assessment
interview. Phases of Interview

Purpose 1. Introductory
2. Working
• To document the responses of the client and 3. Summary and closing
actual and potential concerns.
• To obtain information about the client’s health. Communication during the Interview

Interviewing Non-verbal communication

• Obtaining a valid nursing health history requires • Facial Expression

professional, interpersonal and interviewing skills • Appearance
• Demeanor
Focuses of Interview • Silence
• Attitude
• Establishing rapport and trusting relationship • Listening
• Client’s response to the health concern as a whole
person Verbal communication

Planning the Interview and Setting (TP SA DL) • Closed-ended question

o (when or did)
Time • Open-ended question
o (how or what)
• When client is physically comfortable and free • Rephrasing
from pain • Inferring
• Minimal interruptions • Providing information

Place Guidelines of an effective interview

• Well lighted, well ventilated • Ask only one question at a time. Multiple
• Free of distractions questions limit the client to one choice and may
• Place where others cannot overhear or see client confuse the client.
• Acknowledge the client’s right to look at things
the way they appear to him or her and not the way
they appear to the nurse or someone else.
Seating Arrangement • Do not impose your own values on the client.

Eloisa BSN 1-Y2-5 11

 • Avoid using personal examples, such as saying, § Cancer pain
“if I were you…” ® It can be dull, achy, sharp, burning.
• Nonverbally convey respect, concern, interest, ® It can be constant, intermittent,
and acceptance. mild, moderate, severe
• Be aware of the client’s and your own body
language. Types of pain
• Be conscious of the client’s and your own voice
inflection, tone, and affect. • Radiating pain
• Referred pain
Special considerations • Intractable pain
• Phantom pain
Gerontologic variations
• Hearing acuity ® speak slowly, face the client, Sources of pain
position on the better acuity
• Feel vulnerable and scared • Nociceptors / pain receptors
• Speak clearly and use straightforward language o Somatic
• Ask questions in simple terms o Visceral
• Neuropathic
th
Pain – 5 Vital sign o Deep somatic
o Cutaneous
• Whatever the experiencing person says it is;
existing whenever he or she says it does. Phases of nociception
• An unpleasant sensory and emotional experience 1. Transduction
associated with actual or potential tissue damage 2. Transmission
(Merskey & Bogduk, 1994). 3. Perception
4. Modulation
Terminologies
Transduction
• Pain threshold
• Pain tolerance • Noxious stimuli trigger the release of biochemical
• Hyperalgesia mediators or algogenic substances:
o Bradykinin ® Universal stimulus for pain
Theories of Pain
o Prostaglandin
o Serotonin
• Intensity theory – Plato 428 to 347 BC
o Histamine
• Cartesian theory – Rene Descartes 1644
o Substance P (SP)
• Specificity theory – John Paul Nafe 1929
• Gate control theory – Patric David Wall and
Transmission
Ronald Melzack
• Peripheral nerve fibers form synapses with
Duration and Intensity of pain
neurons in the SC
• It will ascend to RAS (reticular activating system),
• Acute pain
limbic system, thalamus, cerebral cortex
o Lasts only through the expected recovery
period
o Does not last longer than six months
o Eventually resolves with or without treatment
after injured it area heals
o Unrelieved acute pain can progress to
chronic pain
o It increases the vital signs of the client

• Chronic pain
o Ongoing pain and last longer than 6 months
o People suffer chronic pain even when there
is no past injury or any body damage
§ Non-cancer pain
® Moderate to severe lasting 6 months
or more

Eloisa BSN 1-Y2-5 12

Pain stimuli Factors influencing pain

• Mechanical • Psychological
• Chemical o Past experience
• Thermal o Depression anxiety
• Physiological
Perception o Age
o Gender
• Client becomes conscious of pain • Cultural

Modulation

• “Descending system”
o Neurons in the brain stem send signals
back down to the dorsal horn of the
spinal cord.
o Descending fibers:
o Endogenous opioids (endorphins or
enkephalins), serotonin, and Reaction to pain according to age group
norepinephrine
• Endogenous opioids (endorphins or • Infant
enkephalins), serotonin, and • Toddler / preschool
norepinephrine • School-age
• Adolescent
• Adult
• Older adult

Assessing pain

• Client’s description of pain

• Factors that influence the pain of the client
• Client’s response to the pain relief strategies

Eloisa BSN 1-Y2-5 13

Pain assessment scales

Eloisa BSN 1-Y2-5 14

Physical Assessment Snellen chart Otoscope

Objectives

1. Identify and explain the process of Physical

Assessment
2. Identify the four physical assessment techniques
3. Understand the different guidelines involve during
physical examination
4. Enumerate the importance of physical
assessment technique

Physical Assessment

• A systematic way of collecting objective data from

a client using the four examination techniques. Penlight

Purpose of Physical Assessment Ophthalmoscope

1. Obtain physical data about the client’s functional

abilities
2. Supplement, confirm, or refute data obtained in
the client’s health history
3. Obtain data that will help the nurse data establish
diagnoses and plan the client’s care
4. Evaluate the physiologic outcomes of health care
and thus the progress of a patient’s health
problem
5. To make clinical judgments about a client’s health
status
6. To identify areas for health promotion and disease Percussion hammer Cotton balls
prevention

Preparatory phase

1. Introduce self to the client. Verify his identity.

Explain the purpose why such procedure is
necessary and how he could cooperate (i.e.
positioning).
2. Help him put on a clean gown and offer a bedpan
or a urinal to empty his bladder.
3. Ensure privacy by closing the doors or pulling the
curtains around him.
4. Invite a relative or a significant other to stay with Weight scale with height measurement
the client, as necessary
5. Provide adequate lighting.
6. Gather the Materials or Equipment.
7. Ensure the examination table is at a comfortable
working height. Perform hand hygiene

Assessment tools

Sterile gloves Ruler

Eloisa BSN 1-Y2-5 15

Paper clips Skin calliper Pen and paper Watch with second hand

Tuning fork Tongue depressor Positioning you Patient

Standing / Erect
For: assessment of
posture, gait & balance

Contraindications:
Patients who are weak,
disabled, or paralyzed
may need assistance or
Vaginal speculum Nasal speculum
may not be able to
assume this position

Scoliosis
Kyphosis
Lordosis

Sitting
seated position, back unsupported and
legs hanging freely
Thermometer Pulse oximeter
For: Head neck posterior and anterior
thorax, Breasts axillae heart vital signs,
upper extremities lower extremities and
reflexes.

CI: Elderly and weak clients may require

support

Dorsal Recumbent
BP Apparatus Stethoscope Back lying position with knees
flexed and hips externally rotated;
small pillow under the head; soles
of the feet on the surface

For: Head and neck, axillae,

anterior & thorax, lungs, breasts,
heart, extremities, peripheral
pulses, vital signs and vagina

CI: Clients with cardio pulmonary

problems Not used for abdominal
testing because of the increased
tension in abdominal muscles If
patient has abdominal pain, flexing
knees is usually more comfortable
Eloisa BSN 1-Y2-5 16
Sim’s Physical Assessment Techniques
The client is lying on the side with the body turned at 45
degrees. The lower leg is extended, with the upper leg Inspection
flexed at the hip and knee to a 45 to 90 degree angle.
• Vision
For: Assessment of rectum and vagina • Smell
• Hearing
CI: Difficult for elderly and people with limited joint • Observe for color
movement • Size
• Location
• Movement
• Textures
• Symmetry
• Odors
• Sounds

Prone Palpation

The client is lying on the abdomen with head turned to the • Light palpation – Assess for texture, tenderness,
side. temperature, moisture, elasticity, pulsations,
superficial organs, and masses. Depress the skin
For: Posterior thorax, hip joint movement ½” to ¾” (1.5 to 2 cm) with your finger pads, using
the lightest touch possible.
CI: Often not tolerated by the elderly and people with
cardiovascular and respiratory problem

Lithotomy
The client is lying on the back with the hips and knees • Deep palpation – Depress the skin 1 1/2” to 2” (4
flexed at right angles and feet in stirrups. to 5 cm) with firm, deep pressure. Use one hand
on top of the other to exert firmer pressure, if
For: Assessment of female rectum and vagina. (for a brief needed.
period only)

CI: May be uncomfortable and tiring for elderly people.

Often embarrassing

• Bimanual deep palpitation – Deep Palpation is

done with two hands (bimanually) or one hand

Knee-chest Jack Knife

Assessment of rectal area (for a brief period only)

Eloisa BSN 1-Y2-5 17

Percussion • Use the bell to pick up low-pitched sounds, such
as third (S3) and fourth (S4) heart sounds. Hold
• Striking of the body surface with short, sharp the bell lightly against the patient’s skin, just
strokes enough to form a seal. Holding the bell too firmly
• Palpable vibrations and characteristic sound causes the skin to act as a diaphragm, obliterating
• Location, size, shape low-pitched sounds. Should be at least 1 inch
• Density of underlying structures wide
• To detect the presence of air or fluid in a body
space Characteristics of sound heard during Auscultation
• Elicit tenderness
• Pitch – ranging from high to low
• Loudness – ranging from soft to loud
• Quality – gurgling or swishing
• Duration – short, medium or long

Assessment in Pregnancy

Objectives

• Identify anatomical and physiological variations in

Types of Percussion body systems
• Compute for expected date of confinement
1. Direct percussion – using sharp rapid • Know how to assess a pregnant woman
movements from the wrist, strike the body surface • Identify signs and symptoms of pregnancy
to be percussed with the pads of two, three, or • Perform Leopold’s maneuver
four fingers or middle finger alone. Primarily used
to assess sinuses in the adult. Using one hand to Terminologies
strike the surface of the body
• Gravida / Gravidity
o number of times a woman is or has been
pregnant
• Para / Parity
o number of pregnancy that reach the age of
viability
• Primigravida
o a woman who is pregnant for the 1st time
2. Indirect percussion – percussion in which two • Multigravida
hands are used and the plexor strikes the finger of o woman who is pregnant for at least 2nd time
the examiner’s other hand, which is in contact and up
with the body surface being percussed • Grand Multigravida
(pleximeter-the middle finger of the nondominant o woman who delivered 5 or more infants
hand) using the finger of the one hand to tap the • Multipara
finger of the other o woman who has had more than one
pregnancy that reach the age of viability
• Nulligravida
o a woman who hasn’t given birth to a child
• Multiple Pregnancy
o a woman who gets pregnant to twins or
triplets
• Term
o if the baby born anytime between 37 – 42
Auscultation weeks
• Preterm
• Use the diaphragm to pick up high-pitched o if the baby born before 37 weeks
sounds, such as first (S1) and second (S2) heart • Abortion
sounds. Hold the diaphragm firmly against the o if the baby delivered before the age of viability
patient’s skin, enough to leave a slight ring on the • LMP
skin afterward. Should be 1.5 inches wide for o Last menstrual period
adult

Eloisa BSN 1-Y2-5 18

 • Obstetrics Week 13 to 28
2nd visit
o branch of medicine and surgery concerned in (2nd Trimester)
child birth and care of woman who is giving Week 29 to 40
3rd visit
birth (3rd Trimester)
• AOG 9th month 2x every other week
o Age of Gestation
Normal weight gain
Pre-Natal check up
TRIMESTER WEIGHT GAIN
• Early identification of risk factors during
1st Trimester 1 pound / mos
pregnancy
3 to 4 lbs / 3 mos
• Early management of problems
• Decrease both maternal and infant mortality and
morbidity 2nd 0.9 to 1 pound / mos
10 to 12 lbs / 3 mos
Schedule of visit: As soon as the mother missed a
menstrual period 3rd 0.5 pound / mos
8 to 11 lbs/ 3 mos
Initial visit:
TOTAL WEIGHT GAIN 25 to 35 lbs
• Baseline data collection
• Obstetric history Expected date of Confinement / Delivery
• Medical and surgical history (EDC / EDD) Computation
• Family history
• Current problems Naegele’s Rule
• Initial and subsequent visit • calculation of expected date of confinement
• Baseline vital signs (EDC)
• LMP
Obstetrical history (GPTPALM)
January to March
• Gravida + 9 months + 7 days
o number of pregnancies April to December
• Para - 3 months + 7 days + 1 year
o total no. of deliveries > 20 weeks AOG
Jan 2, 2021 June 11, 2020
• Term
o total no of infants born at term / 37 weeks / 1 – 2 – 2021 6 – 11 – 2020
more + 9 +7 -3+7+1
• Preterm 10 - 9 - 2021 / Oct 9, 2021 3 - 18 - 2021 /
o total no. of infants born before 37 weeks Mar 18, 2021
• Abortion
o total number of spontaneous or induced Age of Gestation Computation
abortions below 20 weeks gestation
• Living Mc Donald’s Rule
o total number of children currently living • determines AOG in month by measuring from
• Multiple symphysis pubis (cm) to the fundus
o total number of multiple pregnancies
Fundic Height in cm x 8 = AOG in weeks
G7P5T4P1A1L6M1 7

Aisha Vasquez 38 year old, female is 35 weeks pregnant. Fundic Height in cm x 2 = AOG in months
Four of them were born at 39 weeks of gestation and twins 7
was born at 34 weeks gestation. Two years ago she had
miscarriage at 10 weeks gestation.

Frequency of Prenatal Visit according to DOH

WEEKS OF GESTATION FREQUENCY OF VISIT

Week 0 to 12 1st visit
(1st Trimester)

Eloisa BSN 1-Y2-5 19

Bartholomew’s Rule Johnson’s Rule
• Estimate age of gestation by the relative position • For estimation of fetal weight
of the uterus in the abdominal cavity
Formula:
Fundic height in cm – n X 155 = fetal weight in
grams
n = 12 if the fetus is not engaged
n = 11 if the fetus is engaged

example:

• 28cm not engaged

o 28cm - 12 = 16
16 x 155 = 2480gms
• 34cm engaged
o 34cm – 11 = 23
23 x 155 = 3565gms

Signs of Pregnancy
3rd mo. – the fundus is palpable above symphysis pubis
5th mo. – the fundus is palpable at the level of umbilicus PRESUMPTIVE SIGNS
9th mo. – the fundus is below xiphoid process
OTHER
Fundic Height based on home-based maternal record OCCURENCE SIGN POSSIBLE
by DOH CAUSE
• 5th month: 20 cm
• 6th month: 21-24 cm 3 - 4 wk Breast Pre-menstrual
• 7th month: 25-28 cm changes changes; oral
• 8th month: 29-30 cm contraceptives
• 9th month: 30-34 cm
4 wk Amenorrhea Stress, exercise,
Haase’s Rule malnutrition,
• To determine the length of the fetus in centimeter endocrine
problems
Formula: 4 - 14 wk N&V Gastrointestinal
1st half of pregnancy x square at month disorder
2nd half of pregnancy X at month by 5
6 - 12 wk Urinary Infection
1st half of pregnancy 2nd Half of pregnancy frequency
• 3 mos x 3 = 9cm • 6 mos x 5 = 30cm
• 4 mos x 4 = 16cm • 7 mos x 5 = 35cm 12 wk Fatigue Stress, illness
• 5 mos x 5 = 25cm • 8 mos x 5 = 40cm
16 - 20 wk Quickening Gas, peristalsis
Manual computation of AOG
PRESUME mnemonics
• JAN - 31 days example: LMP June 11, 2020
• FEB - 28/29 days 6 - 11 - 2020 • Period absent (amenorrhea)
• MAR - 31 days - 30 • Really tired (fatigue)
• APR - 30 days 19 Jun • Enlarged breast
• MAY - 31 days 31 Jul • Sore breast
• JUN - 30 days 31 Aug • Urination increased
• JUL - 31 days 30 Sep • Movement of fetus (quickening)
• AUG - 31 days 31 Oct • Emesis and nausea
• SEPT - 30 days 30 Nov
• OCT - 31 days 31 Dec
• NOV - 30 days 31 Jan
• DEC - 31 days 23 Feb
257/7 = 37 wks AOG

LMP Aug 12, 2020 = 195/7 = 27.85 = 28 1/7 wks AOG

Eloisa BSN 1-Y2-5 20

 PROBABLE SIGNS
Hegar’s sign
OTHER
OCCURENCE SIGN POSSIBLE
CAUSE

5 wk Goodell’s Pelvic
Sign congestion

6 - 8 wk Chadwick’s Pelvic POSITIVE SIGNS

Sign congestion
OTHER
6 - 12 wk Hegar’s Pelvic OCCURENCE SIGN POSSIBLE
Sign congestion CAUSE
4 - 12 wk +PT (blood) H-mole, 5 - 6 wk Fetus in UTZ
choriocarcinoma
6 wk FHT detected
6 - 12 wk +PT (urine) Pelvic infection in UTZ
16 wk Braxton Myoma 8 - 17 wk FHT detected
Hicks in doppler
Contraction stethoscope
16 – 28 wk Ballottement Tumor 17 - 19 wk FHT detected
in fetal No other cause
• Goodell’s sign stethoscope
o softening of the cervix ® increased
19 - 22 wk Fetal
vascularity, slight hypertrophy and
movements
hyperplasia
palpated
• Chadwick sign
o violet-bluish color of the vaginal mucosa and Late Fetal
cervix ® increased vascularity pregnancy movements
• Hegar’s sign visible
o softening of the lower uterine segment
• Braxton Hicks Contraction
FETUS mnemonics
o irregular, painless, and occur intermittently
throughout pregnancy facilitate blood flow to
• Fetal movements
the placenta
• Electronic device detects fetal heart sounds
PROBABLE mnemonics • The delivery of the baby
• Ultrasound detects the fetus
• Positive pregnancy test • See visible movements of the baby
• Returning of the fetus (ballotment)
• Outline of fetus can be palpated Physiological changes in Pregnancy
• Braxton hicks contraction
• A softening of the cervix (Goodell) • Cardiovascular system
• Endocrine system
• Bluish color of vulva, cervix, vagina (Chadwick)
• Respiratory system
• Lower uterine segment becomes soft (Hegar)
• Gastrointestinal system
• Enlarged uterus
• Urinary / renal system
• Musculoskeletal system
• Reproductive system
• Integumentary system

Cardiovascular system

• Increased cardiac output (30 – 50%) / (1500cc)

• Fatigue
• Epistaxis due to hyperemia

Eloisa BSN 1-Y2-5 21

 • Heart rate increases 10 – 15 beats per minute Integumentary system
• Edema
• Varicosities Stria gravidarum / Protruding umbilicus
• Hgb and Hct Decrease ® “Anemia of Pregnancy” stretchmarks

Endocrine system

• Elevated hCG levels

• Estrogen and progesterone increase
• Thyroid activity is increased
• Estriol levels increased

Respiratory system
Linea nigra Diaphoresis
• Shortness of breath
• Hyperventilation
• Nasal congestion
• Increase oxygen consumption and product of
carbon dioxide
o Increase uterus size ® diaphragm will be
pushed and displace ® crowding chest
cavity

Gastrointestinal system Chloasma “mask of pregnancy” Increase production of

melanocytes by the pituitary gland (MSH)
• Morning sickness
• Hyperemesis gravidarum
• Heartburn
• Food cravings
• Ptyalism – increase salivation
• Flatulence
• Constipation
• Hemorrhoids
Spider nevi Palmar erythema
Renal system

• Urinary frequency
• Kidneys increase in size
• Glycosuria
• Nocturia
• Proteinuria

Musculoskeletal system
Local changes
• Lordosis
• Softening of all ligaments and joints • Head and Scalp – Hair tends to grow faster
• Waddling gait during pregnancy. Oily hair is common, excess
• Leg cramps hair dryness indicates poor nutrition
• Eyes – Pale conjunctiva indicates anemia, Edema
Reproductive system of the eyes accompanied by visual disturbances
indicates PIH
• Amenorrhea • Nose – Normal nasal congestion occurs due to
• Uterus increase in size Estrogen
• Chadwick’s sign – purplish discoloration of the • Ears – Nasal stiffness results in blockage in
cervix and vaginal mucosa Eustachian tube which may affect a woman’s
• Goodell’s sign – softening of the cervix hearing
• Hegar’s sign – softening of the lower uterine • Mouth and Teeth – Cracked corners of the mouth
segment maybe caused by vitamin deficiency which
• Breast changes pregnant are prone to develop

Eloisa BSN 1-Y2-5 22

 • Breast • Assess heart rate using doppler
o Enlargement, wider and darker areola, o Uterine soufflé – corresponds with maternal
prominent veins and Montgomery’s tubercle. heart rate
Colostrum can be expressed as early as the o Funic soufflé – corresponds with fetal heart rate
first trimester.
o Increase estrogen ® preparation for lactation
a) Nipples erect
areola becomes darker and colostrum is
formed
b) Production of colostrum and estrogen

Leopold’s Maneuver 3

Pawlik’s grip

• Using the dominant hand, grasp the symphysis

pubis using thumb and fingers
• Assess whether the presenting part is engaged in
Leopold’s Maneuver the pelvis
o Floating/movable – presenting part is not
• A systemic way to determine the position, engaged
attitude, fetal presentation, presenting part, o Immovable – presenting part is engaged
estimate fetal size, fetal back, number of fetus
• Christian Gerhard Leopold

Leopold’s Maneuver 1

Fundal Grip

• While facing the client, palpate the client’s upper

abdomen with both hands. Assess size, shape,
movement, and firmness of the part
• Determine presentation
o Cephalic – hard, firm, and round and moves Leopold’s Maneuver 4
independently
o Breech – softer, symmetric, has bony Pelvic grip
prominences and moves
• The examiner changes the position by facing the
feet. With two hands, assess the descent of the
presenting part by locating the head or brow of
the fetus.
• Assess fetal attitude (relationship of the fetus to
one another)
o If the fetal head of the fetus is well flexed, it
should be on the opposite side from the fetal
back
o If the fetal head is extended though the
occiput is instead felt and is located on the
Leopold’s Maneuver 2 same side as the back

Umbilical grip

• With both hands moving down, identifying the fetal

back and fetal extremities
• Fetal back: hard, resistant, convex structure
• Fetal extremities: nodular and irregular

Eloisa BSN 1-Y2-5 23

Fetal heart tone site

Fetal Lie

Pregnancy discomforts

• Urinary frequency
o Void as necessary
o Decrease fluids before bed
o Avoid caffeine
o Perform Kegel exercises
o Report signs of infection
• Fatigue
o Try to get a full night’s sleep
o Schedule a daily rest time
o Maintain good nutrition
• Breast tenderness / soreness
Fetal Attitude o Wear a supportive and well-fitting bra
o Bra may be worn at night
• Vaginal discharge
o Wear cotton underwear
o Avoid tight fitting pantyhose
o Bathe daily
• Backache
o Emphasize posture
o Avoid standing for long periods
o Apply local heat
o Stoop to lift objects
o Wear good shoes
• Round ligament pain
o Slowly rise from sitting position
o Bend forward to relieve pain
o Avoid twisting motions
• Constipation
o Increase fiber intake in the diet
o Set a regular time for bowel movements
o Drink more fluids
o Avoid caffeinated drinks
o Rest on the left side with the hips and lower
extremities elevated
• Hemorrhoids
o Avoid constipation
o Apply witch hazel pads to the hemorrhoids

Eloisa BSN 1-Y2-5 24

 o Take sitz baths with warm water as often as
needed
• Nausea & vomiting
o Dry crackers on arising
o Eat small frequent meals
• Varicosities
o Apply ice packs for reduction of swelling, if
preferred over heat
o Walk regularly
o Rest with the feet elevated daily
o Avoid standing for long periods
o Avoid crossing the legs
o Avoid wearing constrictive knee-high
stockings; wear support stockings instead
• Ankle edema
o Avoid standing for long periods
o Rest with the feet elevated
o Avoid wearing garments that constrict the
lower extremities

Psychological Adaption to Pregnancy

• Accepting the pregnancy

• Accepting the baby
• Preparation to parenthood

Nutrition

• Weight gain
o Variable, but 25 lb usually appropriate for
average woman with single pregnancy
o Woman should have consistent, with only 2
- 3 lbs in first trimester, then average 12 oz
gain every week in second and third
trimesters
• Nutrition
o Increase energy & caloric requirements to
create new tissue and meet increased
metabolic needs (+300 kcal/ day)
o Protein 60g
o Fat-soluble vitamins (Vit. A, D, E)
o Water-soluble vitamins (Vit. C, Folic acid,
Niacin, Riboflavin, Thiamine, Vit. B6, and Vit.
B1)
o Minerals (Calcium (1200mg/day),
Phosphorus, Iodine, Iron, and Zinc)
• Nutritional requirement
o Calorie : 2, 500 kcal
o CHON : 40 grams
o Vitamin C : 85 mg
o Folic Acid : 600 mg
o Calcium : 1,200 mg
o Phosphorus : 700 mg
o Iron : 30mg

Eloisa BSN 1-Y2-5 25