HEALTH ASSESSMENT principles of critical thinking, client-centered

- HEALTH ASSESSMENT is an evaluation of the approaches to treatment, goal-oriented tasks,

health status of an individual by performing a physical evidence-based practice (EDP) recommendations, and
examination after obtaining a health history. Various nursing intuition.
laboratory tests may also be ordered to confirm a - Holistic and scientific postulates are integrated to
clinical impression or to screen for dysfunction. provide the
- The depth of investigation and the frequency of the - basis for compassionate, quality-based care.
assessment vary with the condition and age of the - The nursing process functions as a systematic guide to
client and the facility in which the assessment is client-centered care with 5 sequential steps., diagnosis,
performed. planning, implementation, and evaluation.
- The person's response to any dysfunction present is - A.D.P.I.E.
observed and noted. Nursing Process
- The techniques of the health assessment include The nursing process is a scientific method used by
INSPECTION, PALPATION, PERCUSSION, and nurses to ensure the quality of patient care. This
AUSCULTATION. approach can be broken down into FIVE SEPARATE
- Health assessments are performed by nurses in a STEPS.
variety of settings, including at health fairs, in the 1. Assessment Phase
community, and at schools and hospitals. It involves The first step of the nursing process is
interviewing a patient, inspecting and observing her assessment. During this phase, the nurse
body and actions, and palpating and percussing parts gathers information about a patient’s
of her body. psychological, physiological, sociological, and
PURPOSE OF HEALTH ASSESSMENT spiritual status. This data can be collected in a
- A HEALTH ASSESSMENT is a plan of care that variety of ways. Generally, nurses will conduct a
identifies the specific needs of a person and how patient interview. Physical examination
those needs will be addressed by the healthcare referencing a patient’s health history, obtaining a
system or skilled nursing facility. Health assessment patient’s family history and general observation
is the evaluation of the health status by performing a can also be used to gather assessment data.
physical exam and taking a health history. Patient interaction is generally the heaviest
 Information during this evaluative phase.
Health assessments are used by nurses to 2. Diagnosing Phase
gather information about a patient's condition. The diagnosing phase involves a nurse making
This information is used to formulate a nursing an educated judgement about a potential or
plan of care for the patient. actual health problem with a patient. Multiple
 Nursing Diagnoses and Care Planning diagnoses are sometimes made for a single
A nurse takes note of actual or potential patient. These assessments not only include an
problems her patient may have during a health actual description of the problem but also
assessment. From the list of problems, she whether or not a patient is at risk of developing
formulates diagnoses, which she uses to create further problems. These diagnoses are also
a care plan. used to determine a patient’s readiness for
 Managing Problems health improvement and whether or not they
The nurse continuously does a health may have developed a syndrome. The
assessment on her patient to see if her care plan diagnoses phase is a critical step as it is used to
is having the desired effect. If not, she makes determine the course of treatment.
changes to her care plan to address the patient's 3. Planning Phase
health problems. Once a patient and nurse agree on the
 Evaluation diagnoses a plan of action can be developed. If
Evaluation of a patient's health status is done multiple diagnoses need to be addressed, the
through health assessments. Evaluations nurse will prioritize each assessment and devote
determine if a patient has responded to nursing attention to severe symptoms and high-risk
care sufficiently enough to be recommended for factors. Each problem is assigned a clear,
discharge. measurable goal for the expected beneficial
 Discharge Teaching outcome (SMART).
During a health assessment, a nurse may 4. Implementing Phase
become aware that a patient is lacking The implementation phase is where the nurse
information that may help improve his condition. follows through on the decided plan of action.
This provides the nurse with an opportunity to This plan is specific to each patient and focuses
impart this information before he is discharged. on achievable outcomes. Actions involved in a
 Advocate nursing care plan include monitoring the patient
When a nurse performs a health assessment, for signs of change or improvement, directly
she may find a problem that requires the caring for the patient or performing necessary
expertise of other members of the health care medical tasks, educating and instructing the
team. In this case, the nurse notifies the proper patient about further health management, and
health care team member of the problem and referring or contacting the patient for follow-up.
makes sure the patient receives the expert care Implementation can take place over the course
that they need. of hours, days, weeks, or even months.
5. Evaluation Phase
NURSING PROCESS Once all nursing intervention actions have taken
- In 1958, Ida Jean Orlando started the nursing process place, the nurse completes an evaluation to
determine if the goals for patient wellness have
that still guides nursing care today. Defined as a
systematic approach to care using the fundamental been met. The possible patient outcomes are
generally described under these three terms:
 patient's condition improved, patient's condition - The focused assessment is the stage in which the
stabilized, and patient's condition deteriorated, problem is exposed and treated.
died, or discharged. In the event the condition of - Due to the importance of vital signs and their ever-
the patient has shown no improvement, or if the changing nature, they are continuously monitored
wellness goals were not met, the nursing during all parts of the assessment.
process begins again from the first step. - Depending on the disease/disorders, initial
*All nurses must be familiar with the steps of the treatment for pain and long-term treatment for the
nursing process. If you’re planning on studying to root cause of the problem is administered and
become a nurse. BE PREPARED TO USE THESE monitored.
PHASES EVERYDAY IN YOUR CAREER. - Part of the goal of the focused assessment is to
diagnose and treat the patient in order to stabilize
her condition. Focused assessments may also use
other types of tests and laboratories.
- You use clinical experience, knowledge, expertise,
and judgement to determine priorities. Life –
threatening situations or any issue that needs
immediate attention are addressed first.
 Time-Lapsed Assessment
- Once the treatment has been implemented, a time
– lapsed assessment must be conducted to
ensure that the patient is recovering from his
problem and his condition has stabilized.
- Depending on the nature of the problem, the time
– lapsed assessment may span the length of one
or two hours or a couple of months.
- During the time – lapsed assessment, the current
status of the patient is compared to the previous
baseline during and prior to treatment.
- Similar to the focused assessment, the time –
lapsed assessment may also include lab work, X –
rays, or other diagnostic medical testing.
 Emergency Assessment
- During emergency procedures, a nurse is focused
HEALTH ASSESSMENT IN NURSING PRACTICE on rapidly identifying the root causes of concern
- In order to effectively determine a diagnosis and for the patient and assessing the airway,
treatment for a patient, nurses make four types of breathing, and circulation (ABCs) of the patient.
assessments. INITIAL, FOCUSED, TIME – LAPSED, - Once the ABCs are stabilized, the emergency
AND EMERGENCY. assessment may turn into an initial or focused
- One of the most important parts of nursing education, assessment, depending on the situation.
as well as the health care industry overall, is the group - If the nurse is not in a health care setting,
of routine procedures and processes involved with emergency assessments must also include
patient assessment and care. assessment for a scene safety so that no other
- As a result, nurses and other health care professionals individuals, including the nurse himself, are hurt
are able to quickly assess and determine the best during the rescue and emergency response
treatment for an ailing patient. process.
- Health assessment in the nursing process is the
evaluation of the health status of an individual along RESPONSIBILITIES OF THE NURSE
the health continuum. The purpose of the health 1. The nurse has the responsibility to carry out health
assessment is to establish where on the health assessment on every person under his/her care.
continuum the individual is because this guides how to 2. The nurse should regularly perform focused
approach and treat the individual. assessments in response to client needs.
- The health continuum approaches range from 3. The nurse needs to obtain client's consent prior to
preventive, to treatment, to palliative care in relation to health assessment.
the individual's status on the health continuum. 4. The nurse should demonstrate a caring attitude,
respect and concern for each client when doing a
TYPES OF HEALTH ASSESSMENT health assessment.
 Initial Assessment 5. The nurse has the responsibility in keeping
- The initial assessment, also known as triage, confidentiality about the data being collected from
helps to determine the nature of the problem and his/her client.
prepares the way for the ensuing assessment 6. The nurse obtains information on a client using
stages. various techniques and tools, such as history taking,
- Components may include obtaining a patient's physical examination, reviewing clients records and
medical history through a physical exam or results of diagnostic tests. He/she has to draw
preparing a psychosocial assessment for a mental interference form data collected in order to make
health patient. appropriate and sound clinical judgement.
- Other components may include obtaining a 7. The nurse has to acquire specialized skills and
patient's vital signs and taking subjective competence in collecting accurate and relevant
statements form the patients, as well as double – information on the patient's health in performing
checking the subjective symptoms with the health assessment in order to make sound clinical
objective signs of the condition. judgement
 Focused or Problem Oriented Assessment
8. The nurse should document the results of health - Subjective data also includes demographic
assessment, analyze the data collected, evaluate the information, patient and family information about past
client's response to health problems and and current medical conditions, and patient
interventions, and provide feedback to the client as information about surgical procedures and social
appropriate. history.
9. The nurse should continuously advance their - Taken all data, the data collected provides A
competence in health assessment throughout one's HEALTH HISTORY that gives the health care
nursing career. professional an opportunity to assess health
10.The nurse who takes up an advance practice role has promotion practices and offer patient education
the responsibility to prepare himself/herself in order to (Stephen et al., 2012).
perform advanced and focused health assessment.
HEALTH HISTORY
FOUR MAIN GOALS OF NURSING - The purpose of obtaining a health history is to gather
 To promote health (state of optimal functioning or well subjective data from the patient and/or the patient's
– being with physical, social, spiritual, and mental family so that the health care team and the patient
components). can collaboratively create a plan that will promote
 To prevent illness (primary, secondary, and tertiary). health, address acute health problems, and minimize
 To treat human responses to health or illness. chronic health conditions.
 To advocate for individuals, families, communities, - The health history is typically done on admission to
and populations. hospital, but a health history may be taken whenever
additional subjective information from the patient may
METHODS OF HEALTH ASSESSMENT be helpful to inform care (Wilson & Giddens, 2013).
The following are the primary methods in performing
proper health assessment: Steps Additional Information
 OBSERVING (the use of senses) Determine the ff:
 INTERVIEWING (different sources) 1. Biographical Data  Source of history
 EXAMINING (techniques)  Name
 Age
STEPS OF HEALTH ASSESSMENT  Occupation (past or
COLLECTION OF DATA THROUGH? present)
 Interview 2. Reason for seeking  Chief complaint
care and history of  Onset of present health
 Subjective data
present health concern concern
 Objective Data
 Duration
 Biographic data
 Course of health concern
 Reason for seeking Health Care  Signs, symptoms, and
 Chief Complaint related problems
 Health History  Medications or treatments
 Present and Past Illness/Health History used (ask how effective
 Family Health History they were)
 Medications  What aggravates this health
 Lifestyle concern
 Developmental Level  What alleviates the
 Psychosocial History symptoms
 What caused the health
concern to occur
COLLECTION OF DATA
 Related health concerns
SUBJECTIVE DATA are information from the client's
3. Past health history  Allergies (reaction)
point of view (“symptoms''), including feelings,
perceptions, and concerns obtained through interviews.  Serios or chronic illness
OBJECTIVE DATA are observable and measurable  Recent hospitalizations
data (“signs") obtained through observation, physical  Recent surgical procedures
examination, and laboratory and diagnostic testing.  Emotional or psychiatric
problems (if pertinent)
 Current medications:
COLLECTION OF SUBJECTIVE DATA
prescriptions, over-the
1. SUBJECTIVE DATA
counter, herbal remedies
 Personal Profile
 Drug/alcohol consumption
 Biographic data 4. Family History  Pertinent health status of
 Reason for seeking Health Care family members
 Chief Complaint  Pertinent family history of
 Health History heart disease, lung
 Present and Past Illness/Health History disease, cancer,
 Family Health History hypertension, diabetes,
 Medications tuberculosis, arthritis,
 Lifestyle neurological disease,
obesity, mental illness,
 Developmental Level
genetic disorders
 Psychosocial History 5. Functional  Activity/exercise, leisure
- Subjective data is information reported by the patient assessment (including and recreational activities
and may include signs and symptoms described by activities of daily living) (assess for falls risk)
the patient but not noticeable to others.  Sleep/rest
  Nutrition/elimination - Moreover, it is a unique situation in which both patient
 Interpersonal and physician understand that the interaction is
relationship/resources intended to be diagnostic and therapeutic.
 Coping and stress - The physical examination, thoughtfully performed,
management should yield necessary and important data needed for
 Occupational/environmental patient diagnosis and management.
hazards - Aside from the hospital room and office, physical
examination may occur in a variety of other settings
6. Developmental  Current significant physical where it is difficult to establish privacy and quiet.
tasks and psychosocial - The best resource available to the health care
changes/issues providers to set the stage for the physical
7. Cultural assessment  Cultural/health – related examination is to communicate respect and a
beliefs and practices genuine interest in the patient's welfare.
 Nutritional considerations - The patient should be addressed politely and asked
related to culture to perform the required maneuvers of the
 Social and community examination, a technique far preferable to imperative
considerations language such.
 Religious affiliation/spiritual - Patients should be prepared for unpleasant portions
beliefs and/or practices of the examination.
 Language communication
THINGS TO REMEMBER IN PERFORMING P.E.
MEDICATIONS AND LIFESTYLE - Aside from explanations and reassurance, it is not
 Current medication (Purpose, Date Started, Dosage) necessary to maintain a continuous conversation
 Taking any Supplement with the patient during the examination.
 Treatment of any illnesses - Avoid embarrassing the patient.
 Physical Exercise - Be certain that draping material is used
 Smoking appropriately and that personal areas are not
 Alcohol Intake subjected to undue exposure.
 Socialization - An examination that ends abruptly may diminish the
 Food Preferences value of the doctor-patient relationship and may
destroy its therapeutic content.
COLLECTION OF OBJECTIVE DATA - The patient may benefit from a brief summary of
2. COLLECTION OF OBJECTIVE DATA relevant findings and may require reassurance
OBJECTIVE DATA are observable and measurable about what has and has not been found.
data (“signs") obtained through observation, physical
examination, and laboratory and diagnostic testing. MATERIALS NEEDED FOR P.E.
OBJECTIVE DATA INCLUDES:  Consent (Legal Person/s)
 PHYSICAL EXAMINATION  Quiet, and room with privacy
 DIAGNOSTIC/LABORATORY PROCEDURES  The single most useful device for optimal
 OTHER SOURCES performance of the physical examination is an
 PATIENT CHART inquisitive and sensitive mind.
 REFERRALS FROM PREVIOUS HEALTH CARE  Next most useful is mastery of the techniques of
PROVIDERS observation, palpation, percussion, and
auscultation.
1. PHYSICAL EXAMINATION  Important are the tools required for the
- A PHYSICAL EXAMINATION is a routine test where examination.
the primary care provider performs to check the
overall health of the patient. COMPONENTS/TECHNIQUES OF P.E.
- This may be conducted by a doctor, a nurse  In a physical examination, there are many things
practitioner, or a physician assistant. that the healthcare provider can find out by using
- The PE is performed to both sick and healthy the different components or technique of
individuals. assessment.
- The physical exam is a good time to ask the health  From the use of their hands to feel (PALPATE),
providers questions about the health or discuss any stethoscope and ears to listen (AUSCULTATE),
changes or problems that the patient has noticed. and eyes to see (INSPECTION), or the use of
- There are different tests that can be performed during their hands to “tap” on an area of your body
the physical examination. (PERCUSSION).
- Depending on the different factors such as age or  Findings that are present on the physical exam
medical or family history, the PCP may recommend may by themselves diagnose, or be helpful to
additional testing such as laboratory examinations. diagnose, many diseases or abnormalities of the
genitourinary system.
PHYSICAL EXAMINATION
- PHYSICAL EXAMINATION is the process of The Components/Techniques of Physical
evaluating objective anatomic findings through the Examination
use of OBSERVATION, PALPATION,  Inspection
PERCUSSION, AND AUSCULTATION.  Palpation
- The information obtained must be thoughtfully  Auscultation
integrated with the patient's history and  Percussion
pathophysiology. The Components/Techniques of Physical
Examination
 1. INSPECTION - The patient sits at the edge of the examining table
 The examiner will look at, or “inspect” specific without back support. The physician examines the
areas of the body for normal color, shape, and patient's head, neck, heart, back, and arms.
consistency. SUPINE
 Certain findings on inspection” may alert the - The patient lies flat on the back. The physician
healthcare provider to focus other parts of the examines head, neck, chest, heart, abdomen, arms,
physical exam on certain areas of the body. and legs.
 This technique uses the sense of sight. DORSAL RECUMBENT
 For example, your legs may be swollen. Your - The patient lies face up, with his back supporting all
healthcare provider will then pay special his weight. The patient's knees are drawn up and the
attention to the common things that cause leg feet are flat on the table. The physician may examine
swelling, such as extra fluid caused by your the head, neck, chest, and heart.
heart, and use this information to help them LITHOTOMY
make a diagnosis. - The patient lies on her back with her knees bent and
2. PALPATION her feet in stirrups attached to the end of the
 This is when the examiner uses their hands to examining table. This position is used during exam of
feel for abnormalities during a health the female genitalia.
assessment. TRENDELENBURG’S
 This technique uses the sense of touch. - The patient is supine on a tilted table with the head
lower than the legs. This position is used in certain
 Things that are commonly palpated during an
surgical procedures or emergencies, and also on
exam include your lymph nodes, chest wall (to
patients with low blood pressure or a patient
see if your heart is beating harder than
experiencing shock.
normal), and your abdomen.
FOWLER’S POSITION
 You will use palpation to see if there are any
- The patient lies back on an examining table on which
masses or lumps, anywhere in the body.
the head is elevated. The doctor may examine the
3. PERCUSSION
head, neck, and chest areas, it is one of the best
 This is when the examiner uses their hands to
positions for examining patients who are experiencing
"tap" on an area of the patient's body.
shortness of breath, or lower-back injury.
 The "tapping" produces different sounds. PRONE POSITION
 Sounds depends on the kind of sounds that are - The patient lies flat on the table, facedown. The
produced over the abdomen, on the back or patient's head is turned to one side, and his arms are
chest wall. placed at his sides or bent at the elbows. The
 Healthcare provider may determine anything physician can examine the back, feet, or
from fluid in the lungs, or a mass in the musculoskeletal system.
stomach. SIM’S POSITION
 This will provide further clues to a possible - The patient lies on the left side. His or her left leg is
diagnosis. slightly bent, and the left arm is placed behind the
4. AUSCULTATION back so that the patient's weight is resting primarily
 This is an important physical examination on the chest. It is used during anal or rectal exams.
technique used by the healthcare provider, KNEE – CHEST POSITION
where he or she will listen to the heart, lungs, - The patient is lying on the table facedown, supporting
neck or abdomen. the body with the knees and chest. The patient
 This is to identify if any problems are present. should have the thighs at a 90-degree angle to the
 Auscultation is often performed by using a table and slightly separated, the head turned to one
STETHOSCOPE. side, and the arms are placed to the side or above
 The stethoscope will amplify sounds heard in the head. It is used during exams of the anal and
the area that is being listened to. If there is an perineal areas and during certain proctologic
abnormal finding on the examination, further procedures.
testing may be suggested.

POSITIONING
- Positioning patients properly in performing physical
examination is critical to providing the best care
possible and protecting against complications against
complications such as nerve damage, and accident
such as fall.
- These preventable injuries can be devastating to the
patient and have significant consequences.
- In performing Physical Examination, correct position/s
is required in able to accomplish assessment of the
patient's physical body correctly and accurately.
- Proper position will also help the health care provider
to collect data from the physical examination with
eased, and be able to perform the assessment
quickly.

DIFFERENT POSITIONS:
SITTING
2. DIAGNOSTIC/LABORATORY PROCEDURES o COMPUTED TOMOGRAPHY SCAN
 A medical test or DIAGNOSTIC/LABORATORY o MAMMOGRAPHY
PROCEDURES are a medical procedure performed o BONE SCAN
to DETECT, DIAGNOSE, or MONITOR DISEASES,
DISEASE PROCESSES, SUSCEPTIBILITY, OR TO Other Sources of Objective Data
DETERMINE A COURSE OF TREATMENT.  PATIENT CHART
 Medical tests relate to clinical chemistry and  REFERRALS FROM PREVIOUS HEALTH
molecular diagnostics, and axe typically performed in CARE PROVIDERS
a medical laboratory
 A technician or your health care provider analyses 3. PATIENT CHART
the test samples to see if your results fall within the  A PATIENT’S CHART or also known as
normal range. MEDICAL CHARTS is a complete record of a
 The tests use a range because what is normal differs patient’s key clinical data and medical history,
from person to person. Many factors affect test such as demographics, vital signs, diagnoses,
results. medications, treatment plans, progress notes,
 Laboratory tests are performed to help diagnose problems, immunization dates, allergies,
diseases or other health conditions. radiology images, and laboratory and test
 A diagnostic test are procedures performed or results.
determine the presence of disease in an to confirm  A medical chart is comprised of medical notes
individual suspected of having a disease, usually made by a physician, nurse, lab technician or
following the report of symptoms, or based on other any other member of a patient's healthcare
medical test results. team.
DIAGNOSTIC/LABORRTORY PROCEDURES are  Accurate and complete medical charts ensure
performed to: systematic documentation of a patient's medical
 Identify changes in the health condition before any history, diagnosis, treatment and care.
symptoms occur THE CHART INCLUDES:
 Diagnose or aid in diagnosing a disease or condition  Surgical history (e.g., operation dates, operation
 Plan management and treatment for a disease or reports, operation narratives)
condition  Obstetric history: (e.g., pregnancies, any
 Evaluate the patient's response to a treatment complications, pregnancy outcomes)
 Monitor the course of a disease over time.  Medications and medical allergies
DIAGNOSTIC OR LABORATORY TEST  Family History (e.g., immediate family member
 BLOOD EXAMINATION health status, cause of death, common family
 BLOOD SUGAR diseases)
 BLOOD CHEMISTRY (Cholesterol, Uric Acid,  Social History (e.g., community support, close
Electrolytes) relationships, past and current occupation)
 BLOOD TYPING (ABO, Rh TYPING)  Habits (e.g., smoking, alcohol consumption,
 ARTERIAL BLOOD GAS LEVEL (ABGs) exercise, diet, sexual history)
 PRESENCE OF INFECTION IN THE BLOOD:  Immunization Records (e.g., vaccinations,
o HEPATITIS B, C, D immunoglobulin test)
o MALARIA  Developmental History (e.g., growth chart, motor
o SYPHILIS development, cognitive/intellectual development,
o S.T.I. social-emotional development, language
o DENGUE development)
 Demographics (e.g., race, age, religion,
 NEWBORN SCREENING TEST
occupation, contact information)
 URINE ANALYSIS
 Medical encounters (e.g., hospital admissions,
o Components of Urine
specialist consultations, routine checkups)
o Presence of Infection
WHO HAS ACCESS TO MEDICAL/ PATIENT'S
o Acidity CHARTS?
o Kidney Status  Only the patient and the health care providers
 FECAL/STOOL ANALYSIS directly involved in her or his care can view a
o Occult Blood Test (Blood in the Stool) medical chart.
o Presence of parasites (Worms, Ascaris)  The medical chart belongs to the patient, and
o Bacteria she or he has the right to make sure the charts
o Viruses are accurate or grant another party access to
 CULTURE AND SENSITIVITY them.
o TYPE OF BACTERIA/VIRUSES -  Patients can petition their providers for
SENSITIVITY TEST checks to see what amendments to inaccurate medical charts.
kind of medicine, such as an antibiotic,
will work best to treat the illness or 4. REFERRALS FROM PREVIOUS HEALTH CARE
infection. PROVIDERS
 SPUTUM, URINE, BLOOD  In medicine, referral is the transfer of care for a
 TISSUE SAMPLE TEST patient from one clinician or clinic to another by
o Biopsy (Benign or Malignant) request.
o Abnormal Cell Formation  It is an important tool to emphasize other
 SCAN/RADIOLOGICALEXAMINATION objective data regarding the patient.
o X-RAYs  Consist of management or treatment performed
o ULTRASOUND  Used for continuity of care
  Includes important details about the patient's - A command by the court to a witness to produce
health condition documents.
 Gives better understanding of the patient's - A writ or process of the same kind as the
health needs. subpoena ad testificandum including a clause
 This prevent redundancy on activities, laboratory requiring the witness to bring with him and
produce to the court, books, papers, patient's
test, medication, and other management of the
record or chart in his hands, to elucidate the
patient's health.
matter in issue.
4. REGULATION AND LEGISLATION
NURSING DOCUMENTATION - Audits of reports and clinical documentation provide
- NURSING DOCUMENTATION is the record of a method to evaluate and improve the quality of
nursing care that is planned and delivered to patient care, maintain current standards of care, or
individual clients by qualified nurses or other provide evaluative evidence when standards require
healthcare providers. modification in order to achieve the goals,
- It contains information in accordance with the steps legislative mandates, or address quality initiatives.
of THE NURSING PROCESS. 5. RESEARCH
- Nursing documentation is the principal clinical - Data from documentation provides information
information source to meet LEGAL AND about patient characteristics and care outcomes.
PROFESSIONAL REQUIREMENTS, and one of - Evaluation and analysis of documentation data are
the most significant components in nursing care. essential for attaining the goals of evidence-based
- Quality nursing documentation plays a vital role in practice in nursing and quality health care.
the delivery of quality nursing care services through
supporting BETTER COMMUNICATION FORMAT OF DOCUMENTATION 
BETWEEN DIFFERENT CARE TEAM MEMBERS 1. WRITTEN NOTES/DOCUMENTATION
to facilitate continuity of care and safety of the 2. ELECTRONIC HEALTH RECORDS/ (EHRS)
clients. DOCUMENTATION
NURSING DOCUMENTATION
- Nursing documentation is essential for good clinical GUIDELINES FOR DOCUMENTATION
communication. The 20 fundamental principles of Documentation:
- Appropriate legible documentation provides an
 Don’t erase what is recorded.
accurate reflection of nursing assessments,
changes in conditions, care provided and  Record all relevant information.
pertinent patient information to support the  Don’t write critical comments.
multidisciplinary team to deliver great care.   Don’t leave white space.
- Documentation provides EVIDENCE OF CARE and  Record in black or blue ink.
is an important PROFESSIONAL AND MEDICO  Clarify orders and treatment.
LEGAL requirement of nursing practice.  Chart your own nursing process.
 Only use approved abbreviations.
PURPOSE OF DOCUMENTATION
 Date/time/sign.
1. COMMUNICATION WITH OTHER
PROFESSIONALS  Write legibly.
- Patient documentation frequently is used by  Use ‘late entries’ notation.
professionals and health care providers who are  Don’t write in anticipation.
directly involved with the patient's care.  Follow organization policies.
- However, it can also be used by those who are not  Record telephone calls.
directly involved with patient care such as lawyers,  Complete action and outcomes.
and significant others.  Co – signing.
- If patient documentation is not timely, accurate.
 Use 24 – hour clock.
accessible, complete, legible, readable, and
standardized, it will interfere with the ability of those  Monitoring.
who were not involved in and are not familiar with  Confidentiality/security.
the patient's care to use the documentation.
2. CREDENTIALING CONFIDENTIALITY/SECURITY
- Nursing documentation, such as patient care - Health care professionals should view the security
documents, assessments of processes, and of client documentation as a serious issue.
outcome measures across organizational settings, - Failure to comply with legislation, falsifying
serve to monitor performance of health care information or providing information without the
practitioners' and the health care facility's client or agency’s consent may constitute
compliance with standards governing the profession professional misconduct.
and provision of health care. - Sharing confidential information is only acceptable
- Such documentation is used to determine what in an effort to support the provision of quality care
credentials will be granted to health care with health care team members who are a part of
practitioners within the organization.
the client’s circle of care.
3. LEGAL PURPOSES
- Documentation in any format should be maintained
- Patient clinical reports, providers'
documentation, administrators' records, and in areas where the information cannot be easily
other documents related to patients and accessed by casual observers or those not directly
organizations providing and supporting patient involved in the care of the client.
care are important evidence in legal matters. - Health record maintained in a client’s home should
- Documentation that is incomplete, inaccurate, be stored in a manner to reduce the risk of family
untimely, illegible or inaccessible, or that is false members or others (e.g., visitors, guests) accessing
and misleading can lead to a number of confidential information.
undesirable outcomes, including: - Agencies should have policies outlining who has
 Impeding legal fact finding access of the health records and how clients and
SUBPOENA DUCES TECUM
 their family members are made aware of the alcohol and speech was slurred". Instead of noting,
importance of maintaining confidentiality. "client is aggressive" it would be correct to state,
- Technology does not change a client’s rights to "client has been shouting and using obscene
privacy of their health information. Maintaining language".
confidentiality (including access, storage, retrieval,
and transmission) of the client’s health record is LATE ENTRIES
essential regardless of its format. - Documentation should occur as soon as possible
after an event has occurred.
DATE, TIME, SIGNATURE AND DESIGNATION  - When it is not possible to document at the time of or
- Documentation in the health record begins with date immediately following an event, or if extensive time
and time and ends with the recorder's signature and has elapsed, a late entry is required.
designation. - Late entries or corrections incorporating omitted
- Signatures and initials need to be identifiable and information in a health record should be made only
follow specific agency policy. when a nurse can accurately recall the event or
- Personal initials can only be used if a master list care provided.
matching the caregiver's initials with a signature and - Late entries must be clearly identified, individually
designation is maintained in the health record. dated and follow agency policy.
- They should reference the actual time recorded as
VERBAL ORDERS AND TELEPHONE ORDERS well as the time when the care/event occurred and
- Authorized prescribers are expected to write orders must be signed by the nurse involved. If extensive
whenever possible. time has elapsed between the care and the
- Verbal orders should only be accepted in emergent documentation entry, seek guidance from your
or urgent situations where the prescriber cannot employer before adding notes (CRNBC, 2017).
document their medication orders.
- Telephone orders should be limited to situations REMEMBER
when the prescriber is not present. - Nurses should recognize that the documentation of
- The prescriber may be accountable to review and their nursing decisions and actions is equally as
co-sign their verbal or telephone orders as soon as valuable, professionally and legally, as the direct
reasonably possible or within the timeframe care provided to clients.
indicated in an agency's policy that is usually within - Quality documentation is an important element of A
24 hours time. Nursing practice, essential to positive client
outcomes and a key component of meeting their
TEXT MESSAGE AND EMAIL ORDERS Standards of Practice.
- Increasing numbers of health care professionals are
using mobile devices to communicate prescriber "WHAT IS NOT DOCUMENTED (WRITTEN) IS
orders by text message or email. CONSIDERED UNDONE/UNPERFORMED".
- This type of communication is discouraged due to
the risk of violation of confidential health information OBJECTIVE DATA INCLUDES:
and incomplete communication of client status.  PHYSICAL EXAMINATION
- Unauthorized disclosure of client's personal health  DIAGNOSTIC/LABORATORY PROCEDURES
information (PHI) is a risk because mobile devices  OTHER SOURCES
can store and retain data on the device itself. Also, o PATIENT CHART
mobile devices are vulnerable to loss and theft o REFERRALS FROM PREVIOUS
because of their small size and portability (CNPS, HEALTH CARE PROVIDERS
2013).
- Encryption and the use of strong passwords are the
DIAGNOSTIC/LABORATORY PROCEDURES
most effective way to safeguard a client's PHI.
Without encryption, any emails, voicemails, pictures  A medical test or DIAGNOSTIC/LABORATORY
or text could be inappropriately accessed or PROCEDURES are a medical procedure
disclosed if the mobile device is lost, stolen or performed to DETECT, DIAGNOSE, or
inadvertently viewed by another person. MONITOR DISEASES, DISEASE
- Vital information related to the context of the client PROCESSES, SUSCEPTIBILITY, OR TO
assessment may be lost when using text or email to DETERMINE A COURSE OF TREATMENT.
communicate. Text can be subject to interpretation  Medical tests relate to clinical chemistry and
and lead to inappropriate incomplete or insufficient molecular diagnostics, and axe typically
prescriber orders. performed in a medical laboratory
- Text or email should not be used for provider  A technician or your health care provider
convenience; however, if text or email analyses the test samples to see if your results
communication is the only way health professionals fall within the normal range.
can communicate in the best interest of the client,  The tests use a range because what is normal
agencies must have policies to support this
differs from person to person. Many factors
practice. Policies, protocols and systems should
affect test results.
enable health care practitioners to use secured
wireless devices to interact with each other and to  Laboratory tests are performed to help diagnose
access client records. diseases or other health conditions.
 A diagnostic test are procedures performed or
AVOID BIAS AND LABELS determine the presence of disease in an to
- Only document conclusions that can be supported confirm individual suspected of having a
by data and avoid value judgments or unfounded disease, usually following the report of
conclusions. symptoms, or based on other medical test
- Select neutral terminology or describe observed results.
behaviors. DIAGNOSTIC/LABORRTORY PROCEDURES are
- For example, rather than stating that the "client was performed to:
drunk” it would be correct to state, "noted an odor of
 Identify changes in the health condition before  Accurate and complete medical charts ensure
any symptoms occur systematic documentation of a patient's medical
 Diagnose or aid in diagnosing a disease or history, diagnosis, treatment and care.
condition
 Plan management and treatment for a disease THE CHART INCLUDES:
or condition  Surgical history (e.g., operation dates, operation
 Evaluate the patient's response to a treatment reports, operation narratives)
 Monitor the course of a disease over time.  Obstetric history: (e.g., pregnancies, any
DIAGNOSTIC OR LABORATORY TEST complications, pregnancy outcomes)
 BLOOD EXAMINATION  Medications and medical allergies
 BLOOD SUGAR  Family History (e.g., immediate family member
 BLOOD CHEMISTRY (Cholesterol, Uric Acid, health status, cause of death, common family
Electrolytes) diseases)
 BLOOD TYPING (ABO, Rh TYPING)  Social History (e.g., community support, close
 ARTERIAL BLOOD GAS LEVEL (ABGs) relationships, past and current occupation)
 PRESENCE OF INFECTION IN THE BLOOD:  Habits (e.g., smoking, alcohol consumption,
o HEPATITIS B, C, D exercise, diet, sexual history)
o MALARIA  Immunization Records (e.g., vaccinations,
o SYPHILIS immunoglobulin test)
o S.T.I.  Developmental History (e.g., growth chart, motor
development, cognitive/intellectual development,
o DENGUE
social-emotional development, language
 NEWBORN SCREENING TEST development)
 URINE ANALYSIS  Demographics (e.g., race, age, religion,
o Components of Urine occupation, contact information)
o Presence of Infection  Medical encounters (e.g., hospital admissions,
o Acidity specialist consultations, routine checkups)
o Kidney Status WHO HAS ACCESS TO MEDICAL/ PATIENT'S
 FECAL/STOOL ANALYSIS CHARTS?
o Occult Blood Test (Blood in the Stool)  Only the patient and the health care providers
o Presence of parasites (Worms, Ascaris) directly involved in her or his care can view a
o Bacteria medical chart.
o Viruses  The medical chart belongs to the patient, and
 CULTURE AND SENSITIVITY she or he has the right to make sure the charts
o TYPE OF BACTERIA/VIRUSES - are accurate or grant another party access to
SENSITIVITY TEST checks to see what them.
kind of medicine, such as an antibiotic,  Patients can petition their providers for
will work best to treat the illness or amendments to inaccurate medical charts.
infection.
 SPUTUM, URINE, BLOOD REFERRALS FROM PREVIOUS HEALTH CARE
 TISSUE SAMPLE TEST PROVIDERS
o Biopsy (Benign or Malignant)  In medicine, referral is the transfer of care for a
o Abnormal Cell Formation patient from one clinician or clinic to another by
 SCAN/RADIOLOGICALEXAMINATION request.
o X-RAYs  It is an important tool to emphasize other
objective data regarding the patient.
o ULTRASOUND
 Consist of management or treatment performed
o COMPUTED TOMOGRAPHY SCAN
 Used for continuity of care
o MAMMOGRAPHY
 Includes important details about the patient's
o BONE SCAN
health condition
 Gives better understanding of the patient's
Other Sources of Objective Data
health needs.
 PATIENT CHART
 This prevent redundancy on activities, laboratory
 REFERRALS FROM PREVIOUS HEALTH
test, medication, and other management of the
CARE PROVIDERS
patient's health.
PATIENT CHART
 A PATIENT’S CHART or also known as Purpose of a Nutritional Assessment
MEDICAL CHARTS is a complete record of a  Identify individuals who are malnourished
patient’s key clinical data and medical history,  Provide data for designing a nutrition plan of care that
such as demographics, vital signs, diagnoses, will prevent or minimize the development of
medications, treatment plans, progress notes, malnutrition
problems, immunization dates, allergies,  Identifying those who are at risk for malnutrition
radiology images, and laboratory and test  Establish a baseline data for evaluating the efficacy
results. of nutritional care
 A medical chart is comprised of medical notes
made by a physician, nurse, lab technician or Nutrients – measured by kilocalorie
any other member of a patient's healthcare Carbohydrates – 50 – 60% of daily caloric intake
team. Proteins – supply nine essential amino acids, 10 – 20%
of caloric intake
Fats – 20 – 30% of daily caloric intake  Dysuria
Vitamins – fat soluble and water soluble  Nocturia
Minerals – macromolecules (large amount) and  Incontinence
microminerals (small amount) Characteristic of Chief Complaint
Water – 50 – 60% of body weight, average adult needs  Quality
8 – 12 glasses of water per day  Quantity
 Associated manifestations
Components of a Nutritional Assessment
 Aggravating factors
 Nutritional history
 Alleviating factors
 Physical assessment
 Setting
 Anthropometric measurement
 Timing
 Laboratory data
 Diagnostic data Past Health History
Medical
Nutritional History  Abdomen specific
 Food intake history  Nonabdomen specific
- 24 – hour recall – the easiest and most Surgical
popular method for obtaining information  GI procedures
about dietary intake Social History
- food diary  Alcohol use
 Calorie Count  Drug use
 Evaluation of adequacy of diet  Travel history
 Home and work environments
Anthropometric measurement
 Hobbies and leisure activities
 Height
 Economic status
 Weight
 Ideal body weight, percent IBW Health Maintenance Activities
- a practical marker of optimal weight for  Sleep
height and an indicator of obesity or protein
 Diet
calorie malnutrition
 Exercise
- percent ideal body weight = (current
 Stress management
weight/ideal weight) x 100
 Use of safety devices
 Body mass index
- BMI Normal – 18.5 – 24.9  Health check – ups
- BMI Underweight: <18.5
Assessment of the Abdomen
- BMI Overweight: >25.0
 Equipment
 Percent weight change
 Order
 Waist to hip ratio o Inspection
 Assess body fat distribution as an indicator of
o Auscultation
health risk
o Percussion
Skinfold thickness
o Palpation
- Common side – Triceps skinfold (TSF)
- Mid – arm muscle circumference (MAMC)
Inspection
Abdominal Assessment (IPPA to IAPP)  Striae
 Identify the physiological function of the  Respiratory movement
gastrointestinal organs  Masses or nodules
 Assess the health status of a patient with a  Visible peristalsis
gastrointestinal complaint  Pulsation
 Demonstrate the techniques of gastrointestinal  Umbilicus
assessment
 Relate abnormal physical gastrointestinal findings to Inspection: Normal Findings
pathological processes  Abdomen is flat or round, symmetrical
 Uniform in color and pigmentation
Health History  No scars or striae present
 Patient profile  No respiratory retractions
o Age  No masses or nodules
 Child to young adult:  Ripples of peristalsis may be visible
appendicitis  Nonexaggerated pulsation of the abdominal
 Adult: peptic ulcers, aorta may be present
cholecystitis, diabetes mellitus  Umbilicus is depressed
o Gender
 Female: gallbladders disease Auscultation
 Male: GI cancers, cirrhosis,  Bowel sounds
duodenal ulcers o Assess all four quadrants
o Listen for at least 5 minutes before
Common Chief Complaints concluding bowel sounds are absent
 Nausea and vomiting  Vascular sounds
 Diarrhea or constipation  Venous hum
 Abdominal distension  Friction rubs
 Abdominal pain
 Increased eructation or flatulence Auscultation: Normal Findings
  Bowel sounds o May indicate hydronephrosis,
o Are heard in all four quadrants neoplasms, polycystic kidney disease
o Usually are high pitched  Aorta width > 4cm
o Occur 5 to 30 times per minute o May indicate abdominal aortic aneurysm
 Vascular sounds: no audible bruits  Able to palpate recently emptied bladder
 No venous hum o May indicate urinary retention
 No friction rub  Palpable inguinal lymph noes > 1cm in diameter
or tender
Auscultation: Abnormal Findings o May indicate systemic infections, cancer
 Absent, hypoactive, or hyperactive bowel
sounds Advanced Techniques
 Pathophysiological indications  Rebound tenderness
o Absent and hypoactive bowel sounds  Rovsing’s sign
may indicate decreased motility and  Iliopsoas muscle test
possible obstruction  Obturator muscle test
o Hyperactive bowel sounds indicate  Ballottement
increased motility and possible diarrhea,
gastroenteritis Abdominal Assessment
 Patient needs to be exposed from above the
Percussion xiphoid process to the symphysis pubis.
 Percuss all four quadrants  Also, make sure your patient does not have a full
 Assess liver span, liver descent, margins of bladder.
spleen, stomach, kidneys, liver, bladder  Place patient in a supine position: pillow under
 Sounds heard: tympany or dullness the head and knees.
 Helps to relax abdominal muscles.
Percussion: Normal Findings  Have patient point out any areas of pain or
 No tenderness elicited over kidneys and liver tenderness.
 Empty bladder is not percussable above the  Examine these last.
symphysis pubis  During exam continue to monitor your patient’s
facial expression for pain and discomfort.
Percussion: Abnormal Findings  Use inspection, auscultation, percussion, and
 Dullness over areas where tympany is normally palpation to perform the exam.
heard  Always auscultate before percussing or
o May indicate a mass or tumor, palpating.
pregnancy, ascites, full intestine  These manipulations may alter your patient’s
 Liver span > 12cm or < 6cm bowel mobility and resulting bowel sounds.
o May indicate hepatomegaly or cirrhosis
 Liver descent > 2 to 3cm Abdominal Assessment
o May indicate hepatomegaly or cirrhosis  Inspect the skin of the abdomen and flank’s for:
 Spleen dullness > 8cm line 1. Scars
o May indicate splenic enlargement 2. Dilated veins
 Costovertebral angle tenderness 3. Stretch marks
o May indicate pyelonephritis 4. Rashes
 Ability to percuss a recently emptied bladder 5. Lesions
o May indicate urinary retention 6. Pigmentation changes

Palpation Abdominal Assessment

 Light vs deep  Look for discoloration over the umbilicus:
1. Cullen’s Sign: discoloration over the
 Palpate all quadrants
umbilicus
 Normal findings
2. Grey Turner’s Sign: discoloration over
o No tenderness
the flanks
o Smooth with consistent softness  These are both late signs suggesting intra –
o No muscle guarding abdominal bleeding.
Palpation: Abnormal Findings Abdominal Assessment
 Tenderness on palpation  Assess the size and shape of your patient’s
o May indicate inflammation, masses, or abdomen to determine:
enlarged organs 1. Scaphoid (concave)
 Muscle guarding on expiration 2. Flat
o May indicate peritonitis 3. Round
 Presence of masses, bulges, or swelling 4. Distended
o May indicate enlarged organs,  Ask the patient if it is its usual size and shape
cholecystitis, hepatitis, cirrhosis  Check for:
 Liver is palpable below costal margin 1. Bulges
o May indicate CHF, hepatitis, cirrhosis, 2. Hernias
encephalopathy, cancer 3. Distended flanks
 Spleen is palpable  Ascites appears as bulges in the flanks and
o May indicate inflammation, CHF, cancer, across the abdomen and indicates edema
cirrhosis, mononucleosis caused by CHF, or liver failure.
 Kidneys are palpable  Look at your patient’s umbilicus
 Note location and contour and observe for any
signs of herniation or inflammation.
  Check for: Nephrology: is the branch of medicine concerned with
1. Visible pulsation the kidney.
2. Visible peristalsis (wavelike motion of Genetic/Hereditary: this refers to acquiring a condition
organs moving their contents through from a family member.
the digestive tract). May indicate bowel Congenital: inborn, or a condition started while still in
obstruction. the womb.
3. Visible masses Idiopathic: term used to describe some acquired
 Next auscultate for bowel sounds and other diseases from UNKNOWN CAUSE.
sounds such as bruits throughout the abdomen. Dysuria: defined as painful urination.
 Gently place the diaphragm on your patient’s Pyuria: presence of puss in the urine.
abdomen and proceed systematically, listening Polyuria: frequent urination.
for bowel sounds in each quadrant. Oliguria: difficulty of urination.
 Note location, frequency, and character Nocturia: frequent urination usually occurs at night.
 Normal bowel sounds consist of a variety of high Hematuria: presence of blood in urine.
– pitched gurgles and clicks that occur every 5 –
Melena: black tarry stools, occurs as a result of upper
15 seconds.
gastrointestinal bleeding.
 More frequent sounds indicate increased bowel
Hematochezia: fresh blood through the anus, usually in
motility in conditions such as diarrhea or an early
intestinal obstruction. or with stools.
Menarche: first menstruation.
 You may hear loud, prolonged, gurgling sounds
known as borborygmi. Occult Blood Test: laboratory test to detect presence of
 These indicate hyperperistalsis. blood in the stool.
 Decreased or absent sounds suggest a paralytic
ileus or peritonitis. Goal/Purpose
 The goal of the clinical evaluation of the
Abdominal Assessment GENITOURINARY SYSTEM is the diagnosis of
 Percussing the abdomen produces different disorders and diseases of the entire urinary tract and
sounds based on the underlying tissues. the genital tract.
 Sound help you detect excessive gas and solid  From the production of urine by the nephrons to the
or fluid – filled masses eventual elimination of urine via the external urethral
 Also help you determine the size and position of meatus, malfunctions of the urinary tract may become
solid organs such as the liver and spleen manifest in a variety of ways.
 Percuss the abdomen in the same sequence  This transport of urine to the outside embodies the
you used for auscultation most important functions of the kidneys, ureters,
 Palpate the abdomen last to detect: bladder, and urethra.
1. Tenderness  Problems with the urinary or reproductive systems can
2. Muscular rigidity not only affect these systems but they can trigger
3. Superficial organs and masses problems in other body systems.
 Before you begin, palpation, ask your patient if  In addition, difficulties with these systems can affect
he has any pain or tenderness.
the patient’s quality of life and sense of well – being.
 Palpate that area last, using gentle pressure with
 Early detection of problem with these systems can help
a single finger.
our patient to recover and prevent further complication
 Ask him to cough and tell you if and where he
experiences nay pain to arise.
 This is typical for peritoneal inflammation.  Proper assessment will lead the health provider to
 If you note a protruding abdomen with bulging appropriate managements.
flanks and dull percussion sounds in dependent
areas, you might perform two tests for ascites. System Overview
1. Reproductive System
 The reproductive system or genital system is a
system of sex organs within an organism which
work together for the purpose of sexual
reproduction.
 Biological function is to perpetuate the species.
 The reproductive role of the male is to
manufacture sperm and to deliver them to the
GENITOURINARY SYSTEM
female reproductive tract.
 The Genitourinary System or Urogenital System is
 The female, in turn, produces eggs.
the organ system of the reproductive organs and the
urinary system.  If the time is suitable, the combination of sperm
and egg produces a fertilized egg.
 These are grouped together because of their
proximity to each other, their common embryological  Once fertilization has occurred, the female
origin and the use of common pathways, like the uterus provides a nurturing, protective
male urethra. environment in which the embryo, later called
the fetus, develops until birth.
 Also, because of their proximity, the systems are
Problem/Disorders of Reproductive System:
sometimes imaged together.
 Reproductive system disease: these are any of the
 GENITOURINARY is a word that refers to the urinary
diseases and disorders that affect the human
and genital organs.
reproductive system such as:
TERMS TO REMEMBER:
Urology: is the branch of medicine concerned with the  Abnormal Hormone Production by the ovaries or the
urinary tract in both genders and the genital tract of the testes.
reproductive system in males.  Conditions/Disorders of the Endocrine Glands,
such as the pituitary, thyroid, or adrenals.
 Genetic or Family History the urinary tract and kidneys because urine
 Congenital Abnormalities backs – up and pools in various areas along the
 Infections tract. Pooling of urine in the bladder, ureters, or
 Mass or Tumors kidneys can lead to infections, scarring, and long
 Disorders of unknown cause (Idiopathic) – term kidney failure.
2. Urinary System Physical and Health Assessment
 The excretory/kidney/urinary system is a passive  In a physical examination, there are many things
biological system that removes excess, that the healthcare provider can find out by using
unnecessary materials from the body fluids of an the different components or technique of
organism, so as to help maintain internal chemical assessment.
homeostasis and prevent damage to the body.  From the use of their hands to feel (PALPATE),
 The dual function of excretory systems is the stethoscope and ears to listen (AUSCULTATE),
elimination of the waste products of metabolism and and eyes to see (INSPECTION), or the use of
to drain the body of used up and broken – down their hands to “tap” on an area of your body
components in a liquid and gaseous state. (PERCUSSION).
 Metabolism of nutrients by the body produces  Findings that are present on the physical exam
wastes that must be removed from the body. may by themselves diagnose, or be helpful to
 Although excretory processes involve several organ diagnose, many diseases or abnormalities of the
systems (the lungs excrete carbon dioxide, and skin genitourinary system.
glands excrete salts and water), it is mainly the
urinary system that removes nitrogenous wastes The Components/Techniques of Physical
from the body. Examination
5. INSPECTION
 The kidneys also maintain the electrolyte, acid –
base, and fluid balances of the blood, and  The examine will look at, or “inspect” specific
considered as the major homeostatic organ of the areas of the body for normal color, shape, and
body. consistency.
 Preventing the buildup of wastes and extra fluid.  Certain findings on inspection” may alert the
healthcare provider to focus other parts of the
 Regulation of electrolyte balance such as sodium,
physical exam on certain areas of the body.
potassium, calcium and magnesium which affect
and regulate hydration of the body as well as blood  This technique uses the sense of sight.
pH.  For example, your legs may be swollen. Your
 Producing blood pressure regulating hormones. healthcare provider will then pay special
attention to the common things that cause leg
 Help regulate blood pressure in the body.
swelling, such as extra fluid caused by your
 Act as filters and homeostasis regulators.
heart, and use this information to help them
 Help in the production of red blood cells, which are
make a diagnosis.
used to carry oxygen around the body. 6. PALPATION
 Help maintain healthy bones.  This is when the examiner uses their hands to
feel for abnormalities during a health
The Main Structures of the Urinary System assessment.
Two Kidneys – which lie behind the other major organs
 This technique uses the sense of touch.
in the lower back area. They are bean – shaped organs
 Things that are commonly palpated during an
and measure about 11cm long, 6cm wide and 3cm deep.
exam include your lymph nodes, chest wall (to
They have 5 main functions, which will be discussed at a
see if your heart is beating harder than
later stage.
normal), and your abdomen.
Two Ureters – (tube – like features) which run from the
 You will use palpation to see if there are any
kidneys to the bladder carrying urine.
One Bladder – which collects urine from the kidneys, via masses or lumps, anywhere in the body.
the ureters, and stores it temporarily. 7. PERCUSSION
One Urethra – through which the urine is excreted out of  This is when the examiner uses their hands to
the body, allowing the bladder to empty and dispose of "tap" on an area of the patient's body.
the waste.  The "tapping" produces different sounds.
Two Sphincter Muscles – circular muscles that help  Sounds depends on the kind of sounds that are
keep urine from leaking by closing tightly like a rubber produced over the abdomen, on the back or
band around the opening of the bladder. chest wall.
Problem/Disorders of Urinary System:  Healthcare provider may determine anything
 In children, problems of the urinary system from fluid in the lungs, or a mass in the
include acute and chronic kidney failure, urinary stomach.
tract infections, obstructions along the urinary  This will provide further clues to a possible
tract, and abnormalities present at birth. diagnosis.
 Diseases of the kidneys often produce a 8. AUSCULTATION
temporary or permanent change to the small  This is an important physical examination
functional structures and vessels inside the technique used by the healthcare provider,
kidney. Frequent urinary tract infections can where he or she will listen to the heart, lungs,
cause scarring to these structures leading to neck or abdomen.
renal (kidney failure).  This is to identify if any problems are present.
 Disorders of the urinary tract are often related to  Auscultation is often performed by using a
blockage that prevents complete emptying of the STETHOSCOPE.
bladder and often leads to reverse flow of urine.  The stethoscope will amplify sounds heard in
A urinary tract obstruction can cause damage to the area that is being listened to. If there is an
 abnormal finding on the examination, further
testing may be suggested. HEALTH HISTORY TAKING
Assessing the Health History of the patient with
HEALTH ASSESSMENT problems and conditions of the Genitourinary system
 ASSESSMENT is a key component of nursing includes History of:
practice, required for planning and provision of  Urinary Hesitancy
patient and family centered care.  Urinary Frequency
 "Conducts a comprehensive and systematic nursing  Urgency
assessment, plans nursing care in consultation with  Dysuria
individuals/ groups, significant others & the  Pyuria
interdisciplinary health care team and responds  Polyuria
effectively to unexpected or rapidly changing  Oliguria
situation.  Nocturia
 Hematuria
DATA COLLECTION
 Renal or urethral calculi
 HEALTH ASSESSMENT is an evaluation of the
 Incontinence
health status of an individual by performing the
two most important parts of assessment that  Urinary retention
includes:  Dribbling
1. Physical Examination  Testicular pain
2. Obtaining health history  Poor stream
 History of UTI
TYPES OF DATA  Abnormal color and odor of urine
 SUBJECTIVE DATA are information from the client's  And history of urinary catheterization
point of view ("symptoms”), including feelings,
perceptions, and concerns obtained through PHYSICAL EXAMINATION OF THE GENITOURINARY
interviews. SYSTEM
 OBJECTIVE DATA are observable and measurable Assessment of the Genitourinary system includes the
data ("signs") obtained through observation, physical different parts of the patient's body
examination, and laboratory and diagnostic testing.  FEMALE GENITALIA
o VULVA
SOURCE OF DATA o CLITORIS
 PRIMARY SOURCE: The patient is the main source o LABIA
of information. o URETHRAL ORIFICE
 SECONDARY SOURCES: sources of information o VAGINAL ORIFICE
come from the significant others, guardians or  MALE GENITALIA
relatives, laboratory examination. o PENIS (Shaft Gland)
o TESTES SCROTUM
EVALUATIION PHASE
 INGUINAL AREA
 In the evaluation phase of assessment, the health
 PUBIC HAIR
care provider ensures the information collected is
complete, accurate and documented appropriately.
This also includes Problem in the Physical and History
 The nurse must draw on critical thinking and problem
of:
– solving skills to make clinical decisions and plan
 SEXUAL
care for the patient being assessed.
 MENSTRUAL CYCLE
 If any abnormal findings are identified; the nurse must
 OBSTETRICAL
ensure that appropriate action is taken.
 This may include communicating the findings to the
FEMALE GENITALIA
medical team, or to relevant allied health team.
 Presence of Infection
 Patients should be continuously assessed for
 Prolapse (Uterus, Labia)
changes in condition and assessments are
documented regularly.  Vaginal discharges (Blood, Pus)
 Abnormal odor
ASSESSMENT OF THE GENITOURINARY SYSTEM  Pruritus (Itchiness)
An assessment of the renal system includes all aspects  Lesions
of urinary elimination such as:  Pain on palpation
 Urinary pattern, incontinence, frequency, urgency,  Inflammation
dysuria.  Nodes
 Hydration status including fluid balance.  History of sexually transmitted diseases
 Blood Pressure and weight. VULVA/URETHRA/VAGINAL ORIFICE
 Growth and feeding, diet or fluid restrictions.  Observe for lesions
 Skin condition: temperature, skin turgor and moisture.  Note for any discharge for the urethral meatus or
 Urine output (Normal U/ O: CHILDREN: <2yrs is vaginal orifice.
between 2-3m1/kg/hr, >2yrs is between MENSTRUAL
0.5-1m1/kg/hr) (ADULT: 30cc per Hour). Menstrual:
 Urinalysis (pH, ketones, protein, blood, leukocytes,  Age of onset
specific gravity).  Regularity
 Review blood chemistry results, urea, creatinine,  Menarche
electrolytes, albumin and hemoglobin.  Menopause (date of onset)
  Post-menopausal bleeding  Review the patient's chart if there is a need of
 Last menstrual period (LMP) date Genitourinary Assessment
 Amount of flow (number of pads/tampons/day)  Obtain consent from our patient or Guardian
 Duration of menses  Explain the procedure
 PMS  Observed the patient's right
 Dysmenorrhea  Maintained a caring atmosphere
OBSTETRICAL  Respect the patient
Obstetrical:  Provide Privacy and
 Chronological sequence of pregnancies (weight and  Maintained Confidentiality
sex of each child)
 Abortion
 Miscarriages
 Blood transfusions MIDTERMS
 Stillbirths
 Complications of pregnancies HEALTH ASSESSMENT
 Rh sensitivity history 1. AS A NURSE, IT IS YOUR RESPONSIBILITY TO
ASSESS THE HEAD AND NECK TO A PATIENT WHO
MALE GENITALIA JUST ARRIVED AT THE ER COMPLAINING FEVER.
 PENIS (Shaft, Gland) BEFORE YOU PALPATE THE ENTIRE NECK FOR
 TESTES ENLARGED LYMPH NODES, FACE THE PATIENT,
 SCROTUM AND BEND THE PATIENT'S HEAD FORWARD
MALE GENITALIA SLIGHTLY OR TOWARD THE SIDE BEING EXAMINED
 Lesions TO:
 Nodes / Lump
-MAKE THE LYMPH NODES VISIBLE
 Pain on palpation
 Prostate problems 2. TO ASSESS FOR MUSCLE STRENGTH, YOU NEED
 Masses or Tumors TO ASK THE CLIENT TO SHRUG THE SHOULDERS
 Presence of infections AGAINST THE RESISTANCE OF YOUR HANDS. THIS
 Abnormal Odor DETERMINES THE FUNCTION OF WHAT MUSCLE
 Discharges
PENIS, SCROTUM and TESTES –TRAPEZIUS MUSCLE
 Note whether or not the patient is circumcised and if
3.FOR CLIENTS WHI HAVE LUNGS PROBLEMS, YOU
the foreskin refracts completely
NEED TO PALPATE ALL THORAX AREAS FOR
 Observe for SMEGMA (a whitish substance under BULGES, TENDERNESS, OR ABNORMAL
the foreskin). MOVEMENTS. HOWEVER, DEEP PALPATION FOR
 Note the appearance of the urethral meatus and PAINFUL AREA IS AVOIDED, ESPECIALLY IF A
whether or not there is a discharge. FRACTURED RIB IS SUSPECTED BECAUSE
 Palpate the testes for tenderness or masses.
 The testes are normally equal in size, however -IT COULD LEAD TO DISPLACEMENT OF THE BONE
when the male is standing, it is normal for one FRAGMENT AGAINST THE LUNGS
testicle to be lower in the scrotal sac than the other.
 Observe the penis and testes for any lesions or 4. NURSE EVEN IS AWARE THAT THE RATIONALE
rashes. FOR THORAX PERCUSSION IS TO:
 Scrotal Hernia
-COMPARE FINDINGS AT EACH POINT WITH THE
 Testicular pain CORRESPONDING POINT ON THE OPPOSITE SIDE
PUBIC HAIR and PUBIC AREA OF THE THORAX
PUBIC HAIR:
 Assess for normal hair distribution 5. CRANIAL NERVE RESPONSIBLE FOR MUSCLE
 Amount and characteristic MOVEMENT THAT PERMITS SHRUGGING OF
 Presence of body lice SHOULDERS BY TRAPEZIUS MUSCLES AND
 Parasites TURNING HEAD AGAINST RESISTANCE BY
 Inflammation, swelling, and lesions in the pubic STERMASTOID MUSCLE
area
-CRANIAL NERVE XI
SEXUAL
SEXUAL:
6. TEMPOROMANDIBULAR JOINTS ARE TWO
 Dyspareunia (painful intercourse in the female) JOINTS THAT CONNECT THE LOWER JAW AND THE
 Birth control used SKULL. HOW DO YOU PALPATE
 Degree of sexual activity TEMPOROMANDIBULAR JOINT?
 Frequency of Intercourse
 Sexual preference -PLACE THE INDEX FINGER OVER THE FRONT OF
 Multiple Partner EACH EAR AS YOU ASK THE PATIENT TO OPEN
REMEMBER THE MOUTH
Assessment of the Genitourinary System is very
7. A NURSE IS ASSESSING A CLIENT WITH
sensitive, this is because we are going to assess
HYPERTHYROIDISM FOR THE PRESENCE OF A
sensitive area of the body of our client/patients.
BRUIT. WHICH ASSESSMENT TECHNIQUE SHOULD
In doing this, we must NOT forget to DO the THE NURSE USE?
following:
-INSPECTION
 18. TO COMPLETE A HEALTH HISTORY, NURSE
8. MANG ISKO IS A 75-YEAR OLD PATIENT WITH A EDITH SHOULD IDENTIFY RISK FACTORS ABOUT
DIAGNOSED CASE OF PNEUMONIA. WHICH DATA THORAX PROBLEMS BY ASKING WHICH OF THE
WOULD BE OF GREATEST CONCERN TO THE FOLLOWING:
NURSE WHEN PERFORMING THE ASSESSMENT?
-ALL OF THE ABOVE
-BUCCAL CYANOSIS AMD CAPILLARY REFILL
GREATER THAN 3SECS 19. LUNG AUSCULTATION ASSESSES FOR NORMAL
BREATH SOUNDS AND FOR ABNORMAL
9. DURING ASSESSMENT, WHICH SATA SPEAKS (ADVENTITIOUS) BREATH SOUNDS. ABNORMAL
INFORMATION ABOUT HEALTH BELIEFS? BREATH SOUNDS INDICATE WHICH OF THE
FOLLOWING?
-USE OF PRESCRIBED AND OVER-THE-COUNTER
MEDICATIONS -BRONCHITIS

10. IN OBSERVING THE HEAD MOVEMENT, YOU 20. NURSE WILLIAM KNOWS THAT THE FOLLOWING
NEED TO ASK THE PATIENT TO MOVE HIS CHIN TO FINDINGS ARE NORMAL EXCEPT:
THE CHEST TO DETERMINE THE FUN CTION OF
WHAT MUSCLE? -VISIBLE DIFFUSENESS IN THE THYROID GLAND

-STERNOCLEIDOMASTOID MUSCLE 21. WHICH OF THE FOLLOWING IS AN

ENLARGEMENT OF THE HEAD AND BONY FACIAL
11. LYKA WAS PLANNED FOR A PHYSICAL STRUCTURES CAUSED BY EXCESSIVE SECRETION
ASSESSMENT. WHEN PERCUSSING THE PATIENT'S OF GROWTH HORMONE?
THORAX, THE NURSE WOULD EXPECT TO FIND
WHICH ASSESSMENT DATA AS NORMAL SIGN -ACROMEGALLY
OVER HIS LUNGS?
22. IN INSPECTING THE SPIANL ALIGNMENT FOR
-DULLNESS DEFORMITIES, ASK THE CLIENT TO STAND. FROM
A LATERAL POSITION, THESE THREE CURVATURES
12. GAILE VISITED THE CLINIC FOR AN ANNUAL ARE OBSERVED EXCEPT:
ASSESSMENT. WHICH STATEMENT WOULD BE THE
BEST WAY TO END THE HISTORY INTERVIEW? -COCCYGEAL

-WOULD YOU DESCRIBE YOUR OVERALL HEALTH 23. A TYPE OF BREATH SOUND FOUND BETWEEN
AS GOOD? THE SCAPULAE AND LATERAL TO THE STERNUM
AT THE FIRST AND SECOND INTERCOSTAL
13. KAITE UNDERWENT AN OPEN REDUCTION AND SPACES WITH MODERATE-INTSENSITY AND
INTERNAL FIXATION OF THE RIGHT HIP. ONE DAY MODERATE PITCHED 'BLOWING' SOUNDS
AFTER THE OPERATION, THE PATIENT IS CREATED BY AIR MOVING THROUGH LARGER
COMPLAINING OF PAIN. WHICH DATA WOULD AIRWAY
CAUSE THE NURSE TO STOP FROM
ADMINISTERING THE PAIN MEDICATION AND TO -BRONCHIAL (TUBULAR)
NOTIFY THE ATTENDING PHYSICIAN
IMMEDETIATELY? 24. A TYPE OF BREATH SOUND THAT HAS
SUPERFICIAL GRATING OR CREAKING SOUNDS
-LEFT FOOT COLD TO TOUCH; NO PALPATE PEDAL HEARD DURING INSPIRATIONNAND EXPIRATION,
PULSE HEARD MOST OFTEN IN AREAS OF GREATEST
THORACIC EXPANSION
14. WHICH PATIENT HAS A HIGHER CHANCE TO
HAVE PALPATE LYMPH NODES IN THE NECK? -FRICTION (RUB)

-MALE, 61 WITH RHEUMATIC FEVER 25. A CONTINOUS, HIGH-PITCHED, SQUEAKY

MUSICAL SOUNDS CAUSED BY AIR PASSING
15. PATIENT TESS WAS CURIOUS ABOUT LYMPH THROUGH A CONSTRICTED BRONCHUS AS A
NODES ASSESMENT. SHE ASKED NURSE TOM RESULT OF SECRETIONS, SWELLING, TUMORS
ABOUT NORMAL LYMPH NODES. HE IS CORRECT
WHEN HE STATES THAT IT IS: -WHEEZE

-NON PALPABLE 26. THIS IS THE PREFERRED POSITION WHEN

ASSESSING THE THORAX BECAUSE IT MAXIMIZES
16. WHICH OFNTHE FOLLOWING IS AN ABNORMAL THORAX EXPANSION
FINDING FOR THE NECK MUSCLES?
-SITTING
-COORDINATED, SMOOTH MOVEMENTS
27. UPON INSPECTING THE SHAPE AND SYMMETRY
17. WHILE PERFORMING AN EXAMINATION OF THE OF THE THORAX FROM POSTERIOR AND LATERAL
REGIONAL LYMPH NODES IN THE NECK AREA, YOU VIEWS, YOU FOUND THAT THE
PALPATE A LYMPH NODE THAT FEELS HARD AND ANTEROPOSTERIOR TO TRANSEVERSE DIAMETER
FIXED. WHAT IS THE APPROPRIATE NURSING INRM RATIO OF 1:2. THIS MEANS:
ACTION?
-NORMAL FINDING
-ASK RHE PATIENT IF HE HAS FELT THIS NODE
BEFORE AND IF IT IS PAINFUL
28. IN INFANTS REGARDING THE SKULL THE 40. WHEN PALPATING THE THORAX, WHICH OF THE
DEVELOPMENT OF WHICH TWO BONES IS THE FOLLOWING WOULD BE AN ABNORMAL FINDING?
MOST IMPORTANT?
-MASSES
-ANTERIOR AND POSTERIOR CRANIAL BONES.
41. NURSE IZZA IS KNOWLEDGEABLE THAT THE
29. WHEN DOING A HEALTH HISTORY ON A NORMAL BREATH SOUNDS INCLUDE WHICH OF
PATIENT'S HEAD AND NECK AREA, WHICH IF THE THE FOLLOWING?
FOLLOWING THE NURSE SHOULD ASSESS FOR?
-VESICULAR SOUNDS
-HEADACHE, HEAD INJURY, NECK PAIN, SWELLING,
LIMITATION OF MOVEMENT, DIZZINESS 42. WHEN ASSESSING THE THORAX AND LUNGS, IT
IS IMPORTANT TO:
30. WHEN ASSESSING A PATIENT WITH HEADACHE,
WHICH OF THE FOLLOWING SHOULD THE NURSE -COMPARE EACH SIDE BILATERALLY ON
ASK? AUSCULTATION

-ALL OF THE ABOVE 43. ACCORDING TO THE AUTHORS, AN

OUTSTANDING FEATURE IN ASSESSING A PATIENT
31. A NURSE NEEDS TO PALPATE A CLIENT'S WHO HAS FINDINGS CONSISTENT WITH
SUBMANDIBULAR LYMPH NODES. WHERE SHOULD EMPHYSEMA IS:
THE NURSE PLACE HER HANDS TO DO THIS?
-ALL OF THE ABOVE
-ON THE POSTERIOR BASE OF THE MANDIBLE
44. WHEN PERFORMING A PATIENT HISTORY
32. WHICH OF THE FOLLOWING CONDITION IS ASSESSMENT, WHAT SHOULD BE DONE TO OBTAIN
KNOWN AS ACUTE FACIAL STROKE WITH CLINICAL NECESSARY DATA?
PRESENTATION OF FACIAL MUSCLE WEAKNESS
AND DROOPING ON ONE SIDE OF THE FACE? -QUESTIONING

-BELL'S PALSY 45. WHEN A NURSE PERFORMS AN ASSESSMENT

OF THE SCALP, WHAT CARDINAL TECHNIQUES
33. WHICH OF THE FOLLOWING THE NURSE SHOULD BE USED?
SHOULD DOCUMENT FOR ABNORMAL FINDINGS OF
THYROID GLAND? -INSPECTION AND PALPATION

-MASS, ENLARGED GLAND, PRESENCE OF NODULE 46. AFTER PERFORMING THE PROCEDURE, WHAT
IS THE LAST STEP TO DO TO BE USED FOR
34. THIS CONDITION IS CAUSED BY EXCESSIVE FURTHER REFERENCE?
PRODUCTION OF THYROID HORMONES WITH
CLINICAL MANIFESTATIONS LF EXOPHTHALMOS, -DOCUMENT
WEIGHT LOSS, FINE HAIR AND DIARRHEA.
47. IF THE ASSESSMENT REVEALS THE
-GRAVE'S DISEASE OBJECTIVES WERE NOTBACHIEVED, WHAT
INTERVENTIONS SHOULD BE DONE?
35. THE FOLLOWING ARE THE LOCATIONS OF THE
LYMPH NODES EXCEPT:. -REPORT THE FINDINGS IMMEDIATELY TO THE
PHYSICIAN
-TEMPORAL
48. THIS IS A METABLOIC DISORDER CAUSING
36 WHEN ASSESSING THE LYMPH NODES, THE ENLARGED THYROID DUE TO IODINE DEFICIENCY
NURSE SHOULD DOCUMENT AS A NORMAL
FINDING? -HYPOTHYROIDISM

-UNABLE TO PALPATE NODES 49. NURSE CHESKA NEEDS TO PALPATE A

CLIENT'S SUBMANDIBULAR LYMPH NODES. WHERE
37. THIS CONDITION IS CHARACTERIZED BY AN SHOULD THE NURSE PLACE HERE HANDS TO DO
ENLARGED HEAD, BULGUNG FONTANEL AND THIS?
DILATED SCALP VEINS.
-ON THE POSTERIOR BORDER OF THE MANDIBLE
-HYDROCEPHALUS
50. TO PERCUSSS DOR DIAPHRAGMATIC
38. WHICH IF THE FOLLOWING WOULD INDICATE EXCURSION, YOU SHOULD PERFORM THE
THAT YOUR PATIENT HAS DIFFICULTY OF FOLLOWING EXCEPT:
BREATHING
-USE YOU MOST CONVENIENT PATTERN IN
-RESPIRATORY RATE OF 18 BREATHS PER MINUTE PERCUSSION

39. WHEN AUSCULTATING PATIENT WITH

PNEUMONIA, WHICH OF THE FOLLOWING BREATH
SOUNDS ARE HEARD MORE COMMONLY WITH
Finals
INSPIRATION?
NCM 101 (HEALTH ASSESSMENT LEC) FINALS
-RHONCHI
1. All sensitive and personal information is a. Hyperthermia
published as included in the Data Privacy Act b. Hypothermia
except in certain circumstances, exception to c. Bradycardia
this law includes the following, except? d. Tachycardia
a. Necessity to protect the possession of a e. Dyspnea
person. 9. SITUATION: In handling patient while
b. Necessity to protect the lawful rights of data performing Health assessment, the Nurse must
subjects in court proceedings. always remember and convey the different
c. Necessity to protect life and health of a Ethico – Legal consideration such as Informed
person consent, Patient’s bill of rights, and Data privacy
d. Pursuant to law that does not require act law, to prevent any violation against the
consent. (?) patient’s rights and the law.
2. This aspect of holistic assessment may include You are the Nurse on duty, you were asked
Review of potential stressors and mental about documents or other recordings such as a
problem that might exacerbate the ailment? living will or a health care power of attorney that
a. Nutritional status communicates a person’s wishes about health
b. Developmental care decisions, you know that this is known as?
c. Sociological a. Health care power of attorney
d. Spiritual b. Advance Directives
e. Psychological c. Living will
f. Cultural d. Advance direction
g. Physiological e. Living testament
3. Two numbers are recorded when measuring f. Legal incapacity
blood pressure. Among these, you know that this 10. This aspect of holistic assessment may include
refers to the pressure inside the artery when the assessment of communication with other
heart contracts and pumps blood through the individual and interpersonal relationship?
body. a. Developmental
a. Anatolic b. spiritual
b. Pulse pressure c. Psychological
c. Diastolic d. Nutritional status
d. Cytolysis e. Cultural
e. Systolic f. Sociological
4. Medical term used for respiratory rate below the g. Physiological
normal rate is? 11. You also know that taking blood pressure, this
a. Hypothermia refers to the pressure inside the artery when the
b. Bradypnea heart is at rest and is filling with blood?
c. Bradycardia a. Cytolysis
d. Eupnea b. Diastolic
e. Tachycardia c. Systolic
f. Dyspnea d. Pulse pressure
g. Hypertension e. Anatolic
h. Hypotension 12. This is a command by the court to a witness to
i. Hyperthermia produce document. A writ or process requiring
j. Tachypnea the witness to bring with him and produce to the
k. Apnea court, books, papers, patient’s record or Chart in
5. The law defines personal information included to his hands, tending to elucidate the matter in
the Data Privacy Act of 2012, this includes the issue?
following except? a. Subpoena Ileus Tecum
a. Organizational chart, and line of commands b. Subpoena Dulche Tecum
of an incorporation. c. Subpoena Duces Tecnor
b. About an individual’s health, education, d. Subpoena Duces Tecum
genetic sexual life if a person. 13. In acquiring consent for a certain procedure or
c. About an individual’s race, ethnic group, management, the following except for one is not
marital status, age, color, and religious, a qualification to obtain consent to other
philosophical or political affiliations. individual aside from the patient?
d. Issued by government agencies “peculiar” a. Patient is asleep
(unique) to an individual such as social b. Physically incapacitated
security number. c. Mentally incapacitated
6. In assessing the level of pain of a patient, which d. Minors
of the following pain scale shows a series of 14. This aspect of holistic assessment may include
faces ranging from a happy face at 0 or “no hurt” the ability of those levels to maintain normal
to a crying face at 10 which represents “hurts metabolic integrity?
like the worst pain imaginable”? a. Nutritional status
a. The wong – baker faces pain rating scale b. Physiological
b. FLACC pain scale c. Psychological
c. Numerical rating pain scale d. Sociological
d. Color analog pain scale e. Developmental
7. Documentation could be done by the nurse f. Spiritual
using different format, which include the g. Cultural
following except? 15. According to the Data Privacy Act of 2012, it is
a. Electronic health records shown as a subset of security breach that
b. Computer – based recording actually leads to “accidental or unlawful
c. Verbal documentation destruction, loss, alteration, unauthorized
d. Written notes documentation disclosure of, or access to, personal data
8. Medical term used for high temperature is? transmitted, stored, or otherwise processed?
 a. Personal data breach c. Research
b. Breach of confidentiality d. Credentialing
c. Living breach e. Communication with other professional
d. Breach of action 25. This aspect of nutritional assessment wherein
16. One popular acronym tool is assessing the Physical examination is perform?
spiritual status of a person is the FICA model. a. Clinical methods/ Evaluation
These are the areas of assessment and possible b. Biochemical/ Biophysical Parameters
questions that could be asked to assess the c. Developmental Evaluation
spiritual aspect, these includes the following, d. Anthropometric Measurement
except? 26. Another core value of Nursing considered as a
a. Importance and influence fundamental part of the nursing profession,
b. Fear or fright characterizes our concern and consideration for
c. Address the whole person, our commitment to the
d. Community common good, and our outreach to those who
17. Medical term used for respiratory rate above the are vulnerable?
normal rate is? a. Diversity
a. Tachypnea b. Caring
18. SITUATION: In handling patient, while c. Excellence
performing Health assessment, the Nurse must d. Loyalty
always remember and convey the different e. Integrity
Ethico – Legal consideration such as Informed 27. Medical term used for pulse rate below normal
consent, Patient’s bill of rights, and Data privacy rate is?
act law, to prevent any violation against the a. Bradycardia
patient’s rights and the law. 28. Medical term used for low temperature is?
A document, sometimes called a medical a. Hypothermia
directive, that expresses a person’s wishes 29. The final implementing rules and regulations
regarding future medical interventions when the came into force, adding specificity to the privacy
person no longer has the capacity to make act was implemented on?
health care decisions is called? a. December 9, 2016
a. Living will b. October 9, 2015
b. Health care power of attorney c. September 9, 2016
c. Living testament d. September 9, 2015
d. Advance directives e. October 9, 2016
e. Legal incapacity (incompetency) 30. It is an unpleasant sensory and emotional
f. Advance direction experience, associated with or expressed in
19. The patient asked you about this temperature of terms of actual or potential tissue damage?
98. 2 F, as his nurse, your interpretation on his a. Pain
queries will be? 31. Cultural assessment is also part of taking health
a. Hypothermia history of your patient, as a nurse with
b. Hyperthermia knowledge about it, you know that which of the
c. Hypovolemic shock following are true regarding cultural sensitivity?
d. Normal temperature a. Patient’s response to signs and
20. Another Core Value of Nursing that reflects a symptoms are independent of their
commitment to continuous growth, improvement, cultural values. (?)
and understanding. It is a culture where b. Cultural and ethnic diversity have no impact
transformation is embraced, and the status quo in health care.
and mediocrity are not tolerated? c. All member of one cultural group behaves in
a. Integrity exactly same manner.
b. Loyalty d. As a nurse, it is important to identify and
c. Excellence examine our own cultural and ethnic beliefs.
d. Caring 32. This aspect of holistic assessment may include
e. Diversity psychosocial and cognitive that may affect the
21. Medical term used for normal breathing? patient’s response to the health issue?
a. Eupnea a. Psychological (?)
22. This aspect of holistic assessment may include b. Spiritual
the use of FICA model? c. Sociological
a. Psychological d. Nutritional status
b. Cultural e. Cultural
c. Physiological f. Developmental
d. Sociological g. Physiological
e. Developmental 33. Medical term used for elevated blood pressure?
f. Spiritual a. Hypertension
g. Nutritional status 34. This aspect of holistic assessment may include
23. Medical term used for no breathing? assessment of religious practices and determine
a. Apnea if nursing care will need to be altered?
24. Which of the following purposes of Nursing a. Cultural
Document wherein patient care documents, b. Developmental
assessments of processes, and outcome c. Physiological
measures across organizational settings, serve d. Nutritional status
to monitor performances if health care e. Psychological
practitioners’ and the health care facility’s f. Spiritual
compliance with standard governing the g. Sociological
profession and provision of health care? 35. In 2012, the Philippines passed this Republic
a. Regulation and legislation Act, comprehensive and strict privacy legislation
b. Legal purposes “to protect the fundamental human right of
 privacy, of communication while ensuring free b. Cultural
flow of information, also known as Data Privacy c. Sociological
Act? d. Nutritional status
a. RA No. 10123 e. Psychological
b. RA No. 0123 f. Spiritual
c. RA No. 10173 g. Developmental
d. RA No. 10183 46. Medical term used for decrease or low blood
e. RA No. 101173 pressure?
36. Among four major core values of Nursing, a. Hypotension
respecting the dignity and moral wholeness of 47. Junior went to the clinic where you are working
every person without limitation, and a principle of as a nurse. He is an athlete, a runner, who do a
open communication, ethical decision – making, lot of cardiovascular conditioning, his cardiac
and humility are encourage, and demonstrated rate is 50 BPM, as a nurse, your correct
consistently is integrated to? interpretation for this is?
a. Loyalty a. Cardiac Arrest
b. Integrity b. Bradycardia
c. Diversity c. Tachycardia
d. Excellence d. Normal Cardiac rate
e. Caring 48. SITUATION: In handling patient, while
37. Medical term used for fast or difficulty of performing Health assessment, the Nurse must
breathing? always remember and convey the different
a. Tachypnea Ethico – Legal consideration such as Informed
38. This aspect of nutritional assessment, the consent, Patient’s bill of rights, and Data privacy
patient is sent to the laboratory examination to act law, to prevent any violation against the
assess nutrients form the body? patient’s rights and the law.
a. Biochemical/ Biophysical Parameters (?) This is where the patient is unable to manage
b. Chemical Methods/ Evaluation one’s own affairs because of injury or disability,
c. Anthropometric Measurement as determined by a legal proceeding?
d. Developmental Evaluation a. Living testament
39. Junior, a pediatric patient asked you about the b. Advance direction
different site of the body to acquire body c. Health care power of attorney
temperature, you know that a person’s body d. Legal incapacity
temperature can be taken in any of the following e. Advance directives
ways and site, except for? f. Living will
a. Skin 49. Another measurement used to assess pain for
b. Orally children between the ages of 2 months and 7
c. Axillary years or individuals that are unable to
d. Apical communicate their pain. This scale is scored in a
e. Rectally range of 0 – 10 with 0 representing no pain. This
f. Tympanic scale has five criteria which are assigned a
40. Nutritional Assessment is the interpretation of score of 0.
clinical and dietary to determine whether a a. Numerical rating pai scale
person or groups of people are well nourished or b. Color analog pain scale
malnourished. Nutritional assessment can be c. The wong – baker faces pain rating scale
done using the ABCD methods. These refer to d. FLACC pain scale
the following except? 50. Nurse always make a difference every day
a. Developmental Evaluation because of we are guided by the different goals
b. Anthropometric Measurement of nursing, the following are the four main goals
c. Clinical method/ Evaluation of nursing, except for one?
d. Biochemical/ Biophysical Parameters a. To prevent illness
41. This measurement of the height and weight of a b. To advocate
patient is needed to acquire the body mass c. To treat human illness
index, this include to which of the following? d. To promote health
a. Anthropometric Measurement
b. Developmental Evaluation
c. Clinical method/ Evaluation
d. Biochemical/ Biophysical Parameters
42. Core Value of Nursing affirming the uniqueness
of and differences among persons, ideas,
values, and ethnicities is?
a. Diversity
b. Caring
c. Integrity
d. Excellence
e. Loyalty
43. Both the systolic and diastolic pressures in are
recorded by the nurse using which symbol below
which means millimeters of mercury?
a. mm Hg
44. Medical term used for pulse rate above the
normal rate is?
a. Tachycardia
45. This aspect of holistic assessment may include
assessment of values or ethnicity?
a. Physiological