Health Assessment

ASSESSMENT
A complete health assessment may be conducted starting at the head and proceeding in a
systematic manner downward. The procedure can vary according to different factors such
as, age of the individual, severity of the illness, preferences of the nurse, location of the
examination, and the agency’s priorities and procedures.
Physical health assessment is done to:

• obtain baseline data about the client’s functional abilities;
• supplement, confirm, or refute data obtained in the nursing history;
• obtain data that will help establish nursing diagnoses and plan of care;
• evaluate the physiologic outcomes of health care and thus the progress of a
client’s health problem;
• make clinical judgments about a client’s health status and; identify areas for
health promotion and disease prevention
Head-to-Toe Framework
+ General Survey + Abdomen
+ Vital Signs -Skin
+ Head -Abdominal sounds
-Hair, scalp, cranium, face -Specific organs
-Eyes and vision -Femoral pulses
-Ears and hearing + Genitals
-Nose and sinuses -Testicles
-Mouth and oropharynx -Vagina
-Cranial nerves -Urethra
+ Neck + Anus and rectum
-Muscles + Lower extremities
-Lymph nodes -Skin and toenails
-Trachea -Gait and balance
-Thyroid gland -Joint range of motion
-Carotid arteries -Popliteal, posterior tibial, and
pedal pulses
-Neck veins -Tendon and plantar reflexes
+ Upper extremities
-Skin and nails
-Muscle strength and tone
-Joint range of motion
-Brachial and radial pulses
-Biceps tendon reflexes Tendon reflexes
-Sensation
+ Chest and back
-Skin
-Chest shape and size
-Lungs
-Heart
-Spinal column
-Breasts and axillae
Preparing the Client
The nurse should:

• explain when and where physical examination will take place
• why it is important and
• what will happen during the examination
It is important to determine in advance any positions that are contraindicated for a

particular client. The nurse assists the client in undressing and putting on a gown. Clients
must void before the examination. Doing so, helps them feel more relaxed and facilitates
the palpation of the abdomen and pubic area. Also, doing this will minimize the cause of
disturbance during the examination per se.
In assessing adults, it is important to recognize that they differ markedly.
Health assessment of the Adult
• Be aware of normal physiologic changes that occur with age

• Be aware of stiffness of muscles and joints from aging changes or history of
orthopedic surgery. The client may need modification of the usual positioning
necessary for examination and assessment
• Expose only areas of the body to be examined in order to avoid chilling
• Permit ample time for the client to answer your questions and assume the required
positions
• Be aware of cultural differences. The client may want a family member present
during disrobing
• Arrange for an interpreter if the client’s language differs from that of the nurse
• Ask clients how they wish to be addressed
• Adapt assessment techniques to any sensory impairment
Preparing the Environment
• The time of the examination should be convenient to both the client and the nurse.
• The environment should be well-lighted and the equipment should be organized
for use.
• Provide privacy. Most people are embarrassed if their bodies are exposed to
others.
• The room should be warm enough to be comfortable for the client.
Positioning
Several positions are frequently required during physical examinations. It is important to

consider the client’s ability to assume these positions. The client’s age, physical
condition, and energy level should also be taken into consideration.
Client Positions and Body Areas Assessed
Position Description Areas Assessed Cautions
Back-lying position with knees Head and neck, axillae, May be contraindicated for
Dorsal Recumbent
flexed and hips externally anterior thorax, lungs, breasts, clients who have cardio-
rotated; small pillow under the heart, extremities, peripheral pulmonary problems. Not used
head; soles of feet on the pulses, vital signs, and vagina for abdominal assessment
surface because of the increased
tension of abdominal muscles.
Supine (Horizontal Back-lying position with legs Head, neck, axillae, anterior Tolerated poorly by clients
Recumbent) extended; with or without thorax, lungs, breasts, heart, with cardiovascular and
pillow under the head abdomen, extremities, respiratory problems.
peripheral pulses
Sitting A seated position, back Head, neck, posterior and Elderly and weak clients may
unsupported and legs hanging anterior thorax, lungs, breasts, require support
freely axillae, heart, vital signs,
upper and lower extremities,
reflexes
Lithotomy Back-lying position with feet Female genitals, rectum, and May be uncomfortable and
supported in stirrups; the hips female reproductive tract tiring for elderly people and
should be in line with the edge often embarrassing.
of the table
Side-lying position with Rectum, vagina Difficult for the elderly and
Sims’ lowermost arm behind the people with limited joint
body, uppermost leg flexed at movement
hip and knee, upper arm flexed
at shoulder and elbow
Lies on abdomen with head Posterior thorax, hip joint Often not tolerated by the
Prone
turned to the side, with or movement elderly and people with
without a small pillow cardiovascular and respiratory
problems
Draping
Drapes should be arranged so that the area to be exposed and other body areas are
covered. Exposure of the body is frequently embarrassing to clients. Drapes provide not
only a degree of privacy but also warmth. Drapes are made of paper, cloth, or bed linen.
Instrumentation
All equipment required for the health assessment should be clean, in good working order,
and readily accessible. Equipment is frequently set up on trays, ready for use.
Equipment and Supplies Used for a Health Examination
Supplies Purpose
Flashlight or penlight To assist viewing of the pharynx and cervix
or to determine the reactions of the pupils
of the eye
Laryngeal or dental mirror To observe the pharynx and oral cavity
To permit visualization of the lower and

Nasal Speculum
middle turbinates; usually, a penlight is
used for illumination
Ophthalmoscope A lighted instrument to visualize the

interior of the eye
Otoscope A lighted instrument to visualize the

eardrum and external auditory canal
Percussion Hammer An instrument with a rubber head to test

reflexes
Tuning fork A two-pronged metal instrument used to
test hearing acuity and vibratory sense
Vaginal Speculum To assess the cervix and the vagina
Cotton Applicators To obtain specimens
Disposable Pads To absorb liquid
Gloves To protect the nurse
Lubricant
To ease insertion of instruments
Tongue blades (depressors) To depress tongue during the assessment of

the mouth and pharynx
Methods of Examining
Inspection
It is the visual examination, that is, assessing by using the sense of sight. It
should be deliberate, purposeful, and systematic. The nurse inspects with the
naked eye and with a lighted instrument such as an otoscope. In addition to visual
observations, olfactory and auditory cues are noted. Nurses frequently use visual
inspection to assess moisture, color, and texture of body surfaces, as well as
shape, position, size, color, and symmetry of the body. Lighting must be sufficient
for the nurse to see clearly. Observation can be combined with the other
assessment techniques.
Palpation
It is the examination of the body using the sense of touch. The pads of the
fingers are used because their concentration of nerve endings makes them highly
sensitive to tactile discrimination. Palpation is used to determine: texture;
temperature; vibration; position, size, consistency, and mobility of organs or
masses; distention; pulsation and; presence of pain upon pressure.
Deep palpation is done with extreme caution because pressure can damage
internal organs. It is usually not indicated in clients who have acute abdominal
pain or pain that is not yet diagnosed.
To test for temperature, the back hand is used; to test for vibration, the
palmar surface of the hand.
General guidelines for palpation:

• The nurse’s hands should be clean and warm, and the fingernails short
• Areas of tenderness should be palpated last
• Deep palpation should be done after superficial palpation
Two types of palpation:

a. Light – superficial
- should always precede deep palpation because heavy
pressure on the fingertips can dull the sense of touch
- the nurse extends the dominant hand’s fingers parallel to
the skin surface and presses gently while moving the hand in a circle
- the skin is slightly depressed
b. Deep – bimanual or one hand

- deep bimanual palpation: the nurse extends the dominant
hand as for light palpation, then places the fingerpads of the nondominant
hand on the dorsal surface of the distal interphalangeal joint of the middle
three fingers of the dominant hand. The top hand applies pressure while
the lower hand remains relaxed to perceive tactile sensation
- deep palpation using one hand, the fingerpads of the
dominant hand press over the area to be palpated.
Percussion
It is the act of striking the body surface to elicit sounds that can be heard
or vibrations that can be felt.
Palpation is used to determine the size and shape of internal organs by

establishing their borders. It indicates whether tissue is fluid filled, air filled, or
solid.
Two types:
a. Direct – the nurse strikes the area to be percussed directly with
the pads of two, three or four fingers or with the pad of the middle finger.
The strikes are rapid, and the movement is from the wrist.
b. Indirect – is the striking of an object held against the body area

to be examined. The middle finger of the nondominant hand, referred to as
the pleximeter, is placed firmly on the client’s skin. Only the distal
phalanx and joint of this finger should be in contact with the skin. Using
the tip of the flexed middle finger of the other hand, called the plexor, the
nurse strikes the pleximeter, usually at the distal interphalangeal joint.
Five types of sound:

a. Flatness – is an extremely dull sound produced by very dense tissue
(muscle, bone)
b. Dullness - is a thudlike sound produced by dense tissue (liver, spleen
heart)
c. Resonance – is a hollow sound such as that produced by lungs filled
with air
d. Hyperresonance – is not produced in the normal body. It is described as
booming and can be heard over an emphysematous lung
e. Tympany – is a musical or drumlike sound produced from an air-filled
stomach
Auscultation
It is the process of listening to sounds produced within the body.
Auscultated sounds are described according to their: pitch is the frequency of the
vibrations; intensity refers to the loudness or softness of a sound; duration is the
length of a sound ; and the quality of sound which is a subjective description of a
sound.
Two types:
a. Direct – is the use of the unaided ear,
b. Indirect – is the use of a stethoscope, which transmits the sounds to the
nurse’s ears
GENERAL SURVEY
Involves observation of the client’s general appearance and mental status, and
measurement of vital signs, height, and weight. Many components of the general survey
are assessed while taking the client’s health history, such as the client’s body build,
posture, hygiene and mental status.
Assessing Appearance and Mental Status
Implementation
Performance
1. Explain to the client what you are going to do, why it is necessary, and how he
or she can cooperate. Discuss how the results will be used in planning for further care or
treatments.
2. Wash hands and observe appropriate infection control procedures.
3. Provide for client privacy.
Assessment Normal Findings Deviation from Normal
4. Observe body build, Proportionate, varies Excessively thin or
height, and weight in with lifestyle obese
relation to the client’s
age lifestyle, and health.
5. Observe the client’s Relaxed, erect posture; Tense, slouched, bent

posture and gait, coordinated movement posture; uncoordinated
standing, sitting and movement, tremors
walking.
Dirty, unkempt
6. Observe the client’s Clean, neat
overall hygiene and
grooming. Relate these
to the person’s activities
prior to the assessment.
7. Note body and breath No body odor or minor Foul body odor;
odor in relation to body odor relative to ammonia odor; acetone
activity level. work or exercise; no breath odor; foul breath
breath odor
8. Observe for signs of
distress in posture or No distress noted Bending over because of
facial expression. abdominal pain, wincing
or labored breathing
9. Note obvious signs of Healthy appearance Pallor; weakness;

health or illness obvious illness
Negative, hostile,
10. Assess the client’s Cooperative withdrawn
attitude.
11. Note the client’s Inappropriate to

affect/mood; assess the Appropriate to situation situation
appropriateness of the
client’s responses.
Rapid or slow pace; uses
12. Listen for quantity Logical sequence; generalizations; lacks
of speech, quality, and makes sense; has sense association; exhibits
organization. of reality confabulation
Illogical sequence; flight

13. Listen for relevance Understandable, of ideas; confusion
and organization of moderate pace; exhibits
thoughts. thought association
14. Document findings

in the client record using
forms or checklists.
Vital Signs
Vital signs are measured (a) to establish baseline data against which to compare future
measurements and (b) to detect actual and potential health problems.
Height and Weight
In adults, the ratio of weight to height provides a general measure of health. By asking
clients about their height and weight before actually measuring them, the nurse obtains
some idea of the person’s self-image. Excessive discrepancies between the client’s
responses and the measurements may provide clues to actual or potential problems in
self-concept. It is also important that the nurse and client be aware of any significant
unintentional weight gain or loss.
The nurse measures height with a measuring stick attached to weight scales or walls. The
client removes the shoes and stands erect, with heels together, and the heels, buttocks,
and back of the head against the measuring stick; eyes should be looking straight ahead.
Weight is usually measured when a client is admitted to a health agency and often
regularly. When accuracy is essential, the nurse should use the same scale each time.
THE INTEGUMENT
It includes the skin, hair, and nails. The examination begins with a generalized inspection
using a good source of lighting, preferably indirect natural daylight.
SKIN
Assessment of the skin involves inspection and palpation. The entire skin surface may be
assessed at one time or as each aspect of the body is assessed. In some instances, the
nurse may also need to use the olfactory sense to detect unusual skin odors; these are
usually most evident in the skinfolds or in the axillae. Pungent body odors is frequently
related to poor hygiene, hyperhidrosis (excessive perspiration), or bromhidrosis (foul-
smelling perspiration).
Pallor is the result of inadequate circulating blood or hemoglobin and subsequent

reduction in tissue oxygenation. It may be difficult to determine in clients with dark skin.
It is usually characterized by the absence of underlying red tones in the skin and may be
most readily seen in the buccal mucosa. In brown-skinned clients, the skin may appear
ashen gray. Pallor in all people is usually most evident in areas with the least
pigmentation.
Cyanosis (a bluish tinge) is most evident in the nail beds, lips, and buccal mucosa. In
dark-skinned clients, close inspection of the palpebral conjunctiva and palms and soles
may also show evidence of cyanosis. Jaundice (a yellowish tinge) may first be evident in
the sclera of the eyes and then in the mucous membranes and the skin. Nurses should take
care not to confuse jaundice with the normal yellow pigmentation in the sclera of a dark-
skinned or Black client. Erythema is a redness associated with a variety of rashes.
Localized areas of hyperpigmentation (increased pigmentation) and hypopigmentation

(decreased pigmentation) may also occur as a result of changes in the distribution of
melanin (the dark pigment) or in the function of the melanocytes in the epidermis.
Vitiligo, seen as patches of hypopigmented skin, is caused by the destruction of
melanocytes in the area. Albinism is the complete or partial lack of melanin in the skin,
hair and eyes. Edema is the presence of excess interstitial fluid. An area of edema
appears swollen, shiny, and taut and tends to blanch the skin color or, if accompanied by
inflammation, may redden the skin. Generalized edema is most often an indication of
impaired venous circulation and in some causes reflects cardiac dysfunction or vein
abnormalities.
A skin lesion is an alteration in a client’s normal skin appearance. Primary skin lesions
are those that appear initially in response to some change in the external or internal
environment of the skin. Secondary skin lesions are those that do not appear initially but
result from modifications such as chronicity, trauma, or infection of the primary lesion.
Primary Skin Lesion
a. Macule, Patch Flat, unelevated change in color. Macules are 1 mm to 1cm in size and
circumscribed. Examples: freckles, measles, petechiae, flat moles. Patches are larger than
1 cm and may have an irregular shape. Examples: port whine birthmark, vitiligo, rubella.
b. Papule Circumscribed, solid elevation of the skin. Papules are less than 1 cm.
Examples: warts, acne, pimples, elevated moles.
c. Plaque Plaques are larger than 1 cm. Examples: psoriasis, rubeola
d. Nodule, Tumor Elevated, solid, hard mass that extends deeper into the dermis than a
papule. Nodules have a circumscribed border and are 0.5 to 2 cm. Examples: squamous
cell carcinoma, fibroma. Tumors are larger than 2 cm and may have an irregular border.
Examples: malignant melanoma, hemangioma.
e. Pustule Vesicle or bulla filled with pus. Examples: acne vulgaris, impetigo.
f. Vesicle, Bulla A circumscribed, round or oval, thin translucent mass filled with serous
fluid or blood. Vesicles are less than 0.5 cm. Examples: large blister, second-degree burn,
herpes simplex.
g. Cyst A 1cm. or larger, elevated, encapsulated, fluid-filled or semisolid mass arising
from the subcutaneous tissue or dermis. Examples: sebaceous and epidermoid cysts,
chalazion of the eyelid.
h. Wheal A reddened, localized collection of edema fluid; irregular in shape. Size varies.
Examples: hives, mosquito bites.
Secondary Skin Lesions
Atrophy A translucent, dry, paperlike, Ulcer Deep, irregularly shaped area of skin
sometimes wrinkled skin surface resulting loss extending into the dermis or
from thinning or wasting of the skin due to subcutaneous tissue. May bleed. May leave
loss of collagen and elastin. a scar.
Examples: Striae, aged skin Examples: Decubitus ulcers (pressure

sores), stasis, ulcers, chancres.
Erosion Wearing away of the superficial Fissure Linear crack with sharp edges,
epidermis causing a moist, shallow extending into the dermis.
depression. Because erosions do not extend
into the dermis, they heal without scarring. Examples: Cracks at the corners of the
mouth or in the hands, athlete’s foot
Examples: Scratch marks, ruptured vesicles
Scar Flat, irregular area of connective
Lichenification Rough, thickened, tissue left after a lesion or wound has
hardened area of epidermis resulting from healed. New scars may be red or purple;
chronic irritation such as scratching or older scars may be silvery or white.
rubbing.
Examples: Healed surgical wound or
Examples: Chronic dermatitis injury, healed acne
Scales Shedding flakes of greasy,

keratinized skin tissue. Color may be Keloid Elevated, irregular, darkened area of
white, gray, or silver. Texture may vary excess scar tissue caused by excessive
from fine to thick. collagen formation during healing. Extends
beyond the site of the original injury.
Examples: Dry skin, dandruff, psoriasis Higher incidence in people of African
descent.
Examples: Keloid from ear piercing or

surgery
Crust Dry blood, serum, or pus left on the

skin surface when vesicles or pustules
burst. Can be red-brown, orange, or yellow.
Large crusts that adhere to the skin surface
are called scabs.
Excoriation Linear erosion induced by
Examples: Eczema, impetigo, herpes or scratching
scabs following abrasion.
Assessing The Skin
Implementation
Performance
1. Explain to the client what you are going to do, why it is necessary, and how he or she
can cooperate. Discuss how the results will be used in planning further care or treatments.
4. Inquire if the client has any history of the following: pain or itching; presence and
spread of any lesions; bruises, abrasions, pigmented spots; previous experience with skin
problems; associated clinical signs; family history; presence of problems in other family
members; related systemic conditions; use of medication, lotions, home remedies;
excessively dry or moist feel to the skin; tendency to bruise easily; any association of the
problem to season of year, stress, occupation, medications, recent travel, housing,
personal contact, and so on; any recent contact with allergens.

5. Inspect skin color. Varies from light to Pallor, cyanosis,
deep brown; from ruddy jaundice, erythema
pink to light pink; from
yellow overtones to
olive
6. Inspect uniformity of Generally uniform Areas of either
skin color except in areas exposed hyperpigmentation or
to the sun; areas of hypopigmentation
lighter pigmentation in
dark skinned people
7. Assess edema, if No edema Edema
present
Scale for Edema
1+ Barely detectable (2 mm)
2+ Indentation of 2-4 mm
3+ Indentation of 5-7 mm
4+ Indentation of more than 7

mm
8. Inspect, palpate and Freckles, some

describe skin lesions. birthmarks, some flat Various interruptions in
Apply gloves if lesions and raised nevi; no skin integrity
are open or draining. abrasions or other
Palpate lesions to lesions
determine shape and
texture. Describe lesions
according to location,
color, configuration,
size, shape, type or
structure
9. Observe and palpate Moisture in skin folds Excessive moisture;

skin moisture and the axillae excessive dryness
10. Palpate skin

temperature. Compare Uniform within normal Generalized
the two feet and the two range hyperthermia;
hands, using the back of generalized
your fingers. hypothermia; localized
hyperthermia; localized
hypothermia
11. Note skin turgor
(fullness or elasticity) by When pinched, skin
lifting and pinching the springs back to previous Skin stays pinched or
skin on an extremity. state. tented or moves slowly

forms or checklists
supplemented by
narrative notes when
appropriate. Draw
location of skin lesions
on body surface
diagrams.
Describing Skin Lesions
• Type or Structure.
a. primary – those that appear initially in response to some change in the external
or internal environment of the skin
b. secondary – does not appear initially but result from modifications
• Size, shape and texture. Note size in millimeters and whether the lesion is
circumscribed or irregular; round or oval shaped; flat, elevated, or depressed;
solid, soft, or hard; rough or thicken; fluid-filled or has flakes.
• Color. There may be no discoloration, one discrete color, several colors. When
color changes are limited to the edges pf the lesion, they are described as
circumscribed; when spread over a large area, they are described as diffuse.
• Distribution. Is described according to the location of the lesions on the body and
symmetry or asymmetry of findings in comparable body areas.
• Configuration. Refers to the arrangement of lesions in relation to each other.

Configurations of lesions may be annular, clustered together or grouped, linear,
arc or bow shaped, merged together or indiscrete, follow the course of coetaneous
nerves or meshed in the form of a network.
HAIR
Assessing a client’s hair includes inspecting the hair, considering developmental changes
and ethnicity differences, and determining the individual’s hair care practices ad the
factors influencing them.
Normal hair is resilient and evenly distributed. In people with severe protein deficiency
(kwashiorkor), the hair color is faded and appears reddish or bleached, and the texture is
coarse and dry. Some therapies cause alopecia (hair loss), and some disease conditions
affect the coarseness of hair.
Assessing the Hair
Implementation
Performance
4. Inquire if the client has any history of the following: recent use of hair dyes, rinses, or
curling or straightening preparations; recent chemotherapy; presence of disease, such as
hypothyroidism, which can be associated with dry, brittle hair.
5. Inspect the evenness Evenly distributed hair Patches of hair loss
of growth over the scalp.
6. Inspect hair thickness Thick hair Very thin hair

or thinness.
7. Inspect hair texture Silky, resilient hair Brittle hair; excessively

and oiliness. oily or dry hair
8. Note presence of No infection or Flaking, sores, lice, nits,

infections or infestations infestation and ring worm
by parting the hair in
several areas, checking
behind the ears and
along the hairline at the
neck.
Hirsutism (abnormal
9. Inspect amount of Variable hairiness) in women
body hair.

forms or checklists
supplemented by
appropriate.
NAILS
Nails are inspected for nail plate shape, angle between the nail and the nail bed, nail
texture, nail bed color, and the intactness of the tissues around the nails.
The nail plate is normally colorless and a convex curve. The angle between the nail and
the nail bed is normally 160 degrees. One nail abnormality is the spoon shape, in which
the nail curves upward from the nail bed. This condition, called koilonychia, may be
seen in clients with iron deficiency anemia. Clubbing is a condition in which the angle
between the nail and the nail bed is 180 degrees or greater. Clubbing may be caused by a
lack of oxygen.
Nail texture is normally smooth. Excessively thick nails can appear in the elderly, in the
presence of poor circulation, or in relation to a chronic fungal infection. Excessively thin
nails or the presence of grooves or furrows can reflect prolonged iron deficiency anemia.
Beau’s lines are horizontal depressions in the nail that can result from injury or severe
illness.
The nail bed is highly vascular, a characteristic that accounts for its pink color in white
people. A bluish or purplish tint to the nail bed may reflect cyanosis, and pallor may
reflect poor circulation.
The tissue surrounding the nails is normally intact epidermis. Paronychia is an

inflammation of the tissues surrounding a nail (often referred to as an “ingrown nail”).
The tissues appear inflamed and swollen and tenderness is usually present. A blanch test
can be carried out to test the capillary refill, that is, peripheral circulation. Normal nail
bed capillaries blanch when pressed but quickly turn pink or their usual color when
pressure is released. A slow rate of capillary refill may indicate circulatory problems.
Assessing the Nails
Implementation
Performance
4. Inquire if the client has any history of the following: presence of diabetes mellitus,
peripheral circulatory disease, previous injury, or severe illness.
5. Inspect fingernail Convex curvature; angle Spoon nail; clubbing
plate shape to determine of nail plate about 160
its curvature and angle. degrees
6. Inspect fingernail and Smooth texture Excessive thickness or

toenail texture. thinness or presence of
grooves or furrows;
Beau’s lines
7. Inspect fingernail and Highly vascular and Bluish or purplish

toenail bed color. pink in light-skinned tint(may reflect
clients; dark-skinned cyanosis); pallor(may
clients may have black reflect poor arterial
or brown pigmentation circulation)
in longitudinal streaks
8. Inspect tissues Intact epidermis Hangnails; paronychia

surrounding nails. (inflammation)
9. Perform blanch test of Prompt return of pink or Delayed return of pink

capillary refill. Press casual color (generally or usual color(may
two or more nails less than 4 seconds) reflect circulatory
between your thumb and impairment)
index finger; look for
blanching and return of
pink color to nail bed.

forms or checklists
supplemented by
appropriate.
The Head
➢ the nurse inspects, palpates, and also auscultates

➢ the nurse examines the skull, face, eyes, ears, nose, sinuses, mouth and pharynx
Bones of the Head
Skull and Face
➢ Normocephalic – normal head size

➢ Hyperthyroidism – can cause exophthalmos
➢ Hypothyroidism – myxedema
Assessing the Skull and Face
Equipment
None
Implementation
Performance
1. Prior to performing the procedure, introduce self and verify the client’s identity using
agency protocol. Explain to the client what you are going to do, why it is necessary, and
he or she can cooperate. Discuss how the results will be used in planning further care or
treatments.
2. Perform hand hygiene and observe appropriate infection control procedures.
4. Inquire if the client has any history of the following: past problems with lumps or
bumps, itching, scaling, or dandruff; history of loss of consciousness, dizziness, seizures,
headache, facial pain, or injury; when and how any lumps occurred; length of time any
other problem existed; any known cause of problem; associated symptoms, treatment,
and recurrences.
Assessment
5. Inspect the skull for size, shape, and symmetry.
Normal Findings: Rounded; smooth skull contour

Deviations from Normal: Lack of symmetry; increased skull size with more prominent
nose and forehead; longer mandible
6. Palpate the skull for nodules or masses and depressions.
Normal Findings:
Smooth, uniform consistency; absence of nodules or masses
Deviations from Normal:
Sebaceous cysts; local deformities from trauma; masses, nodules
7. Inspect the facial features.
Normal Findings:
Symmetric or slightly asymmetric facial features; palpebral fissures equal in size;
symmetric nasolabial folds
Increased facial hair; thinning of eyebrows; asymmetric features; exopthalmos;
myxedema facies; moon face
8. Inspect the eyes for edema and hollowness.

Periorbital edema; sunken eyes
9. Note symmetry of facial movements.
Normal Findings:
Symmetric facial movements
Asymmetric facial movements; drooping of lower eyelid and mouth; involuntary
facial movements
10. Document findings in the client record using forms or checklists supplemented by
narrative notes when appropriate.
Evaluation
➢ Perform a detailed follow-up examination of other systems based on findings that

deviated from expected or normal for the client. Relate findings to previous
assessment data if available.
➢ Report significant deviations from normal to the primary care provider.
Eyes and Vision
➢ Assessment of the external structures, visual acuity, ocular movement and visual
fields
Anatomic Structures of the eye
Common refractive errors of the lens of the eye:
- Myopia
- Hyperopia
- Presbyopia
- Astigmatism
Common inflammatory visual problems:
- Conjuctivitis (inflammation of the bulbar and palpebral conjunctiva)

- Dacryocystitis (inflammation of the lacrimal sac)
- Hordeolum (sty)
- Iritis (inflammation of the iris)
➢ Cataracts – tend to occur in persons over 65 years old
➢ Glaucoma – a disturbance in the circulation of aqueous fluid, which causes an
increase in intraocular pressure)
➢ Ptosis – eyelids that lie at or below the pupil margin
➢ Mydriasis – enlarged pupils
➢ Miosis – constricted pupils
➢ Anisocoria – unequal pupils
Assessing the Eye Structures and Visual Acuity
Planning
Place the client in an appropriate room for assessing the eyes and vision. The nurse must
be able to control natural and overhead lighting during some portions of the examination.
Equipment
Cotton tip applicator

Gauze square
Clean gloves
Millimeter ruler
Penlight
Snellen’s or E chart
Opaque card
Implementation
Performance
how he or she can cooperate. Discuss how the results will be used in planning further
care or treatments.
2. Perform hand hygiene, apply gloves, and observe appropriate infection control
procedures.
4. Inquire if the client has any history of the following: family history of diabetes,
hypertension, blood dyscrasia, or eye disease, injury, or surgery; client’s last visit to an
ophthalmologist; current use of eye medications; use of contact lenses or eyeglasses;
hygienic practices for corrective lenses; current symptoms of eye problems.
Assessment
External Eye Structures
5. Inspect the eyebrows for hair distribution and alignment and skin quality and
movement.
Normal Findings:
Hair evenly distributed; skin intact
Eyebrows symmetrically aligned; equal movement
Loss of hair; scaling and flakiness of skin
Unequal alignment and movement of eyebrows
6. Inspect the eyelashes for evenness of distribution and direction of curl.
Normal Findings:
Equally distributed; curled slightly outward
Turned inward
7. Inspect the eyelids for surface characteristics, position in relation to the cornea, ability
to blink, and frequency of blinking. For proper visual examination of the upper eyelids,
elevate the eyebrows with your thumb and index fingers, and have the client close the
eyes. Inspect the lower eyelids while the client’s eyes are closed.
Normal Findings:
Skin intact; no discharge; no discoloration
Lids close symmetrically
Approximately 15 to 20 involuntary blinks per minute; bilateral blinking
When lids open, no visible sclera above corneas, and upper and lower borders of
cornea are slightly covered
Redness, swelling, flaking, crusting, plaques, discharge, nodules, lesions
Lids close asymmetrically, incompletely, or painfully
Rapid, monocular, absent, or infrequent blinking
Ptosis, ectropion, or entropion; rim of sclera visible between lid and iris
8. Inspect the bulbar conjunctiva for color, texture, and presence of lesions. Retract the
eyelids with your thumb and index finger, exerting pressure over the upper and lower
bony orbits, and ask the client to look up, down, and from side to side.
Normal Findings:
Transparent; capillaries sometimes evident; sclera appears white
Jaundiced sclera; excessively pale sclera; reddened sclera; lesions or nodules
9. Inspect the palpebral conjunctiva by everting the lids. Evert both lower lids, and ask
the client to look up. Then gently retract the lower lids with the index fingers.
Normal Findings:
Shiny, smooth, and pink or red
Extremely pale; extremely red; nodules or other lesions
10. Evert the upper lids if a problem is suspected.
▪ Ask the client to look down while keeping the eyes slightly open.
▪ Gently grasp the client’s eyelashes with the thumb and index finger. Pull the
lashes gently downward.
▪ Place a cotton-tipped applicator stick about 1 cm above the lid margin, and push it
gently downward while holding the eyelashes.
▪ Hold the margin of the everted lid or the eyelashes against the ridge of the upper
bony orbit with the applicator stick or the thumb
▪ Inspect the conjunctiva for color, texture, lesions, and foreign bodies
▪ To return the lid to its normal position, gently pull the lashes forward, and ask the
client to look up and blink.
11. Inspect and palpate the lacrimal gland.

▪ Using the tip of your index finger, palpate the lacrimal gland
▪ Observe for edema between the lower lid and the nose
Normal Findings:
No edema or tenderness over lacrimal gland
Swelling or tenderness over lacrimal gland
12. Inspect and palpate the lacrimal sac and nasolacrimal duct.
▪ Observe for evidence of increased tearing

▪ Using the tip of your index finger, palpate inside the lower orbital rim near the
inner canthus
Normal Findings:
No edema or tearing
Evidence of increased tearing; regurgitation of fluid on palpation of lacrimal sac
13. Inspect the cornea for clarity and texture. Ask the client to look straight ahead. Hold a
penlight at an oblique angle to the eye, and move the light slowly across the corneal
surface.
Normal Findings:
Transparent, shiny, and smooth; details of the iris are visible
In older people, a thin, grayish white ring around the margin, called arcus senilis,
may be evident
Opaque; surface not smooth
Arcus senilis in clients unser age 40
14. Perform the corneal sensitivity test to determine the function of the fifth cranial nerve.
Ask the client to keep both eyes open and look straight ahead. Extend your hand behind
the client’s field of vision, then bring the gauze toward the outer canthus. Lightly touch
the cornea with a corner of the gauze.
Normal Findings:
Client blinks when the cornea is touched, indicating that the trigeminal nerve is
intact
One or both eyelids fail to respond
15. Inspect the anterior chamber for transparency and depth. Use the same oblique
lighting as used to test the cornea.
Normal Findings:
Transparent
No shadows of light on iris
Depth of about 3 mm
Cloudy
Crescent-shaped shadows on far side of iris
Shallow chamber
16. Inspect the pupils for color, shape and symmetry of size.
Normal Findings:
Black in color; equal in size; normally 3 to 7 mm in diameter; round, smoothe
border, iris flat and round
Cloudiness, mydriasis, miosis, anisocoria; bulging of iris toward cornea
17. Assess each pupil’s direct and consensual reaction to light to determine the function
of the third and fourth cranial nerves.
▪ Partially darken the room

▪ Ask the client to look straight ahead
▪ Using a penlight and approaching from the side, shine light on the pupil
▪ Observe the response of the illuminated pupil
▪ Shine the light on the pupil again, and observe the response of the other pupil
Normal Findings:
Illuminated pupil constricts
Nonilluminated pupil constricts
Neither pupil constricts
Unequal responses
Absent responses
18. Assess each pupil’s reaction to accommodation.
▪ Hold an object about 10 cm from the bridge of the client’s nose

▪ Ask the client to look first at the top of the object and then at a distant object
behind the penlight. Alternate the gaze from the near to the far object
▪ Observe the pupil response
▪ Next, move the penlight or pencil toward the client’s nose
Normal Findings:
Pupils constrict when looking at near objects; pupils dilate when looking at far
object; pupils converge when near object is moved toward nose
One or both pupils fail to constrict, dilate, or converge
19. Assess peripheral visual fields to determine function of the retina and neuronal visual
pathways to the brain and second cranial nerve.
▪ Have the client sit directly facing you at a distance of 60 to 90 cm

▪ Ask the client to cover the right eye with a card and look directly at your nose
▪ Cover or close your eye directly opposite the client’s covered eye, and look
directly at the client’s nose
▪ Hold an object in your fingers, extend your arm, and move the object into the
visual field from various points in the periphery. The object should be at an equal
distance from the client and yourself. Ask the client to tell you when the moving
object is first spotted
a. To test the temporal field of the left eye, extend and move your right arm in
from the client’s right periphery. Temporally, peripheral objects can be seen at
right angles to the central point of vision.
b. To test the upward field of the eye, extend and move the right arm down from
the upward periphery. The upward field of vision is normally 50 degrees
because the orbital ridge is in the way.
c. To test the downward field of the left eye, extend and move the right arm up
from the lower periphery. The downward field of vision is normally 70
degrees because the cheekbone is in the way.
d. To test the nasal field of the left eye, extend and move your left arm in from
the periphery. The nasal field of vision is normally 50 degrees away from the
central point of vision because the nose is in the way
▪ Repeat the above steps for the right eye, reversing the process
Normal Findings:
When looking straight ahead, client can see objects in the periphery
Visual field smaller than normal; one-half vision in one or both eyes
Extraocular Muscle Tests
20. Assess six ocular movements to determine eye alignment and coordination. These can
be performed on clients over 6 months of age.
▪ Stand directly in front of the client and hold the penlight at a comfortable
distance, such as 30 cm in front of the client’s eyes
▪ Ask the client to hold the head in a fixed position facing you and to follow the
movements of the penlight with the eyes only
▪ Move the penlight in a slow, orderly manner through the six cardinal fields of
gaze, that is, from the center of the eye along the lines of the arrows in and back
to the center
▪ Stop the movement of the penlight periodically so that nystagmus can be detected
Normal Findings:
Both eyes coordinated, move in unison, with parallel alignment
The six muscles that govern eye movement
Eye movements not coordinated or parallel; one or both eyes fail to follow a
penlight in specific directions
Nystagmus (rapid involuntary rhythmic eye movement) other than at end point
may indicate neurologic impairment
21. Assess for location of light reflex by shining penlight on pupil in corneal surface
(Hirschberg test).
Normal Findings:
Light falls symmetrically on both pupils
Light falls off center on one eye
22. Have client fixate on a near or far object. Cover one eye and observe for movement in
the uncovered eye (cover test).
Normal Findings:
Uncovered eye does not move
If misalignment is present, when dominant eye is covered, the uncovered eye will
move to focus on object
Visual Acuity
23. Assess near vision by providing adequate lighting and asking the client to read from a
magazine or newspaper held at a distance of 36 cm. If the client normally wears
corrective lenses, the glasses or lenses should be worn during the test.
Normal Findings:
Able to read newsprint.
Difficulty reading newsprint
24. Assess distance vision by asking the client to wear corrective lenses, unless they are
used for reading only, i.e., for distances of only 36 cm.
▪ Ask the client to stand or sit 6 m from a Snellen chart or character chart, cover the
eye not being tested, and identify the letters or characters on the chart.
▪ Take three readings: right eye, left eye, both eyes.
▪ Record the readings of each eye and both eyes
Normal Findings:
20/20 vision on Snellen-type chart
Denominator of 40 or more on Snellen-type chart with corrective lenses
25. If the client is unable to see even the top lint (20/200) of the Snellen-type chart,
perform functional vision tests
▪ Light Perception
▪ Hand Movements (H/M)
▪ Counting Fingers (C/F)

Functional vision only
Evaluation
▪ Perform a detailed follow-up examination of other systems based on the findings

that deviated from expected or normal for the client. Relate findings to previous
▪ Report significant deviations from normal to the primary care provider. Persons
with denominators of 40 or more on the Snellen or character chart, with or
without corrective lenses, may need to be referred to an optometrist or
ophthalmologist.
Ears and Hearing
➢ Direct inspection and palpation of the external ear, inspection of the remaining
parts of the ear by an otoscope, and determination of auditory acuity
Anatomical Structures of the external, middle, and inner ear
➢ Three parts:
- External Ear
- Middle Ear
- Inner Ear
➢ External Ear
- Auricle
- lobule, helix, antihelix, tragus, triangular fossa, and external auditory meatus
- External auditory canal
- Tympanic membrane
➢ Middle Ear
- Three ossicles
- Malleus, incus, stapes
- Eustachian tube
➢ Inner Ear
- Cochlea
- Vestibule
- Semicircular canals
➢ Air-conducted transmission
1. A sound stimulus eneters the xternal canal and reaches the tympanic membrane
2. The sound waves vibrate the tympanic membrane and reach the ossicles
3. The sound waves travel from the ossicles to the opening in the inner ear
4. The cochlea receives the sound vibrations
5. The stimulus travels to the auditory nerve and the cerebral cortex
➢ Conduction hearing loss – interrupted transmission of sound waves

➢ Sensorineural hearing loss – result of damage to the inner ear
➢ Mixed hearing loss – combination of conduction and sensorineural loss
Assessing the Ears and Hearing
Planning
It is important to conduct the ear and hearing examination in an area that is quiet. In
addition, the location should allow the client to be positioned sitting or standing at the
same level as the nurse.
Equipment
Otoscope with several sizes of ear specula
Implementation
Performance
care or treatments.
4. Inquire if the client has any history of the following: family history of hearing
problems or loss; presence of ear problems or pain; medication history, especially if there
are complaints of ringing in ears; hearing difficulty: its onset, factors contributing to it,
and how it interferes with activities of daily living; use of a corrective hearing device:
when and from whom it was obtained.
5. Position the client comfortably, seated if possible.
Auricles
6. Inspect the auricles for color, symmetry of size, and position. To inspect position, note
the level at which the superior aspect of the auricle attaches to the head in relation to the
eye.
Normal Findings:
Color same as facial skin
Symmetrical
Auricle aligned with outer canthus of eye, about 10˚ from vertical
Bluish color of earlobes; pallor; excessive redness
Asymmetry
Low-set ears (associated with a congenital abnormality, such as Down syndrome)
7. Palpate the auricles for texture, elasticity, and areas of tenderness.
▪ Pull the auricle upward, downward, and backward.

▪ Fold the pinna forward (it should recoil).
▪ Push in on the tragus
▪ Apply pressure to the mastoid process.
Normal Findings:
Mobile, firm, and not tender; pinna recoils after it is folded
Lesions; flaky scaly skin; tenderness when moved or pressed
External Ear Canal and Tympanic Membrane
8. Using an otoscope, inspect the external ear canal for cerumen, skin lesions, pus, and
blood
▪ Attach a speculum to the otoscope. Use the largest diameter that will fit the ear
canal without causing discomfort
▪ Tip the client’s head away from you, and straighten the ear canal. For an adult,
straighten the ear canal by pulling the pinna up and back
▪ Hold the otoscope either (a) right side up, with your fingers between the otoscope
handle and the client’s head or (b) upside down, with your fingers and the ulnar
surface of your hand against the client’s head
▪ Gently insert the tip of the otoscope into the ear canal, avoiding pressure by the
speculum against either side of the ear canal
Normal Findings:
Distal third contains hair follicles and glands
Dry cerumen, grayish-tan color; or sticky, wet cerumen in various shades of
brown
Redness and discharge
Scaling
Excessive cerumen obstructing canal
9. Inspect the tympanic membrane for color and gloss.
Normal Findings:
Pearly gray color, semitransparent
Pink to red, some opacity
Yellow-amber
White
Blue or deep red
Dull surface
Gross Hearing Acuity Tests
10. Assess client’s response to normal voice tones. If the client has difficulty hearing the
normal voice, proceed with the following tests.
Normal Findings:
Normal voice tones audible
Normal voice tones not audible
10A. Perform the watch tick test. The ticking of the watch has higher pitch than the
human voice.
▪ Have the client occlude one ear. Out of the client’s sight, place a ticking watch 2
to 3 cm from the unoccluded ear
▪ Ask what the client can hear. Repeat with the other ear
Normal Findings:
Able to hear ticking in both ears
Unable to hear ticking in one or both ears
10B. Tuning Fork Tests

Perform the Weber’s test to assess bone conduction by examining the lateralization
of sounds
▪ Hold the tuning fork at its base. Actuvate it by tapping the fork gently against the
back of your hand near the knuckles or by stroking the fork between your thumb
and index finger. It should be made to ring softly.
▪ Place the base of the vibrating fork on top of the client’s head and ask where the
client hears the noise .
Conduct the Rinne test to compare air conduction to bone conduction.
▪ Ask the client to block the hearing in one ear intermittently by moving a fingertip
in and out of the ear canal.
▪ Hold the handle of the activated tuning fork on the mastoid process of one ear
until the client states that the vibration can no longer be heard.
▪ Immediately hold the still vibrating fork prongs in front of the client’s ear canal.
Push aside the client’s hair if necessary. Ask whether the client now hears the
sound. Sound conducted by air is heard more readily than sound conducted by
bone. The tuning fork vibrations conducted by air are normally heard longer.
Normal Findings:
Sound is heard in both ears or is localized at the center of the head (Weber
negative)
Air-conducted (AC) hearing is greater than bone-conducted (BC) hearing, i.e., AC
> BC (positive Rinne)
Sound is heard better in impaired ear, indicating a bone
conductive hearing loss; or sound is heard better in ear without a problem, indicating a
sensorineural disturbance (Weber positive)
Bone conduction time is equal to or longer than the air conduction time, i.e., BC >
AC or BC = AC (negative Rinne; indicates a conductive hearing loss)
Evaluation
▪ Perform a detailed follow-up examination of the neurologic system based on

findings that deviated from expected or normal for the client. Relate findings to
previous assessment data if available.
▪ Report significant deviations from normal to the primary care provider.
Nose and Sinuses
➢ Assessment of the nose includes inspection and palpation of the external nose;
patency of the nasal cavities; and inspection of the nasal cavities
➢ The nurse also inspects and palpates the facial sinuses
The facial sinuses
Assessing the Nose and Sinuses
Equipment
Nasal speculum
Flashlight/penlight
Implementation
Performance
treatments.
4. Inquire if the client has any history of the following: allergies, difficulty breathing
through the nose, sinus infections, injuries to nose or face, nosebleeds; medications taken;
changes in sense of smell.
Nose
6. Inspect the external nose for any deviations in shape, size, or color and flaring or
discharge from the nares.
Normal Findings:
Symmetric and straight
No discharge or flaring
Uniform color
Asymmetric
Discharge from nares
Localized areas of redness or presence of skin lesions
7. Lightly palpate the external nose to determine any areas of tenderness, masses, and
displacements of bone cartilage.
Normal Findings:
Not tender; no lesions
Tenderness on palpation; presence of lesions
8. Determine patency of both nasal cavities. Ask the client to close the mouth, exert
pressure on one naris, and breathe through the opposite naris. Repeat the procedure to
assess the patency of the opposite naris.
Normal Findings:
Air moves freely as the client breathes through the nares
Air movement is restricted in one or both nares
9. Inspect the nasal cavities using a flashlight or a nasal speculum.

▪ Hold the speculum in your right hand to inspect the client’s left nostril and your
left hand to inspect the client’s right nostril.
▪ Tip the client’s head back.
▪ Facing the client, insert the tip of the closed speculum (blades together) about 1
cm or up to the point at which the blade widens. Care must be taken to avoid
pressure on the sensitive nasal septum.
▪ Stabilize the speculum with your index finger against the side of the nose. Use the
other hand to position the head and then to hold the light.
▪ Open the speculum as much as possible and inspect the floor of the nose
(vestibule), the anterior portion of the septum, the middle meatus, and the middle
turbinates. The posterior turbinate is rarely visualized because of its position.
▪ Inspect the lining of the nares and the integrity and the position of the nasal
septum.
10. Observe for the presence of redness, swelling, growths, and discharge.
Normal Findings:
Mucosa pink
Clear, watery discharge
No lesions
Mucosa red, edematous
Abnormal discharge
Presence of lesions
11. Inspect the nasal septum between the nasal chambers.
Normal Findings:
Nasal septum intact and in midline
Septum deviated to the right or to the left
Facial Sinuses
12. Palpate the maxillary and frontal sinuses for tenderness.
Normal Findings:
Not tender
Tenderness is in one or more sinuses
Evaluation
▪ Perform a detailed follow-up examination of other systems based on the findings

that deviated from expected or normal for the client. Relate findings to previous
Mouth and Oropharynx
Anatomic Structure of the mouth
➢ Mouth and orophoranyx are composed of a number of structures: lips, inner and
buccal mucosa, the tongue and floor of the mouth, teeth and gums, hard and soft
palate, uvula, salivary glands, tonsillar pillars, and tonsils
➢ Dental caries and periodontal disease – are the two problems and most frequently
affect the teeth
➢ Plaque – is an invisible soft film that adheres to the enamel surface of the teeth
➢ Tartar – is a visible, hard deposit of plaque and dead bacteria that forms at the
gum lines
➢ Gingivitis – red swollen gingiva
➢ Glossitis – inflammation of the tongue
➢ Stomatitis – inflammation of the oral mucosa
➢ Parotitis – inflammation of the parotid salivary gland
➢ Sordes – the accumulation of foul matter on the teeth and gums
Assessing the Mouth and Oropharynx
Planning
If possible, arrange for the client to sit with the head against a firm surface such as a
headset or examination table. This makes it easier for the client to hold the head still
during the examination.
Equipment
Clean gloves
Tongue depressor
2x2 gauze pads
Penlight
Implementation
Performance
treatments.
4. Inquire if the client has any history of the following: routine pattern of dental care, last
visit to dentist; length of time ulcers or other lesions have been present; denture
discomfort; medications client is receiving
Assessment
Lips and Buccal Mucosa

6. Inspect the outer lips for symmetry of contour, color and texture. Ask the client to
purse the lips as if to whistle.
Normal Findings:
Uniform pink color
Soft, moist, smooth texture
Symmetry of contour
Ability to purse lips
Pallor, cyanosis
Blisters; generalized or localized swelling; fissures, crusts, or scales
Inability to purse lips
7. Inspect and palpate the inner lips and buccal mucosa for color, moisture, texture, and
the presence of lesions.
▪ Apply clean gloves.

▪ Ask the client to relax the mouth, and for better visualization, pull the lip outward
and away from the teeth.
▪ Grasp the lip on each side between the thumb and index finger.
▪ Palpate any lesions for size, tenderness, and consistency.
▪ Inspect the front teeth and gums.
Normal Findings:
Uniform pink color
Moist, smooth, soft, glistening, and elastic texture
Pallor; leukoplakia, red, bleeding
Excessive dryness
Mucosal cysts; irritations from dentures; abrasions, ulcerations; nodules
Teeth and Gums
8. Inspect the teeth and gums while examining the inner lips and buccal mucosa.
▪ Ask the client to open the mouth. Using a tongue depressor, retract the cheek.
View the surface buccal mucosa from top to bottom and back to front. A
flashlight or penlight will help illuminate the surface. Repeat the procedure for the
other side.
▪ Ask the client to open the mouth again. Using a penlight to assist visualization,
move a finger along the inside cheek. Another finger may be moved outside the
cheek.
▪ Examine the back teeth for the proper vision of the molars, use the index fingers
of both hands to retract the cheek. Ask the client to relax the lips and first close,
then open, the jaw.
▪ Inspect the gums around the molars. Observe for bleeding, color, retraction,
edema, and lesions.
▪ Assess the texture of the gums by gently pressing the gum tissue with a tongue
depressor.
Normal Findings:
32 adult teeth
Smooth, white, shiny tooth enamel
Pink gums, moist, firm texture to gums
No retraction of gums
Missing teeth; ill-fitting dentures
Brown or black discoloration of the enamel
Excessively red gums
Spongy texture; bleeding; tenderness
Receding, atrophied gums; swelling that partially covers the teeth
Tongue/ Floor of the Mouth
10. Inspect the surface of the tongue for position, color, and texture. Ask the client to
protrude the tongue.
Normal Findings:
Central position
Pink color; moist; slightly rough; thin whitish coating
Smooth, lateral margins; no lesions
Raise papillae
Deviated from center; excessive trembling
Smooth red tongue
Dry, furry tongue, white coating
Nodes, ulcerations, discolorations; areas of tenderness
11. Inspect tongue movement. Ask the client to roll the tongue upward and move it from
side to side.
Normal Findings:
moves freely; no tenderness
Restricted mobility
12. Inspect the base of the tongue, the mouth floor, and the frenulum. Ask the client to
place the tip of the tongue against the roof of the mouth.
Normal Findings:
Smooth tongue base with prominent veins
Swelling, ulceration
13. Palpate the tongue and floor of the mouth for any nodules, lumps, or excoriated areas.
To palpate the tongue, use a piece of gauze to grasp its tip, and with the index finger of
your other hand, palpate the back of the tongue, its borders, and its base.
Normal Findings:
Smooth with no palpable nodules
Swelling, nodules
Salivary Glands
14. Inspect the salivary duct openings for any swelling or redness.
Normal Findings:
Same as color of buccal mucosa and floor of mouth
Inflammation
Palates and Uvula
15. Inspect the hard and soft palate for color, shape, texture, and the presence of bony
prominences. Ask the client to open the mouth wide and tilt the head backward. Then,
depress tongue with a tongue depressor as necessary, and use a penlight for appropriate
visualization.
Normal Findings:
Light pink, smooth, soft palate
Lighter pink hard palate, more irregular texture
Discoloration
Palates the same color
Irritations
Exostoses growing from the hard palate
16. Inspect the uvula for position and mobility while examining the palates. To observe
the uvula, ask the client to say “ah” so that the soft palate rises.
Normal Findings:
Positioned in midline of soft palate
Deviation to one side from tumor or trauma; immobility
Oropharynx and Tonsils
17. Inspect the oropharynx for color and texture. Inspect one side at a time to avoid
eliciting the gag reflex. To expose one side of the oropharynx, press a tongue depressor
against the tongue on the same side about halfway back while the client tilts the head
back and opens the mouth wide.
Normal Findings:
Pink and smooth posterior wall
Reddened or edematous; presence of lesions, plaques, or drainage
18. Inspect the tosils for color, discharge, and size.

Normal Findings:
Pink and smooth
No discharge
Of normal size or not visible
▪ Grade 1 (normal): The tonsils are behind the tonsillar pillars
Inflamed
Presence of discharge
Swollen
▪ Grade 2: The tonsils are between the pillars and the uvula
▪ Grade 3: The tonsils touch the uvula
▪ Grade 4: One or both tonsils extend to the midline of the oropharynx
19. Elicit the gag reflex by pressing the posterior tongue with a tongue depressor.
Normal Findings:
Present
Absent – may indicate problems with glossopharyngeal or vagus nerves
Evaluation
▪ Perform a detailed follow-up examination of neurological and other systems

based on findings that deviated from expected or normal for the client. Relate
findings to previous assessment data if available.
The Neck
Major muscles of the Neck

Structures of the Neck
Lymph Nodes of the Neck
➢ Examination of the neck includes the muscles, lymph nodes, trachea, thyroid
gland, carotid arteries, and jugular veins
➢ Areas of the neck are defined by the sternocleidomastoid muscles, which divide
each side of the neck into two triangles: the anterior and posterior.
➢ The trachea, thyroid gland, anterior cervical nodes, and carotid artery lie within the
anterior triangle; the carotid artery runs parallel and anterior to the
sternocleidomastoid muscle. The posterior lymph nodes lie within the posterior
triangle.
➢ Each sternocleidomastoid muscle extends from the upper sternum and the medial
third of the clavicle to the mastoid process of the temporal bone behind the ear.
➢ Each trapezius muscle extends from the occipital bone of the skull to the lateral
third of the clavicle.
➢ Lymph nodes in the neck that collect lymph from the head and neck structures are
grouped serially and referred to as chains.
Assessing the Neck
Equipment
None
Implementation
Performance
care or treatments.
procedures.
4. Inquire if the client has any history of the following: problems with neck lumps; neck
pain or stiffness; when and how any lumps occurred; previous diagnoses of thyroid
problems; and other treatments provided.
Assessment
Neck Muscles
5. Inspect the neck muscles for abnormal swelling or masses. Ask the client to hold the
head erect.
Normal Findings:
Muscle equal in size; head centered
Unilateral neck swelling; head tilted to one side
6. Observe head movement. Ask client to:
▪ Move the chin to the chest.

▪ Move the head back so that the chin points upward.
▪ Move the head so that the ear is moved toward the shoulder on each side.
▪ Turn the head to the right and to the left.
Normal Findings:
Coordinated, smooth movements with no discomfort
Head flexes 45˚
Head hyperextends 60˚
Head laterally flexes 40˚
Head laterally rotates 70˚
Muscle tremor, spasm, or stiffness
Limited range of motion; painful movements; involuntary movements
Head hyperextends less than 60˚
Head laterally flexes less than 40˚
Head laterally rotates less than 70˚
7. Assess muscle strength
▪ Ask the client to turn the head to one side against the resistance of your hands.
Repeat with the other side.
▪ Ask the client to shrug the soulders against the resistance of your hands.
Normal Findings:
Equal strength
Equal strength
Unequal strength
Unequal strength
Lymph Nodes
8. Palpate the entire neck for enlarged lymph nodes.
▪ Face the client and bend the client’s head forward slightly or toward the side
being examined.
▪ Palpate the nodes using the pads of the fingers.
▪ When examining the submental and submandibular nodes, place the fingertips
under the mandible on the side nearest the palpating hand, and pull the skin and
subcutaneous tissue laterally over the mandibular surface.
▪ When palpating the supraclavicular nodes, have the client bend the head forward
to relax the tissues of the anterior neck and to relax the shoulders so that the
clavicles drop.
▪ When palpating the anterior cervical nodes and posterior cervical nodes, move
your fingertips slowly in a forward circular motion against the
sternocleidomastoid and trapezius muscles, repectively.
▪ To palpate the cervical nodes bend or hook your fingers around the
sternocleidomastoid muscle
Normal Findings:
Not palpable
Enlarged, palpable, possibly tender
Trachea
9. Palpate the trachea for lateral deviation
Normal Findings:
Central placement in midline of neck; spaces are equal on both sides

Deviation to one side, indicating possible neck tumor; thyroid enlargement;
enlarged lymph nodes
Thyroid Gland
10. Inspect the thyroid gland.
▪ Stand in front of the client.

▪ Observe the lower half of the neck overlying the thyroid gland for symmetry and
visible masses.
▪ Ask the client to extend the head swallow.
Normal Findings:
Not visible on inspection
Gland ascends during swallowing but is not visible
Visible diffuseness or local enlargement
Gland is not fully movable with swallowing
11. Palpate the thyroid gland for smoothness.

Stand in front of or behind the client, and ask the client to lower the chin slightly.
Posterior Approach
▪ Place you hand around the client’s neck, with your fingertips on the lower half of
the neck over the trachea.
▪ Ask the client to swallow, and feel for any enlargement of isthmus as it rises.
▪ To examine the right thyroid lobe, have the client lower the chin slightly and turn
the head slightly to the right. With your left fingers, displace the trachea slightly
to the right. With your right fingers, palpate the right thyroid lobe. Have the client
swallow while you are palpating.
▪ Repeat the last step, in reverse, to examine the left thyroid lobe.
Anterior Approach
▪ Place the tips of your index and middle fingers over the trachea, and palpate the
thyroid isthmus as the client swallows.
▪ To examine the right thyroid lobe, have the client lower the chin slightly and turn
the head slightly to the right. With your right fingers, displace the trachea slightly
to the client’s right (your left). With your left fingers, palpate the right thyroid
lobe.
▪ To examine the left thyroid lobe, repeat the above step in reverse.
Normal Findings:
Lobes may not be palpated
If palpated, lobes are small, smooth, centrally located, painless, and rise freely
with swallowing
Solitary nodules
12. If enlargement of the gland is suspected, auscultate over the thyroid area for a bruit.
Normal Findings: Absence of Bruit

Deviations from Normal: Presence of Bruit
Evaluation
▪ Perform a detailed follow-up examination of other systems based on findings that

deviated from expected or normal for the client. Relate findings to previous
The Thorax and Lungs
Chest Landmarks
Chest wall landmarks: A) anterior chest; B) lateral chest; C) posterior chest.

➢ Midsternal line
➢ Midclavicular lines
➢ Posterior axillary line
➢ Midaxillary line
➢ Vertebral line
➢ Scapular lines
Chest landmarks: A) anterior chest landmarks and underlying lungs; B) posterior chest
landmarks and underlying lungs; C) lateral chest landmarks and underlying lungs
➢ Upper and lower lobes

➢ RUL
➢ RLL
➢ LUL
➢ LLL
➢ RML
➢ Angle of Louis – starting point for locating the ribs

➢ Sternum – junction between the body
➢ Manubrium – handlelike superior part of the sternum
Location of the anterior ribs, the Angle of Louis, and the sternum
Chest Shape and Size
Chest deformities: A) pigeon chest; B) funnel chest; C) barrel chest; D) kyphosis; E)

scoliosis
➢ Adults – thorax is oval

➢ Pigeon chest – permanent deformity
➢ Funnel chest – congenital defect
➢ Barrel chest – ration of the anteroposterior to transverse diameter is 1 to 1
➢ Kyphosis – excessive convex curvature of the thoracic spine
➢ Emphysema chronic pulmonary condition
Breath Sounds
➢ Adventitious breath sounds – abnormal breath sounds

➢ Normal Breath Sounds
- Vesicular – “gently sighing” (bronchioles and alveoli)
- Broncho-vesicular – “blowing” (bronchi)
- Bronchial (tubular) – “harsh”
➢ Adventitious breath sounds
- Crackles (rales) – Fine, short, interrupted crackling sounds
- Gurgles (rhonchi) – Continuous, low-pitched, coarse, gurgling, harsh, louder
sounds with a moaning or snoring quality
- Friction rub – Superficial grating or creaking sounds
- Wheeze – Continuous, hig-pitched, squeaky musical sounds
Planning
For efficiency, the nurse usually examines the posterior chest first, then the anterior chest.
Equipment
Stethoscope
Skin marker/pencil
Centimeter ruler
Implementation
Performance
care or treatments.
procedures.
4. Inquire if the client has any history of the following: family history of illness,
including cancer, allergies, tuberculosis; lifestyle habits such as smoking and
occupational hazards; medications being taken; current problems
Assessment
Posterior thorax
5. Inspect the shape and symmetry of thorax from posterior and lateral views. Compare
the anteroposterior diameter to the transverse diameter.
Normal Findings:
Anteroposterior to transverse dimater in ratio 1:2
Chest symmetric

Barrel chest; increased anteroposterior to transverse diameter
Chest asymmetric
6. Inspect the spinal alignment for deformities. Have the client stand. From a lateral
position, observe the three normal curvatures: cervical, thoracic, and lumbar
▪ To assess for lateral deviation of spine (scoliosis) \, observe the standing client
from the rear. Have the client bend forward at the waist and observe from behind.
Normal Findings:
Spinal column is straight, right and left shoulders and hips are at the same height
Spinal column deviates to one side, often accentuated when bending over.
Shoulders or hips not even
7. Palpate the posterior thorax.
▪ For clients who have no respiratory complaints, rapidly assess the temperature
and integrity of all chest skin.
▪ For clients who do have respiratory complaints, palpate all chest areas for bulges,
tenderness, or abnormal movements.
Normal Findings:
Skin intact; uniform temperature
Chest wall intact; no tenderness; no masses
Skin lesions; areas of hyperthermia
Lumps, bulges; depressions; areas of tenderness; movable structures
8. Palpate the posterior chest for respiratory excursion. Place the palms of both your
hands over the lower thorax with your thumbs adjacent to the spine and your fingers
stretched laterally.
Ask the client to take a deep breath while you observe the movement of your hands and
any lag in movement.
Normal Findings:
Full and symmetric chest expansion
Asymmetric and/or decreased chest expansion
9. Palpate the chest for vocal fremitus, the faintly perceptible vibration felt through the
chest wall when the client speaks.
▪ Place the palmar surfaces of your fingertips or the ulnar aspect of your hand or
closed fist on the posterior chest, starting near the apex of the lungs.
▪ Ask the client to repeat such words as “blue moon” or “one, two, three”.
▪ Repeat the two steps, moving your hands sequentially to the base of the lungs,
through positions B-E.
▪ Compare the fremitus on both lungs and between the apex and the base of each
lung.
Normal Findings:
Bilateral symmetry of vocal fremitus
Fremitus is heard most clearly at the apex of the lungs
Low-pitched voices of males are more readily palpated than higher pitched voices
of females
Decreased or absent fremitus
Increased fremitus
10. Percuss the thorax.

▪ Ask the client to bend the head and fold the arms forward across the chest.
▪ Percuss in the intercostals spaces at about 5 cm intervals in a systematic sequence.
▪ Compare one side of the lung with the other.
▪ Percuss the lateral thorax every few inches, starting at the axilla and working
down to the eighth rib.
Normal Findings:
Percussion notes resonate, except over scapula
Lowest point of resonance is at the diaphragm
Asymmetry in percussion
Areas of dullness or flatness over lung tissue
11. Percuss for diaphragmatic excursion.
▪ Ask the client to take a deep breath and hold it while you percuss downward
along the scapular line until dullness is produced at the level of diaphragm. Mark
this point with a marking pencil, and repeat the procedure on the other side of the
chest.
▪ Ask the client to take few normal breaths and then expel the last breath
completely and hold it while you percuss upward from the marked point to assess
and mark the diaphragmatic excursion during deep expiration on each side.
▪ Measure the distance between the two marks.
Normal Findings:
Excursion is 3 to 5 cm bilaterally in women and 5 to 6 cm in men
Diaphragm is usually slightly higher on the right side
Restricted excursion
12. Auscultate the chest using the flat-disc diaphragm of the stethoscope.
▪ Use the systematic zigzag procedure used in percussion.
▪ Ask the client to take the slow, deep breaths through the mouth. Listen at each
point to breath sounds during a complete inspiration and expiration.
▪ Compare findings at each point with the corresponding point on the opposite side
of the chest.
Normal Findings:
Vesicular and bronchovesicular breath sounds
Adventitious breath sounds
Absence of breath sounds
13. Inspect breathing patterns.
Normal Findings:
Quiet, rhythmic, and effortless respirations
Abnormal breathing patterns and sounds
14. Inspect the costal angle and the angle of which the ribs enter the spine.
Normal Findings:
Costal angle is less than 90˚, and the ribs insert into the spine at approximately
45˚ angle
Costal angle is widened
15. Palpate the anterior chest.
16. Palpate the anterior chest for respiratory excursion.

▪ Place the palms of both your hands on the lower thorax, with your fingers
laterally along the lower rib cage and your thumbs along the costal margins.
▪ Ask the client to take a deep breath while you observe the movement of your
hands.
Normal Findings:
Full symmetric excursion; thumbs normally separate 3 to 5 cm
Asymmetric and/or decreased respiratory excursion
17. Palpate tactile fremitus in the same manner as for the posterior chest and using the
sequence shown.
If the breasts are large and cannot be retracted adequately for palpation, this part of
the examination is usually omitted.
Normal Findings:
Same as posterior vocal fremitus; fremitus is normally decreased over heart and
breast tissue
Same as posterior fremitus
18. Percuss the anterior chest systematically.
▪ Begin above the clavicles in the supraclavicular space, and proceed downward to
the diaphragm.
▪ Compare one side of the lung to the other.
▪ Displace female breasts for proper examination.
Normal Findings:
Percussion notes resonate down to the sixth rib at the level of the diaphragm but
are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver,
and tympanic over the underlying stomach
Asymmetry in percussion notes
Areas of dullness or flatness over lung tissue
19. Auscultate the trachea.
Normal Findings:
Bronchial and tubular breath sounds
20. Auscultate the anterior chest. Use the sequence used in percussion, beginning over the
bronchi between the sternum and the clavicles.
Normal Findings:
Bronchovesicular and vesicular breath sounds
Evaluation
Relate findings to previous assessment data if available. Report significant deviations

from normal to the primary care provider.
The Cardiovascular and Peripheral Vascular Systems
Heart
Anatomic sites of the pericordium

➢ Assess the heart through inspection, palpation, and auscultation
➢ The heart is usually assessed during an initial physical assessment
➢ Precordium – are of the chest overlying the heart
➢ S1 – first heart sound
- Dull, low pitched, and longer than S2; sounds like “lub”
➢ S2 – described as “dub”
- Has a higher pitch in S1and is shorter in duration
➢ Systole – period in which the ventricles contract
- Begins with S1 and ends at S2
➢ Diastole – period in which the ventricles relax
- Starts with S2 and ends at the subsequent S1
➢ S3 and S4
➢ S3 – occurs early in diastole right after S2
- sounds like “lub-dub-ee” (S1, S2, S3) or “Kentuc-ky”
➢ S4 – occurs near the very end of diastole just before S1
- created the sound of “dee-lud-dub” (S4, S1, S2) or “Ten-nessee”
Central Vessels
Arteries and veins of the right side of the Neck
➢ The carotid arteries supply oxygenated blood to the head and neck
➢ The carotid is also auscultated for bruit
➢ Bruit – a blowing or swishing sound
➢ If a bruit is found, the carotid artery is then palpated for a thrill
➢ Thrill – vibrating sensation like the purring of the cat or water running through a
nose
Planning
Heart examinations are usually performed while the client is in a semi-reclined position.
The practitioner stand at the client’s right side, where palpation of the cardiac area is
facilitated and optimal inspection allowed.
Equipment
Stethoscope
Centimeter ruler
Implementation
Performance
care or treatments.
procedures.
4. Inquire if the client has any history of the following: family history of incidence and
age of heart disease, high cholesterol levels, high blood pressure, stroke, obesity,
congenital heart disease, arterial disease, hypertension, and rheumatic fever; client’s past
history of rheumatic fever, heart murmur, heart attack, varicosities, or heart failure;
present symptoms indicative of heart disease
Assessment
Simultaneously inspect and palpate the precordium for the presence of abnormal
pulsations, lifts, or heaves. Locate the valve areas of the heart:
▪ Locate the Angle of Louis.

▪ Move your fingertips down each side of the angle until you can feel the second
intercostals spaces.
▪ From the pulmonic area, move your fingertips down three left intercostals spaces
along the side of the sternum.
▪ From the tricuspid area, move your fingertips laterally 5 to 7 cm to the left
midclavicular line.
▪ Inspect and palpate the aortic and pulmonic areas, observing them at an angle and
to the side, to note the presence or absence of pulsations.
▪ Inspect and palpate the tricuspid area for pulsations and heaves or lifts.
▪ Inspect and palpate the apical area for pulsation, noting its location and diameter.
▪ Inspect and palpate the epigastric are at the base of the sternum for abdominal
aortic pulsations.
Normal Findings:
(aortic and pulmonic areas) – No pulsations
(tricuspid area) – No pulsations
No lift or heave
(apical area) – Pulsations visible in 50% of adults and palpable in most PMI in
fifth LICS at or medical to MCL
Diameter of 1 to 2 cm
No lift or heave
(epigastric area) – Aortic pulsations
(aortic and pulmonic areas) – Pulsations
(tricuspid area) – Pulsations
Diffuse lift or heave, indicating enlarged or overactive right
ventricle
(apical area) – PMI displaced laterally or lower
Diameter over 2 cm
Diffuse lift or heave lateral to apex
(epigastric area) – Bounding abdominal pulsations
6. Auscultate the heart in all for anatomic sites: aortic, pulmonic, tricuspid, and apical
(mitral).
▪ Eliminate all sources of room nose.

▪ Keep the client in a supine position with head elevated 30˚ to 45˚.
▪ Use both the diaphragm and the bell to listen to all areas.
▪ In every area of auscultation, distinguish both S1 and S2 sounds.
▪ When auscultating, concentrate on one particular sound at a time in each area.
▪ Later, reexamine the heart while the client is in the upright sitting position.
Normal Findings:
S1: Usually heard at all sites
Usually louder at apical area
S2: Usually heard at all sites
Usually louder at base of heart
Systole: silent interval; slightly shorter duration than diastole at normal heart rate
Diastole: silent interval; slightly longer duration than systole at normal heart rates
S3 in children and young adults
S4 in many older adults
Increased or decreased intensity
Varying intensity with different beats
Increased intensity at aortic area
Increased intensity at pulmonic area
Sharp-sounding ejection clicks
S3 in older adults
S4 may be a sign of hypertension
Carotid Arteries
7. Palpate the carotid artery, using extreme caution.
▪ Palpate one carotid artery at a time.

▪ Avoid exerting too much pressure and massaging the area.
▪ Ask the client to turn the head slightly toward the side being examined.
Normal Findings:
Symmetric pulse volumes
Full pulsations, thrusting quality
Quality remains same when client breathes, turns head, and changes from sitting
to supine position
Elastic arterial wall
Asymmetric volumes
Decreased pulsations
Increased pulsations
Thickening, hard, rigid, beaded, inelastic walls
8. Auscultate the carotid artery.
▪ Turn the client’s head slightly away from the side being examined.
▪ Auscultate the carotid artery on one side and then the other.
▪ Listen for the presence of a bruit. If you hear a bruit, gently palpate the artery to
determine the presence of a thrill.
Normal Findings:
No sound heard on auscultation
Presence of bruit in one or both arteries
Jugular Veins
9. Inspect the jugular veins for distention while the client is placed in a semi-Fowler’s
position, with the head supported on a small pillow.
Normal Findings:
Veins not visible
Veins visibly distended
10. If jugular distention is present, assess the jugular venous pressure (JVP).
▪ Locate the highest visible point of distention of the internal jugular vein.
▪ Measure the vertical height of this point in centimeters from the sterna angle, the
point at which the clavicles meet.
▪ Repeat the preceding steps on the other side.

Bilateral measurements above 3 to 4 cm are considered elevated
Unilateral distention
Evaluation
▪ Perform a detailed follow-up examination based on findings that deviated from

expected or normal for the client. Relate findings to previous assessment data if
available.
Peripheral Vascular System
➢ Measuring the blood pressure, palpating peripheral pulses, and inspecting the skin
and tissues to determine perfusion to the extremities
➢ Perfusion – blood supply to an area
Equipment
None
Implementation
Performance
care or treatments.
procedures.
4. Inquire if the client has any history of the following: past history of heart disorders,
varicosities, arterial disease, and hypertension; lifestyle habits such as exercise patterns,
activity patterns and tolerance, smoking, and use of alcohol.
Assessment
Peripheral Pulses
5. Palpate the peripheral pulses on both sides of the client’s body individually,
simultaneously, and systematically to determine the symmetry of pulse volume.
Normal Findings:
Symmetric pulse volumes
Full pulsations
Asymmetric volumes
Absence of pulsation
Decreased, weak, thread pulsations
Increased pulse volume
Peripheral Veins
6. Inspect the peripheral veins in the arms and legs for the presence and/or appearance of
superficial veins when limbs are dependent and when limbs are elevated.
Normal Findings:
In dependent position, presence of distention and nodular bulges at calves
When limbs elevated, veins collapse
Distended veins in the thigh and/or lower leg or on posterolateral part of calf from
knee to ankle
7. Assess the peripheral leg veins for signs of phlebitis.
▪ Inspect the calves for redness and swelling over vein sites.
▪ Palpate the calves for firmness or tension of the muscles, the presence of edema
over the dorsum of the foot, and areas of localized warmth.
▪ Push the calves from side to side to test for tenderness.
▪ Firmly dorsiflex the client’s foot while supporting the entire leg in extension, or
have the person stand or walk.
Normal Findings:
Limbs not tender
Symmetric in size
Tenderness on palpation
Pain in calf muscles with forceful dorsiflexion of the foot
Warmth and redness over vein
Swelling of one calf or leg
Peripheral Perfusion
8. Inspect the skin of the hands and feet for color, temperature, edema, and skin changes.
Normal Findings:
Skin color pink
Skin temperature not excessively warm or cold
No edema
Skin texture resilient and moist
Cyanotic
Pallor that increases with limb elevation
Dependent rubor, a dusky red color when limb is lowered
Brown pigmentation around ankles
Skin cool
Marked edema
Mild edema
Skin thin and shiny or thick, waxy, shiny, and fragile, with reduced hair and
ulceration
9. Assess the adequacy of arterial flow if arterial insufficiency is suspended.
Buerger’s Test
(Arterial Adequacy Test)
▪ Assist the client to a supine position. Ask the client to raise one leg or one arm
about 30 cm above heart level, move the foot or hand briskly up and down for
about 1 minute, and then sit up and dangle the leg or arm.
▪ Observe the time elapsed until return of original color and vein filling.
Capillary Refill Test
▪ Squeeze the client’s fingernail and toenail between your fingers sufficiently to
cause blanching.
▪ Release the pressure, and observe how quickly normal color returns. Color
normally returns immediately.
Other Assessments
▪ Inspect the fingernails for changes indicative of circulatory impairment.
Normal Findings:
Buerger’s test: Original color returns in 10 seconds; veins in feet or hands fill in
about 15 seconds
Capillary refill test: Immediate return of color
Delayed color return or mottled appearance; delayed venous filling; marked
redness of arms and legs
Delayed return of color
Evaluation
▪ Perform a detailed follow-up examination of the heart or central vessels,

integument, or other systems based on findings that deviated from expected or
normal for the client. Relate findings to previous assessment data if available.
Examination of the Breast
General Considerations
• The patient must be properly gowned for this examination. All upper body
clothing should be removed.
• Breast tissue changes with age, pregnancy, and menstral status.
• The procedure described here can also be used for self-examination using a
mirror for inspection.
Inspection
1. Give a brief overview of examination to patient.

2. Have the patient sit at end of exam table.
3. Ask the patient to remove gown to her waist, assist only if needed.
4. Have the patient relax arms to her side.
5. Examine visually for following:
* Approximate symmetry
* Dimpling or retraction of skin
* Swelling or discoloration
* Orange peel effect on skin
* Position of nipple
6. Observe the movement of breast tissue during the following maneuvers:
* Shrug shoulders with hands on hips
* Slowly raise arms above head
* Lean forward with hands on knees (large breasts only)
7. Have the patient replace the gown.
8. Reassure the patient, if the exam is normal so far, say so.
Palpation
1. Have the patient lie supine on the exam table.

2. Ask the patient to remove the gown from one breast and place her hand behind her
head on that side.
3. Begin to palpate at junction of clavicle and sternum using the pads of the index,
middle, and ring fingers. If open sores or discharge are visible, wear gloves.
4. Press breast tissue against the chest wall in small circular motions. Use very light
pressure to assess superficial layer, moderate pressure for middle layer and firm pressure
for deep layers.
5. Palpate the breast in overlapping vertical strips. Continue until you have covered the
entire breast including the axillary "tail."
6. Palpate around the areola and the depression under the nipple. Press the nipple gently
between thumb and index finger and make note of any discharge.
7. Lower the patient's arm and palpate for axillary lymph nodes.
8. Have the patient replace the gown and repeat on the other side.
9. Reassure the patient, discuss the results of the exam.
Examination of the Abdomen
Equipment Needed
A Stethoscope
• The patient should have an empty bladder.

• The patient should be lying supine on the exam table and appropriately draped.
• The examination room must be quiet to perform adequate auscultation and
percussion.
• Watch the patient's face for signs of discomfort during the examination.
Use the appropriate terminology to locate your findings:
• Right Upper Quadrant (RUQ)

• Right Lower Quadrant (RLQ)
• Left Upper Quadrant (LUQ)
• Left Lower Quadrant (LLQ)
• Midline:
Epigastric
Periumbilical (pertaining to the area around the umbilicus)
Suprapubic
• Disorders in the chest will often manifest with abdominal symptoms. It is always
wise to examine the chest when evaluating an abdominal complaint.
• Consider the inguinal/rectal(pertaining to the groin.) examination in males.
Consider the pelvic/rectal examination in females.
Inspection
• Look for vascular changes, lesions, rashes,scars,

striae(are irregular areas of skin that look like bands, stripes, or lines. Striae are
seen when a person grows or gains weight rapidly or has certain diseases or
conditions.Striae are commonly called stretch marks.), hernias(A hernia occurs
when part of an internal organ bulges through a weak area of muscle. Most
hernias occur in the abdomen. There are several types of hernias, including:
* Inguinal, the most common type, is in the groin

* Umbilical, around the belly button
* Incisional, through a scar
* Hiatal, a small opening in the diaphragm that allows the upper part of
the stomach to move up into the chest.
* Congenital diaphragmatic, a birth defect that needs surgery),
• Look for movement associated with peristalsis (is a series of wave-like muscle
contractions that moves food to different processing stations in the digestive tract.
The process of peristalsis begins in the esophagus when a bolus of food is
swallowed. The strong wave-like motions of the smooth muscle in the esophagus
carry the food to the stomach, where it is churned into a liquid mixture called
chyme. .) or pulsations.
•Note the abdominal contour (the normal outline or configuration of the body or of a
part.). Is it flat, scaphoid ( one whose anterior wall is hollowed, occurring in children
with cerebral disease.), or protuberant(Swelling outward; bulging Kwashiorkor is a
condition resulting from inadequate protein intake. Early symptoms include fatigue,
irritability, and lethargy. As protein deprivation continues, one sees growth failure,
loss of muscle mass, generalized swelling (edema), and decreased immunity. A large,
protuberant belly is common.
Auscultation
• Place the diaphragm of your stethoscope lightly on the abdomen.

• Listen for bowel sounds. Are they normal, increased, decreased, or absent?
• Listen for bruits (are whooshing sound created due to blockages) over the renal
arteries, iliac arteries, and aorta.
Percussion
• Percuss in all four quadrants using proper technique.
1.Hyperextend the middle finger of one hand and place the distal interphalangeal
joint firmly against the patient's chest.
2.With the end (not the pad) of the opposite middle finger, use a quick flick of the
wrist to strike first finger.
3.Categorize what you hear as normal, dull, or hyperresonant.
4.Practice your technique until you can consistantly produce a "normal"
percussion note on your (presumably normal) partner before you work with patients.
Percussion Notes and Their Meaning
1.Flat or Dull 1.Pleural Effusion or Lobar Pneumonia
2.Normal 2.Healthy Lung or Bronchitis
3.Hyperresonant 3.Emphysema or Pneumothorax
• Categorize what you hear as tympanitic(bell-like; tympanic.) or dull(not resonant

on percussion.). Tympany is normally present over most of the abdomen in the
supine position. Unusual dullness may be a clue to an underlying abdominal
mass(An abdominal mass is any localized enlargement or swelling in the human
abdomen. Depending on its location, the abdominal mass may be caused by an
enlarged liver (hepatomegaly), enlarged spleen (splenomegaly).
Liver Span
• Percuss downward from the chest in the right midclavicular line until you detect
the top edge of liver dullness.
• Percuss upward from the abdomen in the same line until you detect the bottom
edge of liver dullness.
• Measure the liver span between these two points. This measurement should be 6-
12 cm in a normal adult.
Splenic Dullness
• Percuss the lowest costal interspace in the left anterior axillary line. This area is
normally tympanitic.
• Ask the patient to take a deep breath and percuss this area again. Dullness in this
area is a sign of splenic enlargement.
Palpation
General Palpation
• Begin with light palpation. At this point you are mostly looking for areas of
tenderness. The most sensitive indicator of tenderness is the patient's facial
expression (so watch the patient's face, not your hands). Voluntary or involuntary
guarding may also be present.
• Proceed to deep palpation after surveying the abdomen lightly. Try to identify
abdominal masses or areas of deep tenderness.
Palpation of the Liver
Standard Method
• Place your fingers just below the right costal margin and press firmly.
• Ask the patient to take a deep breath.
• You may feel the edge of the liver press against your fingers. Or it may slide
under your hand as the patient exhales. A normal liver is not tender.
Alternate Method
This method is useful when the patient is obese or when the examiner is small compared
to the patient.
• Stand by the patient's chest.

• "Hook" your fingers just below the costal margin and press firmly.
• You may feel the edge of the liver press against your fingers.
Palpation of the Aorta
• Press down deeply in the midline above the umbilicus. ++

• The aortic pulsation is easily felt on most individuals.
• A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic
aneurysm(An abdominal aortic aneurysm is when the large blood vessel that
supplies blood to the abdomen, pelvis, and legs becomes abnormally large or
balloons outward.causes The exact cause is unknown, but risk factors for
developing an aortic aneurysm include:
* Smoking
* High blood pressure
* High cholesterol
* Male gender
*Genetic factors
*Obesity.
Palpation of the Spleen
• Use your left hand to lift the lower rib cage and Flank(flank pain refers to pain in
one side of the body between the upper abdomen and the back.Flank pain often
means kidney trouble. If flank pain is accompanied by fever, chills, blood in the
urine, or frequent or urgent urination, then a kidney problem is the likely cause.).
++
• Press down just below the left costal margin with your right hand.
• The spleen is not normally palpable on most individuals.
Special Test
This is a test for appendicitis.
• Place your hand above the patient's right knee.

• Ask the patient to flex the right hip against resistance.
• Increased abdominal pain indicates a positive psoas sign.
• Obturator Sign
Examination of the Female Pelvis
Equipment Needed
• Exam Table Equipped with Stirrups

• Flexible Light Source
• Vaginal Specula in Various Sizes
• Warm Running Water
• Lubricating Jelly
* The patient must have an empty bladder.

* The patient must be appropriately gowned and draped.
* Use non-sterile gloves on both hands. Double-glove your dominant hand if you
intend to perform a rectal or rectovaginal exam.
* Properly dispose of soiled equipment and supplies.
* Both male and female examiners should be chaperoned by a female assistant.
* Always tell the patient what you are about to do before you do it.
* The breast exam is usually done just before routine pelvic exams.
Positioning the Patient
1. Start with the patient lying supine on the exam table with the head elevated 30 to 45
degrees.
2. Assist the patient to place her heels in the stirrups. Adjust the angle and length to
"fit" the patient.
3. Have the patient slide her hips down until she contacts your hand at the edge of the
table.
4. Have the patient relax her knees outward just beyond the angle of the stirrups.
External Exam
1. Uncover the vulva by moving the center of the drape away from you. Try to avoid
creating a "screen" with the drape pulled tight between the patient's knees.
2. Announce what you are going to do and then touch the patient on the thigh with the
back of your hand before proceeding.
3. Inspect the outer genitalia for redness, swelling, lesions, masses, or infestations.
4. Gently palpate the labia majora and minora.
5. Inspect the labia, the folds between them, and the clitoris.
6. Note any redness, swelling, lesions, or discharge.
Internal Exam
Speculum Exam
1. Warm and lubricate the speculum by holding it under running tap water.
speculum before proceeding.
3. Expose the introitis by spreading the labia from below using the index and middle
fingers of the non-dominant hand (peace sign).
4. Insert the speculum at a 45 degree angle pointing slightly downward. Avoid contact
with the anterior structures.
5. Once past the introitis, rotate the speculum to a horizontal position and continue
insertion until the handle is almost flush with the perineum.
6. Open the "bills" of the speculum 2 or 3 cm using the thumb lever. Position the bills
so that the cervix "falls" in between.
7. Secure the speculum by turning the thumb nut (metal speculum) or clicking the
ratchet mechanism (plastic speculum). Do not move the speculum while it is locked open.
8. Observe the cervix and vaginal walls for lesions or discharge. Obtain specimens for
culture and cytology as indicated.
9. Withdraw the speculum slightly to clear the cervix. Loosen the speculum and allow
the "bills" to fall together. Continue to withdraw while rotating the speculum to 45
degrees. Again, avoid contact with the anterior structures.
10. Replace the drape while you prepare for the rest of the exam.
Bimanual Exam
1. Apply a small amount of lubricant to the index and middle fingers of your dominant
hand.
2. Uncover the vulva and lower abdomen by moving the center of the drape away from
you.
back of your hand before proceeding.
4. Spread the labia and insert your lubricated index and middle fingers into the vagina.
Avoid contact with the anterior structures.
5. Place your other hand on the patient's lower abdomen.
6. Examine the cervix:
1. Palpate the cervix with your index finger noting size, shape, and consistency.
2. Gently move the cervix side to side between your fingers and note mobility and
tenderness.
3. Gently lift the cervix forward and note mobility and tenderness.
7. Examine the anterior uterine fundus:
1. Continue to lift the cervix with the vaginal hand.
2. Press downward with the abdominal hand and palpate the uterus *.
3. Note consistancy and tenderness. Attempt to estimate uterine size.
8. Examine the adnexal structures:
1. Pull back vaginal hand to clear cervix.
2. Reposition vaginal hand into the right fornix, palm up.
3. Sweep the right ovary downward with the abdominal hand 3 or 4 cm medial to
the iliac crest.
4. Gently "trap" the ovary between the fingers of both hands *. Note its size and
shape along with any other palpable adnexal structures.
5. Pull back and repeat on the left side.
9. Replace the drape and assist the patient to remove her feet from the stirrups and sit
up.
10. Reassure the patient, if the exam is normal, say so.
11. Leave the room and allow the patient to dress before continuing with the
consultation.
Examination of the Male Genital
• The patient must have an empty bladder.

• The patient must be appropriately gowned and draped.
• Use non-sterile gloves on both hands.
• Properly dispose of soiled equipment and supplies.
• Always tell the patient what you are about to do before you do it.
Male Genitalia Inspection. Examine as follows:
1.Examine the foreskin by retraction. Check for phimosis(constriction of

the preputial orifice so that the prepuce cannot be retracted over the glans).
2.Look for lesions, chancres(primarily sores associated with syphilis).
3.Examine the glans for ulcers, scars, and inflammation.
4.Check the location of the urethra. A congenital defect that appears in the male
is hypospadias in which the urethra opens on the undersurface of the penis.
Epispadias is a congenital defect that can occur in males and females. In the
male, the urethra opens on the dorsal side of the penis; in the female, there is a
fissure in the upper wall of the urethra
5.Check for discharge from the meatus.
6.Examine the skin around the base of the penis for inflammation, nits, or lice
7.Check the scrotum for swelling and inflammation.
Examination of the Muculoskeletal System
• musculoskeletal system physical examination - also known as or related to

orthopedic examination, gals locomotor screen, orthopaedic exam. - general,
orthopaedic examination, assessing the locomotor system, locomotor examination
Body Posture
• Observe the patient in the standing position for postural abnormalities.

• Observe for erect stance and any abnormal curvature: kyphosis(Kyphosis is the
extreme curvature of the upper back also known as a hunchback.), lordosis(An
abnormal forward curvature of the spine in the lumbar region. Also called hollow
back, saddle back.) or scoliosis(Scoliosis is a side-to-side curvature of the spine.).
• Have the patient walk toward and away from you and observe.
Joints
• The patient then sits on the examining table facing the examiner. Each joint is
assessed for tenderness, swelling, erythema, deformity, or asymmetry. Range of
motion, pain with movement, effusion, crepitus, and stability are noted.
Temporomandibular joints
• The temporomandibular joint is examined first, beginning proximally and

working distally. Palpation is done with the mouth closed, then open.
Shoulder joints
• The shoulder joints and contiguous joints are now examined. Observe, palpate,
and assess range of motion of these joints: glenohumeral, acromioclavicular,
sternoclavicular, and costochondral. Also examine the gliding tissue space
between the scapula and thorax, the shoulder capsule or rotator cuff, and the
subacromial bursa. Range of motion is now checked as follows:
*Forward flexion: Normal is parallel to floor.
*Arms over head pressed against the ears: Normal is 180 degrees
*Shoulder adduction: Normal is 90 degrees.
*External rotation: Touch back of neck.
*Internal rotation: Touch back pocket of opposite side
• Proximal musculature is evaluated for strength with the patient abducting both
shoulders parallel to the floor and resisting the examiner's downward pressure.
Elbows
• Examine the depth of the grooves; obliteration is a sign of synovial disease. Look
for subcutaneous nodules just distal to the elbow joint. Evaluate range of motion:
extension of zero degrees, flexion 160 degrees. Test the radiohumeral joint by
having the patient fully pronate, then fully supinate, both hands.
Wrists
• The wrists are next Observe and palpate. Ask the patient to press the palms
together and elevate the forearms parallel to the floor.
• Note the skin temperature as you move from the wrist to the hands unless there is
joint inflammation, temperature should decrease. Individually observe, palpate,
and assess range of motion in the major joints, metacarpophalangeal, proximal
interphalangeal, distal interphalangeal. Record grip strength bilaterally.
Cervical Spine
• The patient remains seated for examination of the cervical spine. Observe for
lordosis or kyphosis. Palpate for tenderness. Check flexion by having the patient
place the chin on the chest , and check extension by having the patient look up at
the ceiling as far back as possible.
* Lateral motion: each ear on shoulder.

* Rotation: chin on each shoulder.
• The patient now stands for further evaluation of the spine. Record the normal
curvatures. Palpate over the spinous processes and paravertebral muscles. Check
range of motion:
* Flexion: Keep knees straight while touching floor.

* Lateral: Maintain feet together while bending first to one side
and then the other.
* Rotary: Turn each shoulder as far to side as possible.
Lower Extremities
• The patient now lies down for examination of the lower extremities. The hip is
examined first. Palpation is of value in the greater trochanter area (the bony
prominence at the lateral aspect of the hip region). Tenderness suggests
trochanteric bursitis. Then the following maneuvers are carried out on the hip:
Auscultation
* Abduction: Fix the pelvis by placing your hand on the side not
being tested. Abduct the leg maximally.
* Flexion: Pelvis is fixed as above. Flex the hip with knee bent and
then with the knee straight.
* External rotation: Ask the patient to place the fifth toe on the
table.
* Internal rotation: Normal is 10 to 15 degrees.
* Flexion contracture: Opposite knee is flexed until the lumbar
lordosis has flattened . The hip should be extended fully (flush with
examining table), if there is no contracture.
* Straight leg raising: As knee is fully extended, the leg is raised
and flexed at the hip; this produces stretch on the sciatic nerve. A positive
test is pain in the hip or low back with radiation in the sciatic distribution
suggestive of nerve root irritation. The angle of elevation of the leg from
the table at the point where the pain is produced is recorded .
* Hyperextension: Patient assumes the prone position and is asked
to lift the leg off the table as far as possible without raising the pelvis.
Knee
• The knee examination is next. Inspection is carried out for discoloration, swelling,
and deformities, particularly lateral angulation (genu varum) or medial angulation
(genu valgum). Note any increased skin temperature or swelling and determine if
the swelling is due to synovial proliferation or thickening as opposed to an actual
effusion. Then the following maneuvers are carried out on the knee:
* Flexion: Note the degree of flexion, which should be at least 135

degrees.
* Extension: Note any deficit in ability to fully extend to 0 degrees.
* Ligamentous laxity: Stretch the medial ligament by placing the
palm of the hand on the lateral side of the knee and pulling the leg toward the
lateral side of the ankle. Correspondingly to stretch the lateral side, place
the palm on the medial knee and place the other hand on the
lateral ankle and pull toward the examiner. Note any obvious laxity.
* Cruciates: Test the stability of anterior and posterior cruciates by
holding the femur in a fixed position with the knee flexed at 90 degrees and
attempting to pull and push the tibia forward and backward on the femur.
Correspondingly forward movement indicates a defect in the
anterior cruciate ligament, whereas backward mobility indicates a defect in the
posterior cruciate ligament.
Ankle
• The ankles are examined next. Observe for discoloration and swelling and palpate
for increased tenderness.
* Dorsiflexion: The patient is asked to pull the toes up toward the

knee.
* Plantar flexion: Ask the patient to push the feet down as far as
they can go.
Feet
• Lastly the feet are inspected for abnormal coloration and localized areas of
swelling. Look for obvious abnormalities in the longitudinal arch, including a
falling of the arch, so-called pes planus or flat foot, or an abnormal elevation of
the arch, so-called pes cavus. The first metatarsophalangeal joints are observed
for lateral angulation, so-called hallux valgus. The other toes are examined for
hammer toe or cock-up deformities, and the metatarsal heads are observed on the
plantar surface for formation of callosities over pressure points. Palpate each
phalangeal and each metacarpophalangeal joint
* Flexion: All toes are actively and passively flexed to their

maximum, observing for decreased mobility or evidence of
crepitus.
* Extension: The aforementioned small joints of the toes are
checked for ability to extend fully.
* Eversion and inversion: Eversion and inversion are primarily a
function of the subtalar and tarsal joints, which after checking will
complete the peripheral joint examination (Figure 158.21).
Examination of Neurologic System
Equipment Needed
• Reflex Hammer
• 128 and 512 (or 1024) Hz Tuning Forks
• A Snellen Eye Chart or Pocket Vision Card
• Pen Light or Otoscope
• Wooden Handled Cotton Swabs
• Paper Clips
• Always consider left to right symmetry

• Consider central vs. peripheral deficits
• Organize your thinking into seven categories:
1. Mental Status
2. Cranial Nerves
3. Motor
4. Coordination and Gait
5. Reflexes
6. Sensory
7. Special Tests
Cranial Nerves
Observation
• Ptosis (III)(Ptosis is the term used for a drooping upper eyelid)

• Facial Droop or Asymmetry (VII)
• Hoarse Voice (X)
• Articulation of Words (V, VII, X, XII)
• Abnormal Eye Position (III, IV, VI)
• Abnormal or Asymmetrical Pupils (II, III)
I - Olfactory
• After assessing patency of both nares, have client close eyes, obstruct one nare,
and sniff. Use common, easily identifiable substances such as coffee, toothpaste,
orange, vanilla, soap, or peppermint. Use different substances for each side.
Bilateral decreased sense of smell occurs with age, tobacco smoking, allergic
rhinitis, cocaine use. Unilateral loss of sense of smell (neurologic anosmia) can
indicate a frontal lobe lesion
II - Optic
Test Visual Acuity
1. Allow the patient to use their glasses or contact lens if available. You are
interested in the patient's best corrected vision.
2. Position the patient 20 feet in front of the Snellen eye chart (or hold a
Rosenbaum pocket card at a 14 inch "reading" distance).
3. Have the patient cover one eye at a time with a card.
4. Ask the patient to read progressively smaller letters until they can go no further.
5. Record the smallest line the patient read successfully (20/20, 20/30, etc.)
6. Repeat with the other eye.
Screen Visual Fields by Confrontation
1. Stand two feet in front of the patient and have them look into your eyes.
2. Hold your hands about one foot away from the patient's ears, and wiggle a finger
on one hand.
3. Ask the patient to indicate which side they see the finger move.
4. Repeat two or three times to test both temporal fields.
5. If an abnormality is suspected, test the four quadrants of each eye while asking
the patient to cover the opposite eye with a card.
Test Pupillary Reactions to Light
1. Dim the room lights as necessary.

2. Ask the patient to look into the distance.
3. Shine a bright light obliquely into each pupil in turn.
4. Look for both the direct (same eye) and consensual (other eye) reactions.
5. Record pupil size in mm and any asymmetry or irregularity.
6. If abnormal, proceed with the test for accommodation.
Test Pupillary Reactions to Accommodation
1. Hold your finger about 10cm from the patient's nose.

2. Ask them to alternate looking into the distance and at your finger.
3. Observe the pupillary response in each eye.
III - Oculomotor
(Note: Cranial Nerves III, IV, and VI are examined together because they control eyelid
elevation, eye movement, and pupillary constriction.)
• Observe for Ptosis

• Test Extraocular Movements
1. Stand or sit 3 to 6 feet in front of the patient.
2. Ask the patient to follow your finger with their eyes without moving
their head.
3. Check gaze in the six cardinal directions using a cross or "H" pattern.
4. Pause during upward and lateral gaze to check for nystagmus.
5. Check convergence by moving your finger toward the bridge of the
patient's nose.
IV - Trochlear and VI - Abducens
• Have patient turn eyes downward, temporally, and nasally. If the eyes will not
do this the patient may have a fracture of the eye orbit or a brain stem tumor.
V - Trigeminal
Test Temporal and Masseter Muscle Strength
1. Ask patient to both open their mouth and clench their teeth.
2. Palpate the temporal and massetter muscles as they do this.
Test the Three Divisions for Pain Sensation
1. Explain what you intend to do.

2. Use a suitable sharp object to test the forehead, cheeks, and jaw on both sides. [7]
3. Substitute a blunt object occasionally and ask the patient to report "sharp" or
"dull."
If you find and abnormality then:
1. Test the three divisions for temperature sensation with a tuning fork heated or
cooled by water. ++
2. Test the three divisions for sensation to light touch using a wisp of cotton. ++
Test the Corneal Reflex
1. Ask the patient to look up and away.

2. From the other side, touch the cornea lightly with a fine wisp of cotton.
3. Look for the normal blink reaction of both eyes.
4. Repeat on the other side.
5. Use of contact lens may decrease this response.
VII – Facial
• Observe for Any Facial Droop or Asymmetry

• Ask Patient to do the following, note any lag, weakness, or assymetry:
1. Raise eyebrows
2. Close both eyes to resistance
3. Smile
4. Frown
5. Show teeth
6. Puff out cheeks
VIII - Acoustic
• Screen Hearing
1. Face the patient and hold out your arms with your fingers near each ear.
2. Rub your fingers together on one side while moving the fingers noiselessly on the
other.
3. Ask the patient to tell you when and on which side they hear the rubbing.
4. Increase intensity as needed and note any assymetry.
5. If abnormal, proceed with the Weber and Rinne tests.
• Test for Lateralization
1. Use a 512 Hz or 1024 Hz tuning fork.
2. Start the fork vibrating by tapping it on your opposite hand.
3. Place the base of the tuning fork firmly on top of the patient's head.
4. Ask the patient where the sound appears to be coming from (normally in the
midline).
• Compare Air and Bone Conduction.
1. Use a 512 Hz or 1024 Hz tuning fork.
2. Start the fork vibrating by tapping it on your opposite hand.
3. Place the base of the tuning fork against the mastoid bone behind the ear.
4. When the patient no longer hears the sound, hold the end of the fork near the
patient's ear (air conduction is normally greater than bone conduction).
IX - Glossopharyngeal and X - Vagus
Listen to the patient's voice, is it hoarse or nasal?

Ask Patient to Swallow
Ask Patient to Say "Ah"
o Watch the movements of the soft palate and the pharynx.
Test Gag Reflex (Unconscious/Uncooperative Patient) ++
1. Stimulate the back of the throat on each side.
2. It is normal to gag after each stimulus.
XI - Accessory
• From behind, look for atrophy or assymetry of the trapezius muscles.

• Ask patient to shrug shoulders against resistance.
• Ask patient to turn their head against resistance. Watch and palpate the
sternomastoid muscle on the opposite side.
XII - Hypoglossal
Motor
Assess tongue control.
Wasting of the tongue, deviation to one side, tremors, and an inability to distinctly say
l,t,d,n sounds can indicate a lower or upper motor neuron lesion.
Reflex Testing
When you strike a slightly stretched tendon with a reflex hammer, a simple muscle
contraction occurs. What kind of information do deep tendon reflexes (DTRs) give the
examiner? DTRs assist with evaluation of lower motor neurons and fibers. For example,
if the patient’s biceps reflex is normal, you know that the lower motor neurons and fibers
at levels C5 and C6 are intact.
There are five reflexes to check which include:
• Biceps: With the patient sitting, flex his arm at the elbow and rest his forearm on
his thigh with the palm up. Place your thumb firmly on the biceps tendon in the
antecubital fossa. Strike your thumb with the hammer. The elbow and forearm
should flex, and the biceps muscle should contract.
• Triceps: The triceps tendon is tested with the patient’s arm flexed at a 90° angle.
Supporting the arm with your hand, strike the triceps tendon on the posterior arm
just above the elbow. The tendon should contract and the elbow extend.
• Brachioradialis: Have the patient rest his slightly flexed arm on his lap with the
palm facing downward. Strike the posterior arm about two inches above the wrist
on the thumb side. The forearm should rotate laterally and the palm turn upward.
• Patellar: Dangle the patient’s legs over the side of the bed. Place your hand on the
patient’s thigh and strike the distal patellar tendon just below the kneecap. (If the
patient must remain supine, flex each leg to a 45° angle and place your dominant
hand behind his knee to support it.) The normal response is contraction of the
quadriceps muscle with extension of the knee.
• Achilles: Have the patient dorsiflex (point downward) his foot slightly and lightly
tap the Achilles’s tendon on the posterior ankle area. A slight jerking of the foot
should be seen.
To assess deep tendon reflexes:
* Encourage the patient to relax the arm or leg being tested.

* Position the arm or leg so the appropriate tendon is slightly stretched.
* Hold the reflex hammer lightly and swing it freely in an arc.
* Strike the tendon with a brisk downward stroke, then lift up on the hammer
immediately. When learning to perform DTRs, many people either tap too lightly or they
strike firmly but leave the hammer on the tendon which reduces the response.
* Be sure to compare responses from one side to the other.
* Grade the reflexes in the following manner:
4+; Hyperactive; Often pathologic; may be associated with disease of the cerebral cortex,
brain stem, and spinal cord. 3+; Brisker than normal; Not necessarily pathologic. 2+;
Normal 1+; Diminished; May be normal 0; Absent; Pathologic; associated with both
upper and lower motor neuron disease or injury.
A patient with multiple sclerosis might have hyperactive reflexes, while areflexia
(absence of reflexes) can appear in Guillain-Barr? syndrome. Depressed or hyperactive
reflexes can also signal an electrolyte imbalance.
Motor System Assessment
Assessment of the motor system includes evaluation of bilateral muscle strength and
coordination and balance tests. Be sure to assess bilaterally and compare findings.
Muscle Strength
Examine the arm and leg muscles looking for atrophy and abnormal movements such as
tremors. For a quick check of muscle tone, perform passive range of motion exercises and
note any resistance. Next, instruct the patient to bend the forearm up at the elbow
(flexion) while you hold the patient’s wrist exerting a slight downward pressure. This
tests the strength of the biceps. Then test the triceps by having the patient extend his arm
while you push against his wrist. Hand grasps should also be assessed. Ensure that the
patient follows instructions to release the hand when assessing grip strength. In some
cases, gripping the examiner’s hands is almost reflex while being able to release the hand
grasp on command is more important.
Assess upper leg muscle strength of a bed patient by having him flex his hip and knee so
that the knee is about 8 inches off the bed. Tell the patient to maintain this position while
you attempt to push down against the thigh. Standing at the foot of the bed, test lower leg
and foot muscle strength by having the patient push his foot against your hand, then have
him pull it up against your hand.
Coordination and Balance Tests
Coordination can be checked by having the patient close the eyes and touch the finger to
the nose. Coordination can also be assessed by having the patient perform rapid
alternating movements (RAMs). The patient is instructed to pat his upper thigh with the
same side hand, alternately patting with the palm and the back of the hand as quickly as
possible. Repeat with both hands. These tests will help you evaluate coordination and
detect intentional tremors.
If your patient is confined to bed, you won’t be able to test his balance. However, if he
can stand beside the bed, you can perform the Romberg test for balance. With the feet
together and arms to the sides as if standing at attention, have the patient maintain this
position for about 30 seconds with the eyes open then another 30 seconds with his eyes
closed. Stay close to the patient in case he starts to fall. It is normal to see minimal
swaying. In some illnesses, vision compensates for a sensory loss. If the patient has a
cerebellar disease, he may be able to maintain his balance with the eyes open, but not
with them closed.
Sensory System Assessment
Follow these steps when testing the patient’s sensory system:
o Instruct the patient to keep his eyes closed during all the tests. o Compare one side with
the other, noting whether sensory perception is bilateral. o If you detect an area of
increase or decreased sensation, mark it with a water-soluble marker and note which
peripheral nerves carry sensation to the area.
The assessment of the sensory system includes the evaluation of Cranial Nerve V, the
trigeminal nerve (see facial evaluation). You will also be testing the patient’s ability to
detect superficial pain. If the pain sensation is present, you do not have to test for
temperature. To test for pain, have the patient close his eyes and let you know when you
are touching a sterile needle to his skin. Lightly touch the proximal and distal aspects of
the arms and legs with the needle.
Age Related Changes of the Neurological System
Decreased sensitivity to outside stimuli slows response time. Older people may not
realize the air temperature is too cold or too warm. Vision is affected by aging as the lens
of the eye begins to stiffen and lose water, compromising its ability to change shape for
focus. Pupils become smaller, decreasing the amount of light reaching the retina, so an
older person may find it hard to see in dim light. Hearing decreases because of natural or
mechanical means. By the time a person reaches age 80, brain weight may be as much as
10% less than it was, blood flow to the brain decreases, and brain metabolism slows.
SUPPORTING PSYCHOLOGICAL HEALTH PATTERNS
A. Self-concept and Role Relationship
1.Definition of Terms:
1.1 self-concept
• Mental image or picture of self(“how I see myself”)
• “Collection of notions, feelings, and beliefs about ourselves with which we
identify and through which we relate and communicate with others and interact
with the environment”
• During the stages of development, self-concept is formed in 6-7 years of age
• Has been referred to as the cognitive component of the self-system
1.2 self-esteem
• “Confidence in one’s abilities and judgment”
• “how I feel about myself”
1.3 role
• Set of expectations about how the person occupying one position behaves toward
a person occupying another position
2. Importance of a Healthy Self-concept

• Individuals with a positive self-concept or high self-esteem are better able to
develop and maintain warm interpersonal relationships and resist psychologic and
physical illness.
• A healthy self-concept enables a person to find happiness in life and to cope with
life’s disappointments and changes.
3. Effect of Self-concept in an Individual

• People with a positive self-concept usually have a greater and more diversified
self-knowledge,(including basic facts, person’s position within social groups and
qualities or traits)more realistic perceptions and expectations and higher self-
esteem, whereas those with negative self-concept tend to exhibit poorer self-
knowledge, less realistic perceptions and expectations and lower self-esteem.
4. Concept of Self and Self-concept

• Global and Specific self-concept
global self -collective beliefs and images one holds about oneself; perceived self
as a whole
specific self –how much one approves of a certain part of oneself
ideal self –constitutes the self one wants to be
real self –constitutes on what we think we really are
Three positions of self-concept:
1.Cognized self, or self as known to the individual (“how I perceive me”)
2.Other self, or social self (“how I perceive others perceiving me”)
3.Ideal self(“how I would like to be)
According to Goldin, people base their self-concept on how they perceive and
evaluate themselves in these areas:
• Vocational performance
• Intellectual functioning
• Personal appearance and physical attractiveness
• Sexual attractiveness and performance
• Being liked by others
• Ability to cope with and resolve problems
• Independence
• Particular talents
5. Components of Self-concept
There are four components of self-concept: body image, role performance,
personal identity and self-esteem
Body image
• The image of physical self or body image is how a person perceives the size,
appearance and functioning of the body and its parts
• Body image is “how one views oneself physically and one’s view of one’s
appearance”
Role Performance
• Relates what a person does in a particular role in relation to the behaviors
expected of that role
Personal Identity (self identity)

• Conscious sense of individuality and uniqueness that is continually evolving
throughout life
• People often view their identity in terms of name, sex, age, race, ethnic origin or
culture, occupation or roles, talents and other situational characteristics(eg.
marital status and education)
Self-esteem
• Constitutes on how we feel about ourselves
• There are two types of self-esteem: global and specific. Global self-esteem is how
much one likes one perceived self as a whole. Specific self-esteem is how much
one approves of a certain part of oneself.
PROTECTION, SAFETY AND COMFORT NEEDS
A. Overview of Body Mechanics
What Are Body Mechanics?
"Body mechanics" is a two-word phrase used to describe the movements we make each
day during normal activities, including lying in bed, sitting, standing, lifting, pulling,
pushing and walking. Body mechanics can be both good and bad and can have direct
effects on back pain. Good body mechanics will help remedy and prevent future back
problems, while bad body mechanics contribute to back problems and other muscle and
bone problems.
Standing Posture
1. Good body mechanics for standing include wearing shoes that provide support
both for the back and for the arches of the feet. Feet should be placed flat on the
floor and kept approximately one foot apart. For great body mechanics, keep your
back straight. Avoid standing or walking for very long periods and on uneven
surfaces.
Sitting Posture
2. Sit in chairs with straight backs, when possible, and use a pillow or rolled-up
blanket or towel for lower back support. Avoid sitting for long periods and take
breaks to move around. Keep objects you need within easy reach to avoid
slouching and inappropriate positions of your back and spine. Elevate your legs to
keep from getting tired, and use seating that allows you to sit comfortably with
both feet flat on the floor.
Moving Posture
3. Different postures are recommended for good body mechanics for pushing,
pulling and carrying objects. Carry objects close to the body and lift with your
legs, keeping your back straight. Never carry objects that are too heavy for you
and place strain on your back. When pushing or pulling, use the full weight of
your body and remember to keep your back as straight as possible.
Lying Posture
4. Body mechanics also affect your back when you are lying in bed. When lying on
your side, put a pillow between your knees to keep your spine straightened and
prevent strain to your back. When lying on your back, use a pillow under your
knees to keep your body aligned and prevent your spine from curving during
sleep.
Practice
5. Practicing good posture and good body mechanics will take a while to get used to.
A physical therapist can help you use good body mechanics. If a physical
therapist is unavailable, try using a yardstick to keep your back straight as you go
about normal daily activities. Keeping the back straightened will be painful until
you get used to it, because more muscles are utilized in standing or sitting upright
than when slouching.
What are the Principles of Body Mechanics?
Eating right, exercising and seeing your doctor are all part of staying fit. Good health is a
lifelong endeavor that pays dividends as we age. Understanding the mechanics of how
your body works best will enhance your efforts. Utilizing proper body mechanics is
essential not only for exercise but also for the sitting, standing and walking we do every
day.
The Human Spine
The human spine is made of vertebrae, small bones that connect to each other and to
tendons, ligaments and muscles. The spine is the basis for good body alignment and is
very strong. The spine and our core muscles are the most important elements of good
body mechanics--proper alignment, good balance and stability.
Core Muscles
Core muscles are the very large muscles that cross the abdomen, hi and lower back. Core
strength development is necessary for good stability, another important principle of body
mechanics. By engaging core muscles in movement or work, we increase what we can
do. Lifting a weight with your arm may work, but positioning your arm to also engage
core musculature takes the load off the small muscles of the arm and transfers it to the
much larger muscles of the core.
Stability
Something that is stable remains in place. Muscle stability can be very subtle. Try
standing on one foot. Notice that the muscles in that foot are constantly making tiny shifts
to keep you balanced. You can use body mechanics for stability and balance by making
small changes to your stance. Place one foot slightly in front of the other for a wider
support base. Bend your knees a little to lower your center of gravity. Both of these
adjustments will make you more stable and comfortable while standing.
Alignment
Proper alignment is central to good body mechanics. The human spine has a natural s-
shaped curve. Maintaining that curve reduces muscle tension and fatigue. Keep your back
straight and your head up with your chin tucked slightly back. Pull your abdomen and
your buttocks both inward, toward your center. Imagine a soldier standing at ease and
you have the picture of proper alignment. Now, move one foot slightly ahead of the other
for stability, and you have excellent body mechanics.
Lifting
The most important application of body mechanics is when we lift something. This is the
time to engage those core muscles to reduce strain elsewhere. If you lift something from
the floor, don't bend over to pick it up, instead, bend at the knees and hips, keeping your
back straight. Pull the object as close to you as possible, toward your center of gravity for
balance and stability.
Elements of Body Mechanics
Stable center of gravity
1. For good body mechanics, it is important to maintain a low center of gravity. To

achieve this, one should keep the back straight and the body should be bent only
at the knees and the hips. A lower center of gravity implies more stability. Also, if
you slightly bend the knees, then the center of gravity is lowered leading to an
increased stability. It is important to develop the strength of the core muscles for
good stability.
Wide Support Base
2. It is important to maintain a wide support base. A wide support base is useful

especially when lifting things. For example, if you try to stand on one foot, the
muscle in the foot continually deflects to maintain the balance. It is here that body
mechanics are applied. If you try to maintain an outstretched support base then
you would be able to balance. A strong core muscle helps to keep the body
upright and to improve the balance of the body. The core muscles are those
muscles in the abdomen, back, pelvic floor, and the hips. Weak core muscles
could certainly lead to knee injuries, back aches, and pulled shoulders.
Line of Gravity
3. It is also critical to ensure that the line of gravity should go vertically through the
support base. To accomplish this, the back should be kept straight and the object
to be lifted should be placed close to the body. When you lift something from the
floor, instead of bending over and picking it up, bend at the knees and the hip and
ensure that the back is straight before lifting. This ensures a proper alignment.
Body Alignment
4. One of the most important elements of body mechanics is body alignment. The
spine is the foundation for a proper body alignment. The spine consists of bones
and vertebrae that connect with each other and with other ligaments and muscles
and it has an S-shaped curve. To maintain the proper body alignment, it is
important to maintain that curve. This reduces muscle tension and gives more
stability. If all of these principles are met, good body mechanics can be achieved.
Uses of Body Mechanics
Body mechanics refers to specific and non-specific ways you use your body to move.
Using proper body mechanics helps prevent injury or further injury to your back. Posture
is an important part of body mechanics. Another is posture in motion (the way we throw
a ball or lift an object). When the spine is in a resting or neutral position, according to
spineuniverse.com, it is considered good posture. Poor posture can lead to neck and back
injuries, but with the awareness of common mistakes, proper ways of moving and simple
exercises, you can make better use of body mechanics.
Lifting and Reaching
1. When you are about to lift, bend at the knees and hips while keeping your back
straight. Using one smooth motion, lift straight upward. For reaching high objects,
use a stool or ladder, and for objects that need to be moved, decide if it is too
large or heavy before making the effort.
Pivoting and Stooping
2. When you need to pivot your feet around, place one foot slightly ahead of the
other and turn both feet at the same time. One foot will have the weight on its heel
while the other will have the weight on its toe. If you're holding or carrying
something, maintain a good center of gravity by keeping it low and keeping your
back straight. Bend at the knees and hips. Instead of stooping, which is the same
as bending at the waist, squat and use your leg muscles to return to an upright
position.
Considerations and Prevention
3. Rather than lifting an object, try rolling, pushing or pulling it. Use less of your
back muscles and more of the arm and leg muscles. Keep the work close to your
body and at a comfortable height. Maintain good overall health to lessen your
chances of injury. By considering these suggestions for proper body mechanics,
you'll prevent muscle and skeletal injuries and excessive fatigue.
Importance of Proper Body Mechanics
The body is one multi-functioning unit, compromised of the kinetic chain. The kinetic
chain is the combination of the nervous, muscular and skeletal systems. All systems must
work together to produce movement. Muscles function in three planes of motion: sagittal,
frontal and transverse. During movement they shorten, stabilize and lengthen. There must
be proper alignment in order to have proper movement.
Significance
1. Proper biomechanics is needed to function normally in everyday life. Proper

biomechanics is needed to sit, stand, lift and bend. Athletes need proper
biomechanics to be in top form and perform at their best.
Identification
2. When suffering from chronic back or knee pain of unknown origin, find a
professional who can assess your condition and examine your posture. Often pain
and inflammation are caused by imbalances in the kinetic chain and faulty
postural alignment. Physical therapists, personal trainers, orthopedic doctors and
coaches can help assess your situation.
Benefits
3. The benefits of proper body mechanics include less chance of injuries, less back
pain, better functioning in everyday life and better athletic performance.
Prevention/Solution
4. The spine is subjected to abnormal stresses when there's a lack of proper body
mechanics. This can cause repetitive-use injuries and lead to degeneration of
spinal structures such as discs and joints.
Imbalances in the kinetic chain can lead to changes in balance and neuromuscular
efficiency. Kinetic chain imbalances include altered force-couple relationships
and length-tension relationships. The length-tension relationship is the length at
which a muscle produces the most force. A force-couple relationship is muscles
producing movement around joints. All must be working properly in order for
movement to occur efficiently.
Good posture leads to proper body mechanics. The spine should be in a "neutral"
position, which means not rounded and not arched. By practicing good posture,
the kinetic chain will align, and movement will be more efficient.
What Are Body Mechanics Guideline for Good Posture?
Proper posture is important when standing, sitting or lying down. It will lead to improved
neuromuscular efficiency and functional strength. Certain precautions can be taken to
ensure proper posture.
Significance
1. Good posture allows for correct functioning of the neuromuscular system and an
optimal level of functional strength. It also alleviates pain in the neck, back and
shoulders, reduces compression in ligaments and allows for improved work
capacity of the internal organs.
Proper posture - Standing
2. Maintain a straight spine without slouching forward, keeping your head centered
over your shoulders, with your chin up. Your feet should be shoulder-width apart,
with a slight bend in the knees.
Proper posture - Sitting
3. When sitting, keep your spine neutral with your knees bent, back straight and
head centered with the shoulders, the same as if you were standing. Avoid
slouching--it will stretch spinal ligaments and lead to pain in the neck and back.
Proper posture - Lying
4. Avoid long periods of lying on your stomach. When lying on your side, have a
pillow in between your legs to reduce lumbar and pelvic torsion.
Pathological Influences on Body Mechanics
The main factors which determine the maintenance of the abdominal viscera in
position are the diaphragm and the abdominal muscles, both of which are relaxed and
cease to support in faulty posture. The disturbances of circulation resulting from a low
diaphragm and sagging, may give rise to chronic passive congestion in one or all of the
organs of the abdomen and pelvis, since the local, as well as general venous drainage,
may be impeded by the failure of the diaphragmatic pump to do its full work in the
drooped body. Furthermore, the drag of these congested organs on their nerve supply, as
well as the pressure on the sympathetic ganglia and plexuses, probably causes many
irregularities in their function, varying from partial paralysis to overstimulation. All these
organs receive fibers from both the vagus and sympathetic systems, either one of which
may be disturbed. It is probable that one or all of these factors are active at various times
in both the stocky and the slender anatomic types, and are responsible for many
functional digestive disturbances. These disturbances, if continued long enough, may lead
to diseases later in life. Faulty body mechanics in early life, then, becomes a vital factor
in the production of the vicious cycle of chronic diseases and presents a chief point of
attack in its prevention ... In this upright position, as one becomes older, the tendency is
for the abdomen to relax and sag more and more, allowing a ptosic condition of the
abdominal and pelvic organs unless the supporting lower abdominal muscles are taught to
contract properly. As the abdomen relaxes, there is a great tendency towards a drooped
chest, with narrow rib angle, forward shoulders, prominent shoulder blades, a forward
position of the head, and probably pronated feet. When the human machine is out of
balance, physiological function cannot be perfect; muscles and ligaments are in an
abnormal state of tension and strain. A well-poised body means a machine working
perfectly, with the least amount of muscular effort, and therefore better health and
strength for daily life.
Misalignment of the pelvis, spine and extremities remains one of the frontiers of
medicine ... the associated biomechanical changes - especially the shift in weight-bearing
and asymmetries of muscle tension, strength, joint ranges of motion − affect soft tissues,
joints and organ systems throughout the body and therefore, have implications for general
practice and most medical sub-specialty areas.
Typical visceral problems that have been attributed to pelvic floor dysfunction include:
• Incontinence of bowel and bladder attributed to a lax floor.

• Constipation and incomplete voiding when there is excessive tension.
• Dysmenorrhea, dyspareunia, impotence and sexual dysfunction.
• Recurrent cystitis and urinary tract infection."
Gravitational force is constant and a greatly underestimated systemic stressor. Of

the many signature manifestations of gravitational strain pathophysiology, the most
prominent are altered postural alignment and recurrent somatic dysfunction. Recognizing
GSP facilitates the selection of new and different therapeutic approaches for familiar
problems. The precise approach selected for each patient, and its predicted outcome, are
strongly influenced by the ratio of functional disturbance to structural change.
Posture is distribution of body mass in relation to gravity over a base of support.

The efficiency with which weight is distributed over the base of support depends on the
levels of energy needed to maintain equilibrium or homeostasis, as well as on the status
of the musculo-ligamentous structures of the body. These factors − weight distribution,
energy availability and musculo-ligamentous condition − interact with the multiple
adaptations and compensations which take place below the base of the skull, all of which
can influence the visual and balance functions of the body.
Over time, adaptational changes are likely to progress from the production of
dysfunction to the evolution of actual pathological changes. These examples show how
structural and functional features strongly influence each other, and how other factors,
ranging from age to available energy, musculo-ligamentous status and gravity, all help
determine the changes that evolve.
B. Mobility Immobility
1. Mobility and Immobility
What is Mobility and Immobility?
MOBILITY - the ability to move freely, easily, rhythmically, and purposely in the
environment.
IMMOBILITY – a reduction in the amount and control of movement a person has.
FACTORS AFFECTING MOBILITY
• Growth and Development

- From ages 1 to 5 years, both gross and fine motor skills are refined. For example,
preschoolers master riding bicycles, dancing, running, and jumping. Immobility
can impair the social and motor development of young children.
- From 6 to 12 years, refinement of motor skills continues and exercise patterns for
later life are generally determined.
- In adolescence, growth spurts and behaviors such as carrying heavy book bag on
one shoulder and extended computer use may result in postural changes that often
persist into adulthood.
- Adults between 20 and 40 years of age generally have few physical changes
affecting mobility, with the exception of pregnant women. Pregnancy alters center
of gravity and affects balance.
- As age advances, muscle tone and bone density decrease joints lose flexibility,
reaction times slows, and bone mass decreases, particularly in women who have
osteoporosis.
- All of these changes affect older adults’ posture, gait, and balance.
• Nutrition
- Both undernutrition and overnutrition can influence body alignment and mobility.
- Poorly nourished people may have muscle weakness and fatigue.
- Vitamin D deficiency causes bone deformity during growth. Inadequate calcium
intake and vitamin D synthesis and intake increase the risk of osteoporosis.
• Personal Values and Attitudes
• External Factors
- Excessively high temperatures and high humidity discourage activity, whereas

comfortable temperature and low humidity are conducive to activity.
- The availability of recreational facilities also influences activity.
• Prescribed Limitations
- Limitations to movement may be medically prescribed for some health problems.

- To promote healing, devices such as casts, braces, splints, and traction are often
used to immobilize body parts.
- In any case, the effects of limiting activity are immediate and negative. For
example, with complete bed rest involving the limiting of all exercises, muscle
strength atrophies at approximately 3 % per day.
REASON FOR CLIENT MOBILITY
- People must move to protect themselves from trauma and to meet their basic
needs.
- Mobility is vital to independence; a fully immobilized person is as vulnerable and
dependent as an infant.
- Mental well-being and the effectiveness of body functioning depend largely on
their mobility status.
- Motion is essential for proper functioning of bones and muscles.
- The ability to move without pain also influences self-esteem and body image. For
most people, self-esteem depends on a sense of independence and the feeling of
usefulness or being needed. Body image can be altered by paralysis, amputations,
or any motor impairment. The reaction of others to impaired mobility can also
alter self-esteem and body image significantly.
DEGREES OF IMMOBILITY
- Unconscious client is often completely immobile.

- The client with a fractured leg is only partially immobile.
- Some clients restrict activity for health reasons.
Nurses use the term bed rest to describe a client’s degree of immobility.
• “Complete bed rest”- the client never moves from the bed and does not go to the
bathroom or sit in a chair
• “Bed rest”- in contrast, the client stays in bed except when using a bedside
commode or going to the bathroom.
PHYSIOLOGICAL RESPONSES TO IMMOBILTY
MUSCULOSKELETAL MOVEMENT
• Disuse Osteoporosis
Without the stress of weight-bearing activity, the bones demineralize. The bones
become spongy and may gradually deform and fracture easily.
• Disuse Atrophy
Unused muscles atrophy (decrease in size), losing most of their strength and
normal function.
• Contractures
When the muscle fibers are not able to shorten and lengthen, eventually a
contracture (permanent shortening of the muscles) forms, limiting joint mobility.
• Stiffness and pain in the joints

Without movement, the collagen (connective) tissues at the joint become
ankylosed (permanently immobile). In addition, as the bones demineralize, excess
calcium may deposit in the joints, contributing to stiffness and pain.
CARDIOVASCULAR SYSTEM
• Diminished cardiac reserve

The immobilized person may experience tachycardia with even minimal exertion.
• Increased use of Valsalva maneuver

The valsalva maneuver refers to holding the breath and straining against a closed
glottis.
• Orthostatic (postural) hypotension

Orthostatic hypotension is a common result of immobilization. When the
immobile person attempts to sit or stand, this reconstricting mechanism fails to function
properly in spite of increased adrenalin output. The blood pools in the lower extremities,
and central blood pressure drops. The cerebral perfusion is seriously compromised, and
the person feels dizzy or light-headed or may even faint. This sequence is usually
accompanied by a sudden and marked increase in heart rate, the body’s effort to protect
the brain from an inadequate blood supply.
• Venous dilation and stasis

In an immobile person, the skeletal muscles do not contract sufficiently, and the
muscles atrophy. The skeletal muscle can no longer assist in pumping blood back to the
heart against gravity. Blood pools in the leg veins, causing vasodilation and engorgement.
The valves in the veins can no longer work effectively to prevent backward flow of blood
and pooling. This phenomenon is known as incompetent valves. As the blood continues
to pool in the veins, its greater volume increases venous blood pressure, which can
become higher than that exerted by the tissues surrounding the vessel.
• Dependent edema
When the venous pressure is sufficiently great, some of the serous part of the
blood is forced out of the blood vessel into the interstitial spaces surrounding the blood
vessel, causing edema. Edema is most common in parts of the body positioned below the
heart. Dependent edema is most likely to occur around the sacrum or heels of a client
who sits up in the bed or on the feet and lower legs of a client who sits in a chair. Edema
further impedes venous return of blood to the heart, causing more pooling and more
edema.
• Thrombus formation
Three factors collectively predispose a client to the formation of a
thrombophlebitis (a clot that is loosely attached to an inflamed vein wall): impaired
venous return to the heart, hypercoagulability of the blood (sometimes caused by
medications such as oral contraceptives), and injury to a vessel wall.
RESPIRATORY SYSTEM
• Decreased respiratory movement

In a recumbent, immobile patient, ventilation of the lungs is passively altered. The
body presses against the rigid bed and curtails chest movement. The abdominal organs
push against the diaphragm, restricting lung movement and making it difficult to expand
the lungs fully.
• Pooling of the respiratory secretions

Inactivity allows secretions to pool by gravity, interfering with the normal
diffusion of oxygen and carbon dioxide in the alveoli.
• Atelectasis
When ventilation is decreased, pooled secretions may accumulate in a dependent
area of a bronchiole and effectively block it. Because of changes in regional blood flow,
bed rest decreases the amount of surfactant (surfactant enables the alveoli open)
produced. The combination of decreased surfactant and blockage of a bronchiole with
mucus can cause atelectasis (the collapse of a lobe or the entire lung) distal to the mucous
blockage.
• Hypostatic pneumonia
Pooled secretions provide excellent media for bacterial growth. Pneumonia
caused by static respiratory secretions can severely impair oxygen-dioxide exchange in
the alveoli and is a fairly common cause of death among weakened, immobile persons,
especially heavy smokers.
METABOLIC SYSTEM
• Decreased metabolic rate

Metabolism refers to the sum of all the physical and chemical processes by which
living substance is formed and maintained and by which energy is made available for use
by the body. In immobile clients, the basal metabolic rate and gastrointestinal motility
and secretions of various digestive glands decrease as the energy requirements of the
body decrease.
• Negative nitrogen balance

Immobility creates a marked imbalance, and the catabolic processes exceed the
anabolic processes.
• Anorexia
Loss of appetite (anorexia) occurs because of the decreased metabolic rate and
the increased catabolism that accompany immobility. Reduced caloric intake is usually a
response to the decreased energy requirements of the inactive person.
• Negative calcium balance

This occurs as a direct result of immobility. Greater amounts of calcium are
extracted from bone than can be replaced. The absence of weight bearing and of stress on
the musculoskeletal structures is the direct cause of the calcium loss from bones.
URINARY SYSTEM
• Urinary stasis
When the person remains in a horizontal position, gravity impedes the emptying
of urine from the kidneys and the urinary bladder. To urinate, the person who is in supine
must push forward, against gravity. The renal pelvis may fill with urine before it is
pushed to ureters. Emptying is not as complete, and urinary stasis (stoppage or slow
down of flow) occurs after a few days of bed rest.
• Renal calculi
In an immobile person in a horizontal position, the renal pelvis filled with
stagnant, alkaline urine is an ideal location for calculi (stones) to form. The stones
usually develop in the renal pelvis and pass through the ureters and into the bladder. As
the stones pass along the long, narrow ureters, they cause extreme pain and bleeding and
can sometimes obstruct the urinary tract.
• Urinary retention
The immobile person may suffer from urinary retention (accumulation of urine
in the bladder), bladder distention, and occasionally urinary incontinence (involuntary
urination). The decreased muscle tone of the urinary bladder inhibits its ability to empty
completely.
• Urinary Infection
Static urine provides an excellent medium fir bacterial growth. The flushing
action of normal, frequent urination is absent, and urinary distention often causes minute
tears in the bladder mucosa, allowing infectious organisms to enter.
GASTROINTESTINAL SYSTEM
Constipation is a frequent problem for immobilized people because of decrease

peristalsis and colon motility. The overall skeletal muscle weakness affects the abdominal
and perineal muscles used in defecation. When the stool is hard, more strength is required
to expel it. The immobile person may lack this strength.
INTEGUMENTARY SYSTEM
• Reduced skin turgor

Shift in the body fluids between the fluid compartments can affect the consistency
and health of the dermis and subcutaneous tissues in independent parts of the body,
eventually causing a gradual loss in skin elasticity.
• Skin breakdown
Immobility impedes circulation and diminishes the supply of nutrients to specific
areas. As a result, skin breakdown and formation of pressure (decubitus) ulcers can occur.
PSYCHONEUROLOGIC SYSTEM
Due to a decline in production of mood-elevating substances such as endorphins,

people experience negative effects on mood when unable to engage in physical activity.
NURSING PROCESS AND IMMOBILITY
• ASSESSING
Assessment relative to a client’s activity and exercise should be routinely
addressed and includes a nursing history and a physical examination of body alignment,
gait, appearance and movement of joints, capabilities and limitations for movement,
muscle mass and strength, activity and tolerance, problems related to immobility, and
physical fitness.
Nursing History
An activity and exercise is usually part of the comprehensive nursing history. If
the client indicates a recent pattern change of difficulties with mobility, a more detailed
history is required. This detailed history should include the specific nature of the
problem, when it first begun, its frequency, its causes if known, how the problem affects
daily living, what the client is doing to cope with the problem, and whether these
methods have been effective.
Physical Examination
This emphasizes body alignment, gait, appearance and movement of joints,
capabilities and limitations for movement, muscle mass and strength, and activity
tolerance.
BODY ALIGNMENT
This includes an inspection of the client while he stands. The purpose of body
alignment assessment is to identify:
1. Normal developmental variations in posture.
2. Posture and learning needs to maintain good posture.
3. Factors contributing to poor posture, such as fatigue or low self-esteem.
4. Muscle weakness or other poor motor impairments.
To assess alignment, the nurse inspects the client from lateral, anterior, and
posterior perspectives. From the anterior and posterior views, the nurse should observe
whether
• The shoulders and hips are level.
• The toes point forward.
• The spine is straight, not curved to either side.
The “slumped” posture is the most common problem that occurs when people stand.
GAIT
The characteristics pattern of person’s gait (walk) is assessed to determine the
client’s mobility and risk for injury due to falling.
Two phases of normal gait:

1. Stance phase
a. The heel of one foot strikes the ground, and
b. Body weight is spread over the ball of that foot while the other
heel pushes off and leaves the ground.
2. Swing phase – The leg from behind moves in front of the body.
The nurse assesses the gait as the client walks into the room or asks the client to
walk a distance of 10 feet down a hallway. The nurse may also assess the pace (the no. of
steps taken per minute), which often slows with age and disability. A normal walking
pace is 70 to 100 steps per minute. The pace of an older person may slow to about 40
steps per minute.
APPERANCE AND MOVEMENT OF JOINTS
This involves inspection, palpation, assessment of range of active motion, and if

active motion is not possible, assessment range of passive motion. The nurse should
assess the following:
• Any joint swelling or redness, which could indicate the presence of an injury or
an inflammation.
• Any deformity, such as a bony enlargement or contracture, and symmetry of
involvement.
• The muscle development associated with each joint and the relative size and
symmetry of the muscles on each side of the body.
• Any reported palpable tenderness.
• Crepitation (palpable or audible crackling or grating sensation produced by joint
motion and frequency experienced in joints that have suffered repeated trauma
over time).
• Increased temperature over the joint.
• Degree of join movement.
Assessment of range of motion should not be unduly fatiguing, and the joint
movements need to be performed smoothly, slowly, and rhythmically. No joint should be
forced.
CAPABILITIES AND LIMITATIONS FOR MOVEMENT
The nurse needs to obtain data that may indicate hindrances or restrictions to the
client’s movement and the need for assistance. The nurse also assesses the amount of
assistance the client requires for the following:
• Moving in the bed.
• Rising from a lying position to a sitting position on the edge of the bed.
• Rising from a chair to a standing position.
• Coordination and balance.
MUSCLE MASS AND STRENGTH

Before the client undertakes a change in position or attempts to ambulate, it is
essential that the nurse assess the client’s strength and ability to move. Providing
appropriate assistance lowers the risk of muscle strain and body injury to both the client
and the nurse.
ACTIVITY TOLERANCE
By determining an appropriate activity level for a patient, the nurse can predict
whether the client has the strength and endurance to participate in activities that require
similar expenditures of energy.
The most useful measures in predicting activity tolerance are heart rate, strength,
and rhythm; respiratory rate, depth, and rhythm; and blood pressure. These data can be
obtained at the following times:
• Before the activity starts (baseline data), while the client is at rest
• During the activity
• Immediately after the activity stops
• Three minutes after the activity has stopped and the client has rested
The activity should be stopped immediately in the event of any physiologic

change indicating the activity is too strenuous or prolonged for the client. These changes
include the following:
• Sudden facial pallor
• Feelings of dizziness or weakness
• Change in level of consciousness
• Heart rate or respiratory rhythm from regular to irregular
• Weakening of the pulse
• Dyspnea, shortness of breath, or chest pain
• Diastolic blood pressure change of 100 mm Hg or more
If, however, the client tolerates the activity well, and if the client’s heart rate
returns to baseline level with 5 minutes after the activity ceases, the activity is considered
safe.
PROBLEMS RELATED TO IMMOBILITY
ASSESSMENT PROBLEM
Musculoskeletal System
Measure arm and leg circumferences Decreased circumference due to decreased muscle mass
Palpate and observe body joints Stiffness or pain in joints
Take goniometric measurements of joint Decreased joint ROM, joint contractures
ROM
Cardiovascular System
Auscultate the heart Increased HR
Measure BP Orthostatic hypotension
Palpate and observe sacrum, legs, and feet Peripheral dependent edema, increased peripheral vein
Palpate peripheral pulse engorgement
Measure calf muscle circumferences Weak peripheral pulse
Observe calf muscle for tenderness, redness, Edema
and swelling Thrombophlebitis
Respiratory System
Observe chest movements Asymmetric chest movements, dyspnea
Auscultate chest Diminished breath sounds, crackles, wheeze, and
increased respiratory rate
Metabolic System
Measure height and weight Weight loss due to muscle atrophy and loss of
Palpate skin subcutaneous fat
Generalized edema due to low blood protein levels
Urinary System
Measure fluid intake and output Dehydration
Inspect urine Cloudy, dark urine; high specific gravity
Palpate urinary bladder Distended urinary bladder due to urinary retention
Gastrointestinal Syatem
Observe stool Hard, dry, small tool
Auscultate bowel sound Decreased bowel sounds due to decreased intestinal
motility
Integumentary System
Inspect skin Break in skin integrity
Psychoneurologic System
Observe behaviors, affect, and cognition Anger, flat effect, crying, confusion, anxiety, decline in
Monitor developmental skills in children cognitive functions, or vegetative signs such as sleep
and appetite disturbances warrant further evaluation
• DIAGNOSING
Mobility problems may be appropriate as the diagnostic label or as the etiology
for other nursing diagnoses. Depending on the data obtained, problems with mobility
often affect other areas of human functioning and indicate other etiology. When problems
associated with prolonged immobility arise, many other diagnoses may be necessary.
E.g. Ineffective Airway Clearance if there is stasis of pulmonary secretions
Risk for Infection if there is stasis of urinary or pulmonary secretions
Risk for Injury if orthostatic hypotension is present
• PLANNING
As part of the planning, the nurse is responsible for identifying those clients who
need assistance with body alignment and determining the degree of assistance they
needed. The nurse should also plan to teach clients applicable skills.
Planning for home care

In preparation for discharge, the nurse needs to determine the client’s actual and
potential health problems, strengths, and resources. A major aspect of discharge planning
involves instructional needs of the client and family.
• IMPLEMENTING
USING BODY MECHANICS

Using good body mechanics reduces energy requirements, fatigue, and risk of
injury for both the client and the nurse.
a. Lifting
b. Pulling and Pushing
c. Pivoting
PREVENTING BACK INJURY
• Avoid lifting anything greater than 51 pounds.

• Become consciously aware of your posture and body mechanics.
• When sitting, keep your knees slightly higher than your hips.
• When standing for a period of time, periodically move legs and hips, and flex
one hip and knee and rest your foot on an object if possible.
• Use a firm mattress and soft pillow that provide good body support at natural
curvatures.
• Exercise regularly to maintain physical condition and regulate weight
• Avoid movements that cause pain or require spinal flexion with straight legs or
spinal rotation.
• When moving an object, spread your feet apart to provide a wide base of support.
• When lifting an object, distribute the weight between large muscles of the legs
and arms, limiting the load to 15 to 25 pounds held at elbow height.
• Wear comfortable low-heeled shoes that provide foot support and reduce the risk
of slipping, stumbling, or turning your ankle
.
POSITIONING CLIENTS
When positioning clients in bed, the nurse can do a number of things to ensure
proper alignment and promote client comfort and safety:
• Make sure the mattress is firm and level yet has enough give to fill in and
support natural body curvatures.
• Ensure that the bed is clean and dry.
• Place support devices in specified areas according to the client’s position.
a. Pillows
b. Mattresses
c. Bed boards
d. Chair beds
e. Foot boot
f. Footboard
• Avoid placing one body part, particularly one with bony prominences, directly
on top of another body part.
• Plan a systematic 12-hour for position changes.
A. Fowler’s position
A semisitting bed position in which the head and trunk are raised 45 to 90
degrees.
a. Low fowler’s or semi-fowler’s position – the head and the trunk are raised 15 to
45 degrees
b. High fowler’s position – the head and the trunk are raised 90 degrees. In this
position, the knees may or may not be flexed.
Fowler’s position is the position of choice for people who have difficulty
breathing and for some people with heart problems. When the client is inn this position,
gravity pulls the diaphragm downward, allowing greater chest expansion and lung
ventilation.
B. Orthopneic position
The client sits either in bed or on the side of the bed with an overbed table across
the lap. This position facilitates respiration by allowing maximum chest expansion. It is
particularly
helpful to clients who have problems exhaling, because they can press the lower part of
the chest against the edge of the overbed table.
C. Dorsal recumbent position
The client’s head and shoulders are slightly elevated on a small pillow. This is
used to provide comfort and to facilitate healing following certain surgeries or
anesthetics.
D. Prone position
The client lies on the abdomen with the head turned to one side. The hips are not
flexed. It is the only bed position that allows full extension of the hip and the knee joints.
It helps to prevent flexion contractures of the hips and the knees thereby counteracting a
problem caused by all other bed positions. It also promotes drainage from the mouth and
is especially useful for unconscious clients or those clients recovering from the surgery of
the mouth or throat.
Disadvantages:
The pull of the gravity on the trunk produces a marked lordosis in most people,
and the neck is rotated laterally to a significant degree. It also causes plantar flexion.
E. Lateral position
The person lies on one side of his body. Flexing the top hip and knee and placing
this leg in front of the body creates wider, triangular base of support and achieves greater
stability. The greater the flexion of the top hip and knee, the greater the stability and
balance in this position. This flexion reduces lordosis and promotes good back alignment.
The lateral position is good for resting and sleeping clients. It helps to relieve
pressure in the sacrum and heel in people who sit for much of the day or who are
confined to bed and rest in Fowler’s or dorsal recumbent position.
F. Sims’ position
The client assumes a posture halfway between the lateral and the prone positions.
This is may be used for unconscious clients because it facilitates drainage from the mouth
and prevents aspiration of fluids. It is also used for paralyzed clients because it reduces
pressure over the sacrum and greater trochanter of the tip.
MOVING AND TURNING CLIENTS IN BED

a. Moving a client up in bed
b. Turning a client to the lateral or prone position in bed
c. Logrolling a client
d. Assisting the client to sit on the side of the bed (Dangling)
TRANSFERRING CLIENTS
Guidelines for transferring a client:
• Plan what to do and how to do it.
• Obtain essential equipment before starting, and check its function.
• Remove obstacles from the area used for the transfer.
• Explain the transfer to the client, including what the client should do.
• Explain the transfer to the nursing personnel who are helping; specify who
will give directions.
• Always support or hold the client rather than the equipment and ensure the
client’s safety and dignity.
• During the transfer, explain step by step what the client should do.
• Make a written plan of the transfer, including the client’s tolerance.
a. Transferring between bed and chair

b. Transferring between bed and stretcher
c. Transferring from bed to chair
USING HYDRAULIC LIFT
Hydraulic lifts, such as Hoyer lift, are an example of assistive equipment to take
the place of manual lifts and transfers. The lift can be used in transferring the client
between the bed and a wheelchair, the bed and the bathtub, and the bed and a stretcher.
Before using the lift, the nurse ensures that it is in working order and that the hooks,
chains, straps, and canvas seat are in good repair.
PROVIDING ROM EXERCISES
When people are ill, they may need to perform ROM exercises until they can
regain their normal activity levels.
a. Active ROM exercises – are isotonic exercises in which the client moves each
joint in the body through its complete range of movement, maximally stretching
all muscle groups within each plane over the joint. These exercise maintain or
increase muscle strength and endurance and to help to maintain cardiorespiratory
function in an immobilized patient. They also prevent deterioration of joint
capsules, ankylosis, and contractures.
b. Passive ROM exercises – another person move each of the client’s joints through
its complete range of movement maximally stretching all muscle groups within
each plane over each joint. This should only be performed if the client is unable to
accomplish the movements actively.
• During active – assistive ROM exercise, the client uses a stronger, opposite arm or
leg to move each of the joints of a limb incapable of active motion.
AMBULATING CLIENTS
Ambulation (the act of walking) is a function that most people take for granted.
• Preambulatory Exercises
Clients who have been in bed for long periods often need a plan of muscle tone
exercises to strengthen the muscles used for walking before attempting to walk.
• Assisting Clients to Ambulate
Clients who have been immobilized for even few days may require assistance
with ambulation. Assistance may mean walking alongside the client while providing
physical support or providing instruction to the client about the use of assistive devices
such as a cane, walker, or crutches.
USING MECHANICAL AIDS FOR WALKING

a. Canes
Two types:
1. Standard Straight-legged Cane – 91 cm (36 inches) long.
2. Quad Cane – has four feet and provides the most support.
b. Walkers
c. Crutches
• EVALUATING
The goals established during the planning phase are evaluated according to
specific desired outcomes, also established in that phase.
If the outcomes are not achieved, the nurse, client, and support person if
appropriate need to explore the reasons before modifying it.
2. Skin Integrity
Etiology of Pressure Ulcers
- due to localized ischemia.

- usually occur over bony prominences.
- two factors that frequently act in conjunction with pressure to produce
pressure ulcers are friction and shearing force.
Pathogenesis of Pressure Ulcers
Tissue is squeezed
by two hard
surfaces
Ischemia
Deprivation of
oxygen and
nutrients in cells
Accumulation of
metabolism waste
products in cells
Necrosis
Categories of Pressure Ulcers
Stage 1: Nonblanchable erythema of intact skin
Stage 2: Partial-thickness skin loss involving epidermis and/or dermis

Ulcer is superficial and presents clinically as an abrasion, blister,
or shallow crater.
Stage 3: Full-thickness skin loss involving damage or necrosis of

subcutaneous tissue that may extend down to, but not through,
underlying fascia.
Ulcer is a deep crater with or without undermining og adjacent
tissue.
Stage 4: Full-thickness skin loss with extensive destruction, tissue necrosis

or damage to muscle, bone, or supporting structures.
Factors affecting Pressure Ulcers
- immobility and inactivity

- fecal and urinary incontinence
- decreased mental status
- diminished sensation
- excessive body heat
- advanced age
- poor lifting techniques
- incorrect positioning
- repeated injections in the same area
- hard support surfaces
- incorrect application of pressure-relieving devices
Nursing Process and Pressure Ulcers
ASSESSMENT
Risk Assessment Tool

- a systematic means to identify clients at high risk for pressure ulcer
development.
- completed when the client is admitted to the hospital.
- repeated 24-48 hours after admission and whenever the client’s condition
changes.
Norton’s Pressure Area Risk Assessment Form

- includes physical condition, mental condition, activity, mobility,
and incontinence.
- scores of 15 or 16 are indicators.
Shannon’s Scoring System to Identify Clients at Risk for Developing Pressure Sores
- includes mental status, continence, mobility, activity, nutrition,
circulation, temperature, medications.
- clients with a score of 16 or less are at significant risk of
developing pressure ulcers.
Waterlow Risk Assessment Card

- includes build, visual skin type, continence, mobility, sex and
age, appetite.
Braden Scale for Predicting Pressure Sore Back
- consists of six subscales; sensory perception, moisture, activity,
mobility, nutrition, friction and shear.
- adult client scoring 16 or below is at risk; geriatric client scoring
17 or 18 is at risk.
ASSESSMENT
Assessing Common Pressure Sites

- Be sure there is good lighting, preferably natural or fluorescent.
- Regulate the environment prior to beginning assessment so that the room is neither
too hot nor too cold.
- Inspect pressure areas for any whitish or reddened spots.
- Inspect pressure areas for abrasions and excoriations.
- Palpate the surface temperature of the skin over the pressure areas.
- Palpate over bony prominences and dependent body areas for the presence of edema,
which feels spongy.
Note the following when a Pressure Ulcer is present:

- Location of the lesion
- Size of lesion in centimeters
- Stage of the ulcer
- Color of the wound bed and location of necrosis
- Condition of the wound margins
- Integrity of surrounding skin
- Clinical signs of infection
- The amount of time the lesion is known to exist
- Any previously used treatment
DIAGNOSING
High-risk for impaired skin integrity - for clients who have skin wounds or at risk
for skin breakdown.
Impaired skin integrity – applies to stage I and II pressure ulcers and to superficial
wounds extending through the epidermis but not through the dermis.
Impaired tissue integrity – applies to stage III and IV pressure ulcers and to
wounds extending into subcutaneous tissue, muscle, or bone.
PLANNING
Outcome Criteria:
- Maintains intact skin tissue
- Demonstrates optimal nutritional intake, as evidenced by ideal body
weight and good skin color and turgor
- Maintains optimal circulation to all body areas
- Verbalizes understanding of
o Risk factors that increase the chance of skin breakdown
o Measures to prevent skin breakdown
- Demonstrates optimal self-care measures to prevent pressure ulcers
IMPLEMENTING
Preventing Pressure Ulcers

o Provide Nutrition
o Maintain skin hygiene
o Avoid skin trauma
o Provide supportive devices
o Client teaching
Treating Pressure Ulcers

o Minimize direct pressure on the sore
o Clean the pressure sore daily
o Clean and dress the sore using surgical asepsis
o Obtain a sample of the drainage for culture and sensitivity to antiseptic agents if
the pressure sore is infected
o Reduce friction
o Reduce shearing force
o Use pressure-relieving devices if the client cannot keep weight off the pressure
sore
o Teach the client to move to relieve pressure
o Encourage ambulation as the client’s condition permits
o Provide ROM exercises as the client’s condition permits
EVALUATING
If outcomes are not achieved, ask yourself the following questions:
o Has the client’s physical condition changed?

o Were risk factors correctly identified?
o Were appropriate lifting devices and techniques used?
o Did the client fail to comply with instructions about moving and turning? Why?
o Were appropriate pressure-relieving devices used, and were they applied
correctly?
o Was the repositioning schedule adhered to?
o Is the client’s diet and fluid intake adequate?
o Were appropriate measures used to control incontinence and protect the client’s
skin?
o If an ulcer is present, was the wound treated appropriately?
o If the client is at home, were support services adequate? Did the support person
have the ability to perform required care?
C. ACTIVITY AND EXERCISE
1. Rehabilitation Concept
• "...the process of helping the psychiatrically disabled person to make the best use
of his/her residual abilities in order to function at an optimum 'level in as normal a
social context as possible." (bennett, 1978).
• The fundamental concept of rehabilitation is that disabled people need skills and
support to function in the living, learning and working environments of their
choice. (anthony, 1977)
• Rehabilitation is not just about discharge from, or keeping people out of, hospital.
This is resettlement.
• It is the process of optimising and maintaining-functioning in various social roles,

a variety of (normal) settings, and various tasks.
Groups involved:
• the old long stay - long -term residents who have grown old in hospital
• the new long stay - people who accumulate in hospital despite efforts to maintain
them outside.
• the new long-term - people with long-standing disabilities who move between
admission wards, day services,
The approach or model used for understanding a person's -problems is critical in:
• assessing 'strengths and difficulties
• determining the priorities amongst problems to be addressed
• determining types of intervention used and how these are organized
• evaluating the effectiveness of interventions
• maintaining constructive and realistic attitudes in patients and staff
THE MUSCULOSKELETAL SYSTEM
The musculoskeletal system is composed of bones, joints, muscles, cartilage, ligaments,

and tendons.
• The skeleton provides a structural framework for the body.
• Bones provides support and protection for vital organs and softer tissues.
• Skeletal muscles and bones work together to make body movement possible.
• Blood cell formation (called hematopoiesis) occurs in bone marrow, and bones
store minerals such as calcium and phosphorus.
The body was designed for motion. Regular exercise contributes to a healthy body;
therefore immobility has a negative effect. A joint that has not been moved sufficiently
can begin to stiffen within 24 hours and will eventually become inflexible. With longer
periods of joint immobility, the tendons and muscles can be affected as well.
Most people move and exercise their joints through the normal activities of daily living.
When any joint cannot be moved in this way, the patient or nurse must move it at regular
intervals to maintain muscle tone and joint mobility.
Range of motion (ROM) exercises are ones in which a nurse or patient move each joint
through as full a range as is possible without causing pain. The effect of both regular
exercise and immobility on major body systems are discussed in this lesson.
• Muscle atrophy. Disuse leads to decreased muscle size, tone, and strength.
• Contracture. Decreased joint movement leads to permanent shortening of muscle

tissue, resistant to stretching. The strong flexor muscles pull tight, causing a
contraction of the extremity or a permanent position of flexion.
• Ankylosis. Consolidation and immobility of a joint in a particular position due to

contracture.
• Osteoporosis. Lack of stress on the bone causes an increase in calcium absorption,

weakening the bone.
TYPES OF BODY MOVEMENT
• Flexion. The state of being bent. The cervical spine is flexed when the chin is
moved toward the chest.
• Extension. The state of being in a straight line. The cervical spine is extended
when the head is held straight.
• Hyperextension. The state of exaggerated extension. The cervical spine is

hyperextended when the person looks overhead, toward the ceiling.
• Abduction. Lateral movement of a body part away from the midline of the body.
The arm is abducted when it is held away from the body.
• Adduction. Lateral movement of a body part toward the midline of the body. The
arm is adducted when it is moved from an outstretched position toward the body.
• Rotation. Turning of a body part around an axis. The head is rotated when moved
from side to side to indicate "no."
• Circumduction. Rotating an extremity in a complete circle. Circumduction is a

combination of abduction, adduction, extension, and flexion. \
• Supination. The palm or sole is rotated in an upward position
• Pronation. The palm or sole is rotated in a downward position.
2. Range of Motion
GUIDELINES FOR RANGE OF MOTION EXERCISES
• Plan when range of motion exercises should be done. Plan whether exercises will
be passive, active-assistive, or active. Involve the patient in planning the program
of exercises and other activities because he/she will be more apt to do the
exercises voluntarily.
• Expect the patient's heart rate and respiratory rate to increase during exercise.
• Range-of-motion exercises should be done at least twice a day. During the bath is
one appropriate time. The warm bath water relaxes the muscles and decreases
spasticity of the joints. Also, during the bath, areas are exposed so that the joints
can be both moved and observed. Another appropriate time might be before
bedtime. The joints of helpless or immobile patients should be exercised once
every eight hours to prevent contracture from occurring.
• Joints are exercised sequentially, starting with the neck and moving down. Put
each joint needing exercise through the range of motion procedure a minimum of
three times, and preferably five times. Avoid overexerting the patient; do not
continue the exercises to the point that the patient develops fatigue. Some
exercises may need to be delayed until the patient's condition improves.
• Start gradually and move slowly using smooth and rhythmic movements
appropriate for the patient's condition.
• Support the extremity when giving passive exercise to the joints of the arm or leg.
• Stretch the muscles and keep the joint flexible.

• Move each joint until there is resistance, but never force a joint to the point of
pain.
• Keep friction at a minimum to avoid injuring the skin.
• Return the joint to its neutral position.
• Use passive exercises as required, however, encourage active exercises when the
patient is able to do so.
CONTRAINDICATIONS TO RANGE OF MOTION EXERCISES
Heart and Respiratory Diseases. Range of motion exercises require energy and tend to
increase circulation. Increasing the level of energy expended or increasing the demand
for circulation is potentially hazardous to patients with heart and respiratory diseases.
Connective Tissue Disorders. Range of motion exercises put stress on the soft tissues of
the joint and on the bony structures. These exercises should not be performed if the joints
are swollen or inflamed or if there has been injury to the musculoskeletal system in the
vicinity of the joint.
3. Ambulation
Ambulation (the act of walking) is a function that most people take for granted. However,
when people are ill they are often confined to bed and are thus nonambulatory. The
longer clients are in bed, the more difficulty they have in walking.
Even 1 or 2 days of bed rest can make a person feel weak, unsteady and shaky when first
getting out of bed. A client who has had surgery, is elderly, or has been immobilized for
longer time will feel more pronounced weakness. The potential problems of immobility
are far less likely to occur when clients become ambulatory as soon as possible. The
nurse can assist clients to prepare for ambulation by helping them become as independent
as possible while in bed. Nurses should encourage clients to perform ADLs (activities of
daily living), maintain good body alignment, and carry out active ROM exercises to the
maximum degree possible yet within the limitations imposed by their illness and recovery
program.
Assisting Clients to Ambulate
Clients who have been immobilized for even a few days require assistance with
ambulation. The amount of assistance will depend on the client’s condition including age,
health status, and length of inactivity. Assistance may mean walking alongside the client
while providing physical support or providing instruction to the client about the use of
assistive devices such as a cane, walker or crutches.
Some clients experience postural (orthostatic) hypotension on assuming a vertical

position from a lying position and may need information about ways to control this
problem. The client may exhibit some or all of the following symptoms: pallor,
diaphoresis, nausea, tachycardia and dizziness. If any of theses are present, the client
should be assisted to a supine position in bed and closely assessed.
Ambulation provides a range of physical and mental benefits to residents, who vary in the
degree of assistance they require. Some residents are able to ambulate by themselves,
some need assistance from CNAs, and some require assistive devices such as gait belts,
canes, and walkers. CNAs should always make the resident’s safety their number one
priority. By this, before you ambulate a resident, you should bear in mind the following:
- The number of staff members required to assist

- The type of assistive device, if one is required
- The distance the resident is to ambulate
- The resident’s normal pulse rate
- Any possible problems you might encounter
- Benefits of ambulation
- It helps strengthen the muscles, especially those of the abdomen and legs
- It helps joint flexibility, especially that of the hips, knees, and ankles
- It stimulates circulation, which helps prevent phlebitis and the development of
stroke-causing clots
- It helps prevent constipation because the movement of the abdominal muscles
stimulates the intestinal tract
- It helps prevent osteoporosis due to the mineral loss from the bones when they
do not bear weight
- It stimulates the appetite
- It helps prevent urinary incontinence and infection—when residents are able
to go to the bathroom on their own, incontinence is reduced
- It relieves pressure on the body and skin, helping to prevent pressure ulcers
- It improves self-esteem and the resident’s feelings of independence
- It improves the resident’s ability to socialize
Lifespan Considerations
Assisting the Client to Ambulate

Elders
Inquire how the client has ambulated previously and modify assistance
accordingly.
Take into account a decrease in speed, strength, resistance to fatigue, reaction
time, and coordination due to a decrease in conduction.
Be cautious when using a transfer belt with belt with a client with osteoporosis.
Too much pressure from belt can increase the risk of vertebral compression
fractures.
If assistive devices, such as walker or cane are used, make sure clients are
supervised in the beginning to learn proper method of using them. Crutches may
be much more difficult for elders due to decreased upper body strength.
Be alert to signs of activity intolerance, especially in elders with cardiac and lungs
problems.
Set small goals and increase slowly to build endurance, strength and flexibility.
Be aware of any risk the elder may have, such as
▪ Effects of medications
▪ Neurological disorders
▪ Environment hazards
▪ Orthostatic hypotension
In elders, the body’s responses return to normal more slowly. For instance, an
increase in heart rate from exercise may stay elevated for hours before returning
to normal.
Home Care Consideration
Assisting the Client to Ambulate

When making a home visit, assess carefully for safety issues for ambulation.
Counsel the client and family about unfastened rugs, slippery floors, and loose
objects on the floors.
Check the surrounding for adequate supports such as railings and grab bars.
Recommend that nonskid strips be placed on outside steps and inside stairs that
are not carpeted.
Using Mechanical aids for Walking

Mechanical aids for ambulation include canes, walkers, and crutches
Cranes
Two types canes are used today: the standard straight-legged cane and the quad
cane, which has four feet and provides the most support. Cane tips should have rubber
caps to improve traction and prevent slipping. The standard cane is 91cm long. The
length should permit the elbow to be slightly flexed. Clients may use either one or two
canes, depending on how much support they acquire.
Walkers
Walkers are mechanical devices for ambulatory clients who need more support
than a cane provides. Walkers come in many different shapes and sizes, with devices
suited to individual needs. The standard type is made of polished aluminum. It has four
legs with rubber tips and plastic hand grips. Many walkers have adjustable legs.
The standard walker needs to be picked up to be used. The client therefore
requires partial strength in hands and wrists, strong elbow extensors, and strong shoulder
depressors. The client also needs the ability to bear at least partial weigh on both legs
Four-wheeled and two wheeled models of walkers (roller walkers) do not need to
be picked up to be moved, but they are less stable than the standard walker is. They are
used by clients who are too weak or unstable to pick up and move the walker with each
step. Some roller walkers have a seat at the back so the client can sit down to rest when
desired.
Crutches
Crutches may have a temporary need for some people and a permanent one for
others. Sometimes clients are discouraged when they attempt crutch walking. Clients
confined to bed are often unaware of weakness that becomes apparent when they try to
stand or walk.
There are several types of crutches. The most frequently used underarm crutch or
axillary crutch with hand bars with hand bars and the Loftstrand crutch, which extends
only to the forearm. On the Loftstrand, the metal cuff around the forearm and the metal
bar stabilize the wrists and thus make walking safer and easier.
Crutch Gaits
The crutch gait is the gait a person assumes on crutches by alternating body
weight on one or both legs and the crutches. Five standard crutch gaits are the four-point
gait, three-point gate, swing-to gait, and swing through gait. The gaits used depend on the
following individual factors: (a) the ability to take steps, (b) the ability to bear weight and
keep balance in a standing position on both legs or only one, and (c) the ability to hold
the body erect.
Crutch Stance (Tripod Position)

Before crutch walking is attempted, the client needs to learn facts about posture
and balance. The proper standing position with crutches is called the tripod (triangle)
position. A tall person requires a wider base support than a short person does. Hips and
knees are extended, the back is straight and the head is held straight and high. There
should be no hunch to the shoulders and thus no weight borne by the axillae. The elbows
are extended sufficiently to allow weight-bearing on the hands. If the client is unsteady,
the nurse places a walking belt around the client’s waist and grasps the belt from above,
not below. A fall can be prevented more effectively if the belt is held from above.
Four-Point alternate Gait

This is the most elementary and safest gait, providing at least three points of
support at all times, but it requires coordination. Client can use it when walking in
crowds because it does not require much space. To use this gait, the client needs to be
able to bear weight on both legs. The nurse asks the client to:
1. Move the right crutch ahead a suitable distance, such as 10 to 15cm (4 to

6inch)
2. Move the left front foot forward, preferably to the level of the left crutch.
3. Move the left crutch forward.
4. Move the right foot forward.
Three-Point Gait
To use this gait, the client must able to bear the entire body weight on the
unaffected leg. The two crutches and unaffected leg bear the weight alternately. The
nurse asks the client to
1. Move both the crutches and the weaker leg forward.
2. Move the stronger leg forward.
Two-Point Alternate Gait

This gait is faster than the four-point gait. It requires more balance because only
two points support the body at one time; it also requires at least partial weight-bearing
foot. In this gait, arm movements with the crutches are similar to the arm movements
during normal walking. The nurse asks the client to
1. Move the left crutch and the right foot forward together.
2. Move the right crutch and the left foot ahead together.
Swing-To Gait
The swing gaits are used by clients with paralysis of the legs and hips. Prolonged
use of these gaits results in atrophy of the unused muscles. The swing-to gait is the easier
of these two gaits. The nurse asks the client to
1. Move both crutches ahead together.
2. Lift body weight by the arms and swing to the crutches.
Swing-Through Gait
This gait requires considerable skill., strength, and coordination. The nurse asks
the client to
1. Move both crutches forward together.
2. Lift Body weight by the arms and swing through and beyond the cruch.
Getting into a Chair

Chairs that have armrests and are secure or braced against a wall are essential for
clients using crutches. For this procedure, the nurse instructs the client to
1. Stand with the back of the unaffected leg centered against the chair. The chair
helps support the client during the next steps.
2. Transfer the crutches to the hand on the affected side and hold crutches by the
hand bars. The client grasps the chair with the hand on the unaffected side.
This allows the client to support the body weight on the arms and the
unaffected leg.
3. Lean forward, flex the knees and hips, lower into the chair
Getting Out of a chair

For this procedure, the nurse instructs the client to
1. Move forward to the edge of the chair and place the unaffected leg slightly
under or at the edge of the chair. This position helps the client stand up from
the chair and achieve balance, since the unaffected leg is supported against the
edge of the chair.
2. Grasp the crutches but the hand bars in the hand on the affected side, and
grasp the arm of the chair by the hand on the unaffected side. The body weight
is placed on the crutches and the hand on the armrest to support the unaffected
leg when the client rises to stand.
3. Push down on the crutches and the chair armrest while elevating body out of
the chair.
4. Assume the tripod position before moving.
Getting up Stairs
For this procedure, the nurse stands behind the client and slightly to the affected
side id needed. The nurse instructs the client to
1. Assume the tripod position at the bottom of the stairs.
2. Transfer the body weight to the crutches and move he unaffected leg onto the
step.
3. Transfer the body weight to the unaffected leg on the step and move the
crutches and affected leg to the step. The affected leg is always supported by
the crutches.
4. Repeat steps 2 and 3 until the client reaches the top of the stairs.
Going Down Stairs

For this procedure, the nurse stands one step below the client on the affected side
is needed. The nurse instructs the client to
1. Assume the tripod position at the top of the stairs.
2. Shift the body weight to the unaffected leg, and move the crutches and
affected leg down onto the next step.
3. Transfer the body weight to the crutches, and move the unaffected leg to that
step. The affected leg is always supported by the crutches
4. Repeat steps 2 and 3 until the client reaches the bottom of the stairs.
Nursing Measures to Promote Activity and Exercise
Exercise or Activity Tolerance

• Physical activity for conditioning body, improving health and maintaining fitness
Assessment of the Mobile and Immobile client

✓ Must assess the patient’s past and present mobility and the potential effects of
immobility
• Health History
• Physical Examination of Mobility
Body alignment
Gait
Joints
Skeletal muscles
Neurovascular Function
Lifting Techniques
✓ Tighten stomach muscles and tuck pelvis.
✓ Bend at the knees.
✓ Keep weight lifted close to the body.
✓ Maintain trunk erect and knees bent.
✓ Avoid twisting.
✓ Maintain a center of gravity.
Positioning Techniques
Fowler’s
✓ HOB elevated, support and align hips and spine
Supine
✓ Back lying, support with pillows, trochanter rolls, splints
Prone
✓ Face down
Lateral
✓ Side lying with proper spine alignment
Sims’
✓ Semi-prone on right or left side with weight placed on ilium, humerus and
clavicle
Transfer Techniques
Immobilized patient
✓ Use of proper body mechanics moves patients safely and protects nurse
from injury
Dependent patient
✓ Assists patient with regaining optimal independence, joint movement
increase
✓ Assess strength, promotes circulation, relieves pressure on skin, improves
respiratory and urinary function
Joint Mobility and Ambulation

Range of joint motion
✓ Active: patient is able to move his or her joints
✓ Passive: nurse moves the patient’s joints
✓ Walking
✓ Canes
✓ Crutches
Interventions to Prevent Disuse

✓ Positioning
✓ Maintaining Joint Mobility: ROM
✓ Muscle Strengthening
✓ Controlling Pain and Discomfort
✓
Interventions to Improve Activity Tolerance
Building Muscle Mass and Strength
✓ Isometric exercises
✓ Isotonic exercises
Mobilizing the Client Progressively
Controlling Pain and Discomfort
D. COMFORT AND PAIN MANAGEMENT
Comforting
Comforting is a characteristic unique to nursing and an essential aspect of caring.

“Making the client as comfortable as possible” has been a frequent nursing action since
the days of Florence Nightingale. Nurses have always provided comfort measures that
provide strength, solace, support, encouragement, hope and assistance.
The Comforting Process
Comforting is a complex process that “include discrete, transitory actions, such as

touching, or broad, longer lasting interventions such as listening” (Morse, 1996, p.6). the
comforting process is a client-led process because it occurs in response to cues presented
by the client. The comforting measures provided, however, are generally nurse controlled
in that nurses select the appropriate comfort measures and adjust them according to the
needs of the client. Comfort is not merely a passive process on the part of the client,
however. Clients are often actively engaged in increasing their personal comfort. In these
instances, nurses support the client’s own attempts to achieve comfort. Thus, the comfort
process, whenever possible, involves the cooperative actions of both clients and nurses.
Comfort
The desired outcome or product of comforting is comfort. The origin of the word
comfort is the Latin word confortare, meaning “to strengthen greatly”. Comfort implies a
renewal, an amplification of power or sense of control, an invigorating influence, a
positive mind-set, and a readiness for action.
Comfort Needs
Kolcaba, identifies comfort needs within four contexts: physical, psychospiritual,

social, and environmental:
· Physical comfort needs relate to bodily sensations and the

physiologic problems associated with the medical diagnosis.
· Psychospiritual comfort needs relate to the internal awareness of

self, including esteem, concept, sexuality, and meaning in one’s life. They
can also include the person’s relationship to a higher order or being.
· Social comfort needs relate to interpersonal, family and social
relationships.
· Environmental comfort needs relate to the external background of

human experience and can include light, noise, ambiance, color,
temperature, and natural versus synthetic elements. They may also include
culturally specific food and language.
Types of Comfort
Three types of comfort described by Kolcaba are relief, ease and transcendence.
Relief from discomfort is the experience of having a specific need met. Relief may be
incomplete, partial or temporary, lasting only a short time until discomfort arises again. It
enables the client to return to former functions or a peaceful death. Ease refers to a state
of calm or peaceful contentment. This state of comfort can exist without a prior state of
discomfort or may indicate complete relief from discomforts that are lasting, rather than
temporary relief from severe discomforts. This state of comfort enables the client to
perform activities efficiently. Transcendence refers to the state in which the client rises
above problems or pain. This state of comfort differs from the other two states in that the
client is invigorated or inspired for extraordinary performance as an end state, rather than
ordinary performance, which is the end state for relief and ease. Extraordinary
performance requires unusual effort to shed one’s preoccupation with pain, disability, or
other difficulties. For example, transcendence may be necessary when illness and injury
cause a permanent change in the body, such as with clients who have debilitating arthritis
and pain or a spinal cord injury.
Comfort Measures
Comfort measures may be provided both directly to the client and indirectly
through other personnel, family or environment. Examples of indirect actions include
maintaining a quiet environment, coordinating the activities of other health care
personnel and supporting the client’s family members or significant others. Comfort
measures are initiated when the nurse perceives client distress or discomfort or the client
indicates a specific need for comforting. Comfort care may require simple physical
actions such as providing a warm blanket, offering a cup of tea, or applying lotion to dry
skin. However, it also requires nursing knowledge and skills specific to the client’s
medical and nursing problems. Examples include interventions for skin breakdown, pain,
infection, airway clearance, and confusion and so on. Comfort measures also encompass
the client’s psychospiritual, social, and environmental realms. Examples of
psychospiritual comfort measures are talking in soothing tones, acknowledging and
accepting feelings, offering your presence, and encouraging decision making. Social
measures may include supporting family and friends and encouraging visits by family
and friends. Environmental comfort may involve merely opening a window or removing
clutter.
Because the goal of any comforting measure is enhanced comfort, success in
comfort care is evaluated by comparing comfort levels before and after intervention.
Absolute or total comfort in hospital setting is often not possible. Nurses are therefore
challenged to encourage and inspire clients to rise above adversities.
Communication Strategies for Providing Comfort

Empathy An expression of understanding of “how it is for the
client” who is distressed, suffering or sad.
Adversity if situation is validated

Positive talk Nurse has a positive impact by keeping the client
informed, encouraged or coached.
Therapeutic touch The nurse, when appropriate, maintains physical contact
with the client, and reassures and comforts the client.
Competent physical and The nurse’s level of professionalism and efficiency
technical skills decreases the anxiety and promotes comfort.
Vigilance The client trusts that the nurse is involved in his/her care.
Coping with Pain
Pain is highly unpleasant and very personal sensation that cannot be shared with
others. It can occupy all of a person’s thinking, direct all activities, and change a person’s
life. Yet pain is a difficult concept for a client to communicate. A nurse can neither feel
nor see a client’s pain.
No two people experience pain in exactly the same way. In addition, the
differences in individual pain perception and reaction, as well as the many causes of pain,
present the nurse with a complex situation when developing a plan to relieve pain and
provide comfort. Effective pain management is an important aspect of nursing care.
Pain is more than a symptom of a problem; it is a high priority problem in itself.

Pain presents both physiologic and psychologic dangers to health and recovery. Severe
pain is viewed as an emergency situation deserving attention and prompt treatment.
Theories of Pain
Specificity Theory
René Descartes of the “I think, therefore I am” fame, introduced one of the
original pain theories in 1664. His practical model proposed a simplified system detailing
how pain messages were transmitted directly from pain receptors in the skin to a pain
center in the brain. He compared it to a bell-ringing mechanism in a church tower pulled
by a rope at the tower’s lower chambers so the bell rings throughout the landscape.
Descartes believed there is a one-to-one relationship between tissue injury and the
amount of pain a person experiences. Think about it. If you stick your finger with a
needle, you would experience minimal pain; whereas, if you cut your hand with a knife,
much more pain would be felt. Thus, the specificity theory proposes that the intensity of
pain is directly related to the amount of tissue injury. The specificity theory was modified
throughout the nineteenth and early twentieth century’s, but the basic assumptions
remained the same.
Descartes’ specificity theory has generally proven to be accurate for acute pain,
but falls short when applied to many types of chronic pain. Regrettably, variations on the
specificity theory are still taught (or at least emphasized) in many medical schools, and a
majority of doctors still ascribe to it in practice. The theory assumes that if surgery or
medication can eliminate the alleged cause of the pain, then the pain will disappear. In
chronic pain cases, particularly of musculoskeletal origin, this is often not true. If a
doctor continues to apply the specificity theory to a chronic pain problem, the patient
may be at risk for surgeries, medications, and procedures that may not work as the search
for the source of the pain presses forward. Ultimately, the validity of the patient’s pain
complaints will be challenged if reasons cannot be found and the treatments do not work.
This can often lead to the familiar “it’s all in your head” diagnosis.
One of many findings that have led to the downfall of the specificity theory was
that of phantom limb pain. Often, patients who have undergone limb amputation continue
to report sensations that seem to emanate from the missing limb. Some report that the
limb feels as if it is still there while others actually feel pain in the area of the missing
body part. Of course, these sensations cannot be coming from the limb since it has been
removed from the person’s body. The specificity theory cannot account for these findings
since there is no ongoing tissue injury in the amputated limb.
The specificity theory also cannot explain how hypnosis can be used for
anesthesia during surgery. Certain people under hypnosis can withstand high levels of
pain that would normally cause them to cry out. Surgery has been done on almost every
part of the body using only hypnosis for anesthesia. Obviously, significant tissue damage
is occurring during the surgery but the patient under hypnosis is experiencing no pain.
This finding dealt the specificity theory a significant blow.
Pattern Theory
Specificity theory (dedicated pain receptor and pathway) has been challenged by
the theory, proposed initially in 1874 by Wilhelm Erb, that a pain signal can be generated
by stimulation of any sensory receptor, provided the stimulation is intense enough: the
pattern of stimulation (intensity over time and area), not the receptor type, determines
whether nociception occurs. Alfred Goldscheider (1894) proposed that over time, activity
from many sensory fibers might accumulate in the dorsal horns of the spinal cord and
begin to signal pain once a certain threshold of accumulated stimulation has been crossed.
In 1953, Willem Noordenbos observed that a signal carried from the area of injury along
large diameter "touch, pressure or vibration" fibers may inhibit the signal carried by the
thinner "pain" fibers - the ratio of large fiber signal to thin fiber signal determining pain
intensity; hence, we rub a smack. This was taken as a demonstration that pattern of
stimulation (of large versus thin fibers in this instance) modulates pain intensity.
Gate Control Theory
According to Melzack and Wall’s gate control theory (1965), peripheral nerve
fibers carrying pain to the spinal cord can have their input modified at the spinal cord
level before transmission to the brain. Synapses in the dorsal horns acts as gates that close
to keep impulses from reaching the brain or open to permit impulses to ascend to the
brain.
Small diameter nerve fibers carry pain stimuli through a gate, but large
diameter nerve fibers going through the same gate can inhibit the transmission of those
pain impulses- that is close the gate. The gate mechanism is thought to be situated in the
substantia gelatinosa cells in the dorsal horn of the spinal cord. Because a limited amount
of sensory information can reach the brain at any given time, certain cells can interrupt
the pain impulses. The brain also appears to influence whether the gate is open or closed.
For example, previous experiences with pain are known to affect the way an individual
responds to pain. The involvement of the brain helps explain why painful stimuli are
interpreted differently by people. Although the gate control theory is not unanimously
accepted, it does help explain why electrical and mechanical interventions as well as heat
and pressure can relieve pain. For example, a back massage may stimulate impulses in
large nerves, which in turn close the gate to back pain.
Physiology of Pain
Nociception
The peripheral nervous system includes primary sensory neurons specialized to

detect tissue damage and to evoke the sensation of touch, heat, cold, pain, and pressure.
The receptors that transmit pain sensation are called nociceptors. These pain receptors or
nociceptors can be excited by mechanical, thermal or chemical stimuli. The physiologic
processes related to pain perception are described as nociception. Four processes are
involved in nociception: transduction, transmission, perception, and modulation.
Types of Pain Stimuli

Stimulus Type Physiologic Basis of Pain
Mechanical
1. Trauma to body tissues (e.g., surgery) Tissue damage, direct irritation of the pain
receptors, inflammation
2. Alteration in body tissues(e.g., Pressure on pain receptors
edema)
3. Blockage of a body duct Distension of the lumen of the duct
4. Tumor Pressure on pain receptors, irritation of
nerve endings
5. Muscle spasm Stimulation of pain receptors
Thermal
1. Extreme heat or cold (e.g. burns) Tissue destruction, stimulation of thermo-

sensitive pain receptors
Chemical
1. Tissue ischemia (e.g., blocked Stimulation of pain receptors because of
coronary artery) accumulated lactic acid (and other
chemicals, such as bradykinin and
enzymes) in tissues
2. Muscle spasm Tissue ischemia secondary to mechanical
stimulation
Transduction
Noxious stimuli (tissue injury) trigger the release of biochemical mediators (e.g.
prostaglandins, bradykinin, serotonin, histamine, substance P) that sensitize nociceptors.
Noxious or painful stimulation also causes movement of ions across cell membranes,
which excites nociceptors. Pain medication can work during this phase by blocking the
production of prostaglandin or by decreasing the movement of ions across the cell
membrane.
Transmission
The second process of nociception , transmission of pain, includes three segments.

During the first segment, the pain impulse travels from the peripheral nerve fibers to the
spinal cord. Substance P serves as a neurotransmitter, enhancing the movement of
impulses across the nerve synapse from the primary afferent neuron to the second-order
neuron in the dorsal horn of the spinal cord. Two types of nociceptor fibers cause this
transmission to the dorsal horn of the spinal cord: C fibers, which transmit dull, aching
pain, and A delta fibers, which transmit sharp, localized pain. The second segment
transmission from the spinal cord and ascension, via spinothalamic tracts, to the brain
stem and thalamus. The third segment involves transmission of signals between the
thalamus to the somatic sensory cortex where pain perception occurs.
Pain control can take place during this second process of transmission. For
example, opioids (narcotics) block the release of neurotransmitters, particularly substance
P, which stops the pain at the spinal level.
Perception
It is when the client becomes conscious of the pain. It is believed that pain
perception occurs in the cortical structures, which allows for different cognitive-
behavioral strategies to be applied to reduce the sensory and affective components of
pain. For example, nonpharmacologic interventions such as distraction, guided imagery
and music can help direct the client’s attention away from the pain.
Modulation
Often described as the “descending system” this fourth process occurs when
neurons in the brain stem send signals back down to the dorsal horn of the spinal cord.
These3 descending fibers release substances such as endogenous opioids, serotonin and
norepinephrine, which can inhibit the ascending noxious (painful) impulses in the dorsal
horn. These neurotransmitters, however, are taken back by the body, which limits their
analgesic usefulness. Clients with chronic pain may be prescribed tricyclic
antidepressants, which inhibit the reuptake of norepinephrine and serotonin. This action
increases the modulation phase that helps inhibit painful ascending stimuli.
Pain Pathway
Pain fibres terminate mainly in the superficial dorsal horn (laminae I- II). Ad
fibres enter lamina I (and V) and synapse on a second set of neurons. These neurons will
carry the signal to the thalamus and are part of the spinothalamic tract (STT). The C
fibres enter the spinal cord and synapse on lamina I cells and lamina II interneurons -
neurons that make synaptic connections with other cells within the local environment.
The interneurons convey the signal to the STT cells that reside mainly in laminae I, IV
and V. The axons of the STT cells project across the spinal cord to the STT, which is
located in the ventrolateral quadrant of the contralateral spinal cord white matter.
The STT transmits information about temperature and pain, as well as “simple”
touch (i.e. related to localisation of stimulus) and visceral sensations. It mediates the
discriminative and arousal-emotional components of these sensations by separating out
the “fast” (discriminative aspect) and “slow” (affective aspect) components of pain into
different regions of the tract that are transmitted in parallel to the thalamus.
Discriminative pain reaches the thalamus directly without making connections elsewhere
in the nervous system, whereas arousal-emotional pain reaches the thalamus indirectly
via connections with brainstem regions. Slow pain is also transmitted by other pathways
such as the spinoreticular tract.
The STT may be divided into the lateral STT and the anterior STT. Pain and
temperature is transmitted mainly in the lateral STT. The lateral-STT transmits the
sensations of both fast and slow pain. The anterior STT conveys sensations of simple
touch (stimulus localisation). The STT ascends the entire length of the cord and the
brainstem, staying in about the same location all the way up. It is here in the brainstem
that the different modalities separate out to terminate in different thalamic and brainstem
nuclei. The fast pain STT axons terminate in the ventroposterior nucleus, which
comprises the ventral posterolateral (VPL) and ventral posteromedial (VPM) and the
posterior (PO) nuclei. These axons seem to mediate mainly the sense of “simple touch”
and pain. These sensations are separated within the thalamus: neurons in the VPL and
VPM do not respond specifically to noxious stimulation, whereas cells in the PO receive
inputs from both low- and high-threshold afferents. These cells are associated with the
conscious perception of pain.
The slow pain-STT axons innervate the non-specific intralaminar nuclei of the
thalamus, and the reticular formation in the brainstem. These axons form at least part of
the forebrain pain pathway associated with the affective quality (unpleasantness and fear
of further injury) of pain and can be dissociated from the discriminative quality (the type
and nature of the injury itself). The projections to the reticular formation may underlie the
arousal effects of painful stimuli. The arousal itself may activate noradrenergic neurons
in the locus coeruleus, and thus decrease the upward pain transmission. This may be an
example of a negative feedback loop in the nervous system.
Comparison of central pathways for pain transmission
Direct (fast) Indirect (slow)

Tract Lateral-STT Lateral-STT
Spinoreticular tract (SRT)
Origin Lamina I & IV, V Lamina I, IV,V, (and VII, VIII)
Somatotopic Yes No
organisation
Body Contralateral Bilateral
representation
Synapse in No Yes
reticular formation
Sub-cortical None Hypothalamus
targets Limbic system
Autonomic centres
Thalamic nucleus Ventral posterolateral (VPL) Intra-laminar nuclei
Other midline nuclei
Cortical location Parietal lobe (SI cortex) Cingulate gyrus
Role Discriminative pain (quality Affective-arousal components of
intensity, location) pain
Other functions Temperature
Simple touch
It has long been known that the STT is an important pain pathway because when
it is damaged, pain and temperature sense is abolished on the contralateral side of the
body below the lesion. It has been used, as a last resort, by surgeons to relieve intractable
cancer pain. However, pain is not permanently abolished because of preservation of one
side of the bilateral indirect pathways. Also, the transmission of simple tactile modalities
(detection, location) via the anterior STT explains why touch sensation is preserved in
people with dorsal column lesions (although they are unable to discriminate the nature of
the stimulus).
Nature of Pain
When an individual perceives pain from injured tissue, the pain threshold is
reached. An individual’s pain threshold is the amount of pain stimulation a person
requires in order to feel pain. People’s pain threshold is generally fairly uniform;
however, it can change. For example, the same stimuli that once produced mild pain can
at another time produce intense pain. Excessive sensitivity to pain is called hyperalgesia.
Pain sensation can be considered the same as pain threshold; pain reaction
includes the autonomic nervous system and behavioral responses to pain. The autonomic
nervous system response is the automatic reaction of the body that often protects the
individual from further harm, for example, the automatic withdrawal of the hand from a
hot stove. The behavioral response is a learned response used as a method of coping with
the pain.
Pain tolerance is the maximum amount and duration of pain that an individual is
willing to endure. Some clients are unable to tolerate even the slightest pain, whereas
others are willing to endure severe pain rather than be treated for it. Thus, pain tolerance
varies greatly among people and is widely influenced by psychologic and socio-cultural
factors.
Acute and Chronic Pain
Pain may be described in terms of duration, location or etiology. When pain lasts
only through the expected recovery period, it is described as acute pain, whether it has a
sudden or slow onset and regardless of the intensity. Chronic pain, on the other hand, is
prolonged, usually recurring or persisting over 6 months or longer and interferes with
functioning. Chronic pain can be further classified as chronic malignant pain, when
associated with cancer or other life-threatening conditions or as chronic nonmalignant
pain when the etiology is a non-progressive disorder. Acute and chronic pain result in
different physiologic and behavioral responses.
Comparison of Acute and Chronic Pain
Acute pain Chronic Pain
Mild to severe Mild to severe
Sympathetic nervous system responses: Parasympathetic nervous system responses:
vital signs normal
Increased pulse rate
Increased respiratory rate
Elevated blood pressure

Diaphoresis Dry, warm skin
Dilated pupils Pupils normal or dilated

Related to tissue injury; resolves with Continues beyond healing
healing
Client appears restles and anxious Client appears depressed and withdrawn
Client reports pain Client often does not mention pain unless
asked
Client exhibits behavior indicative of pain: Pain behavior often absent
crying, rubbing area, holding area
Types of Pain
Pain can be categorized according to its origin as cutaneous, deep somatic or

visceral. Cutaneous pain originates in the skin or subcutaneous tissue. Deep somatic pain
arises from ligaments, tendons, bones, blood vessels, and nerves. It is diffuse and tends to
last longer than cutaneous pain. Visceral pain results from stimulation of pain receptors in
the abdominal cavity, cranium and thorax. Visceral pain tends to appear diffuse and often
feels like deep somatic pain, that is burning, aching, or a feeling of pressure. Visceral
pain is frequently caused by stretching of the tissues, ischemia, or muscle spasms.
Pain may also be described according to where it is experienced in the body.

Radiating pain is perseved at the source of the pain and extends to nearby tissues. Refferd
pain is pain felt in a part of the body that is considerably removed from the tissues
causing the pain.
Intractable pain is pain that is highly resistant to relief. Neuropathic pain is the
result of current or past damaged to the peripheral or central nervous system and may not
have a stimulus, such as tissue or nerve damage for the pain. Phantom pain, which is a
painful sensation percieved in a body part that is missingor paralyzed by a spinal cord
injury.
Factors Affecting Pain Experience

Ethnic and Cultural Values
Behavior related to pain is a part of the socialization process. Although there

appears to be little variation in pain threshold, cultural background can affect the level of
pain that an individual is willing to tolerate. In some Middle Eastern and African Cultures
,. Self infliction of pain is a sign of mourning or grief. In other groups, pain may be
anticipated as part of the ritualistic practices and therefore tolerance of pain signifies
strength and endurance. Additionally, there are significant variations in the expression of
pain. Studies have shown that individuals of northern European descent tend to be more
stoic and less expressive of their pain than individuals from southern European
backgrounds.
Nurses must realize they have their own attitudes and expectations about pain.
Nurses expect people to be objective about pain and to be able to provide detailed
description of the pain. Nurses may deny or downplay the pain they observe in others.
Therefore, identifying your own personal attitude about pain and creating an effective
nurse-client relationship is imperative for providing culturally competent care for the
clients in pain.
Developmental Stage
The age and developmental stage of a client is an important variable that will
influence both the reaction to and the expression of pain.
The field of pain management for infants and children has grown significantly. It
is now accepted that anatomic, physiologic and biochemical elements necessary for pain
transmission are present in newborns regardless of their gestational age. Children may be
less able than an adult to articulate their pain being undertreated.
Elders constitute a major portion of the individuals within the health care system.
The prevalence of pain in the older population is generally higher due to both acute and
chronic disease conditions. Pain threshold does not appear to change with aging, although
the effect of analgesics may increase due to physiologic changes related to drug
metabolism and excretion.
Environment and Support People
A strange environment such as a hospital, with its noises, lights, activity can
compound pain. In addition, the lonely person who is without a support network may
perceive pain as severe, whereas the person who has supportive people around may
perceive less pain. Some people prefer to withdraw when they are in pain, whereas others
prefer the distraction of people and activity around them. Family caregivers can be a
significant support for a person in pain. With the increase in outpatient and homecare,
families are assuming an increased responsibility for the management of pain.
Expectations of significant others can affect a person’s perceptions of and
responses to pain. Family role can also affect how a person perceives or responds to pain.
The presence of support people often changes a client’s reaction to pain.
Past Pain Experiences
Previous pain experiences alter a client’s sensitivity to pain. People who have
personally experienced pain or who have been exposed to the suffering of someone close
are often more threatened by anticipated pain than people without a pain experience. In
addition, the success or lack of success of pain relief measures influences a person’s
expectations for relief.
Meaning of Pain
Some clients may accept pain more readily than other, depending on the
circumstances and the client’s interpretation of its significance. A client who associates
the pain with a positive outcome may withstand the pain amazingly well.
By contrast, clients with unrelenting chronic pain may suffer more intensely.
They may respond with despair, anxiety, and depression because they cannot attach a
positive significance or purpose to the pain. In this situation, the pain may be looked as
on a threat to body image or lifestyle and as a sign of possible impending death.
Anxiety and Stress
Anxiety often accompanies pain. The threat of the unknown and the inability to
control the pain or the events surrounding it often augment the pain perception. Fatigue
also reduces a person’s ability to cope, thereby increasing pain perception. When pain
interferes with sleep, fatigue and muscle tension often result and increase the pain; thus a
cycle of pain-fatigue-pain develops. People in pain who believe that they have control of
their pain have decreased fear and anxiety, which decreases their pain perception. A
perception of lacking control or a sense of helplessness tends to increase pain perception.
Clients who are able to express pain to an attentive listener and participate in pain
management decisions can increase a sense of control and decrease pain perception.
Assessing Pain
Accurate pain assessment is essential for effective pain management. The strategy
of linking pain assessment to routine vital sign assessment and documentation ensures
pain assessment for all clients. Because pain is subjective and experienced uniquely by
each individual, nurses need to assess all factors affecting the pain experience-
physiologic, psychologic, behavioral, emotional, and sociocultural.
The extent and frequency of the pain assessment varies according to the situation.
For clients experiencing acute or severe pain, the nurse may focus only on location,
quality, severity, and early intervention. Clients with less severe or chronic pain can
usually provide a more detailed description of the experience. Frequency of pain
assessment usually depends on the pain control measures being used and the clinical
circumstances. Following pain management interventions, pain intensity should be
reassessed at an interval appropriate for the intervention.
Because it has been found that many people will not voice their pain unless asked
about it, pain assessment must be initiated by the nurse. It is also essential that nurses
listen to and rely on the client’s perceptions of pain. Believing the person experiencing
and conveying the perceptions is crucial in establishing a sense of trust.
Pain assessment consists of two major components: (a) a pain history to obtain
facts from the client and (b) direct observation of behavioral and physiologic responses of
the client. The goal of assessment is to gain an objective understanding of a subjective
experience.
Mnemonics
OLDCART mnemonics
O- onset
L-location
D-duration
C-characteristic
A-aggravating factors
R- radiation
T-treatment ( what was previously ineffective and what has alleviated the pain)
PQRST mnemonic
P- provoked (what brought about pain)
Q-quality
R-region/ radiation
S-severity
T-timing
Pain History
While taking pain histories, the nurse must provide an opportunity for clients to
express on their own words how they view the pain and the situation. This will help the
nurse understand what the pain means to the client and how the client is coping with it.
Remember that each person’s pain experience is unique and that the client is the best
interpreter of the pain experience. This history should be geared to the specific client.
For the person with chronic pain, the nurse may focus on the client’s coping
mechanism, effectiveness of current pain management, and ways in which the pain has
affected activities of daily living.
Data should be obtained in a comprehensive pain history include pain location,

intensity, quality, patterns, precipitating factors, alleviating factors, associated symptoms,
effect on ADL’s past pain experiences, meaning of the pain to the person, coping
resources, and affective responses.
Location
To ascertain the specific location of the pain, ask the individual to point to the site
of the discomfort. A chart consisting of drawings of the body can assist in identifying
pain locations. The client marks the location of pain on the chart. This tool can be
especially effective with clients who have more than one source of pain.
When assessing the location of a child’s pain, the nurse needs to understand the
child’s vocabulary. Again, the use of figure drawings can assist in identifying pain
locations. Parents can also be helpful in interpreting the meaning of a child’s words.
When documenting pain location the nurse may use various body landmarks.
Further clarification is possible with the use of terms such as proximal, distal, medial,
lateral, and diffuse.
Pain Intensity or Rating Scales
The single most important indicator of the existence and intensity of pain is the
client’s report of pain. The top factors identified by nurses were culturally influenced
(e.g. facial expressions, verbalization, request for relief). In addition, studies have shown
that health care providers may underrate or overrate the pain intensity. The use of pain
intensity is an easy and reliable method of determining the client’s pain intensity. Such
scales provide consistency for nurses to communicate with the client and other health
care providers. Most scales use either a 0 to 5 or 0 to 10 range with 0 indicating “no
pain” and the highest number indicating the “worst pain possible” for that individual.
When noting pain intensity, it is important to determine any related factors that
may be affecting the pain. When the intensity changes, the nurse needs to consider the
possible cause. Several factors affect the perception of intensity: (1) the amount of
distraction, or the client’s concentration on another event; (2) the client’s state of
consciousness; (3) the level of activity; (4) the client’s expectations.
Not all clients can understand or relate to numerical pain intensity scales. These
include children who are unable to communicate discomfort verbally, elderly clients with
impairments in cognition or communication, and people who do not speak English. For
these clients the Wong Baker FACES Rating Scale may be easier to use. The face scale
includes a number scale in relation to each expression so that the pain intensity can be
documented. When it is not possible to use any kind of rating scale with a client, the
nurse must rely on observation of behavior and any physiologic cues. The input of the
client’s significant others, such as parents or caregivers, can assist the nurse in
interpreting the observations. An objective description of the behavior and physiologic
data is then documented.
Pain Quality
Descriptive adjectives help people communicate the quality of pain. A headache

may be described as “hammerlike” or an abdominal pain as “piercing like a knife”.
Sometimes clients have difficulty describing pain because they have never experienced
any sensation like it.
Nurses need to record the exact words clients use to describe pain. A client’s
words are more accurate and descriptive than an interpretation in the nurse’s words.
Exact information can be significant in both the diagnosis of the pain etiology and in the
treatment choices made.
Pattern
The pattern of pain includes time of onset, duration, and recurrence or interval
without pain. The nurse therefore determines when the pain began; how long the pain
lasts; whether it recurs and if so, the length of the interval without pain, and when the
pain last occurred.
Precipitating Factors
Certain activities sometimes precede pain. For example, physical exertion may
precede chest pain, or abdominal pain may occur after eating. These observations can
help prevent pain and determine its cause.
Environmental factors such as extreme cold or heat and extremes of humidity can
affect some types of pain.
Physical and emotional stressors can also precipitate pain. Emotional tension
frequently brings on a migraine headache. Intense fear or physical exertion can cause
angina.
Alleviating Factors
Nurses must ask clients to describe anything that they have done to alleviate the
pain. It is important to explore the effect any of these measures had on the pain, whether
or not relief was obtained, or whether the pain became worse.
Associated Symptoms
Also included in the clinical appraisal of pain are associated symptoms such as
nausea, vomiting, dizziness and diarrhea. These symptoms may release to the onset of the
pain or they may result from the presence of the pain.
Effect on Activities of Daily Living
Knowing how ADLs are affected by chronic pain helps the nurse understand the
client’s perspective on pain’s severity. The nurse asks the client to describe how the pain
has affected the following aspects of life: sleep, appetite, concentration, work/school,
interpersonal relationship, martial relations/ sex, home activities, driving/walking, leisure
activities, emotional status (mood, irritability, depression, and anxiety).
Coping Resources
Each individual will exhibit personal ways of coping with pain. Strategies may
relate to earlier pain experiences or the specific meaning of the pain; some may reflect
religious or cultural influences. Nurses can encourage and support the client’s use of
methods known to have helped in modifying pain. Strategies may include withdrawal,
distraction, prayer or other religious practices, and support from significant others.
Affective Responses
Affective responses vary according to the situation, the degree and duration of
pain, the interpretation of it and many other factors. The nurse needs to explore the
client’s feelings of anxiety, fear, exhaustion, depression, or a sense of failure. Because
many people with chronic pain become depressed and potentially suicidal, it may also be
necessary to assess the client’s suicide risk.
Observation of Behavioral and Physiologic Responses
There are wide variations in nonverbal responses to pain. For clients who are very
young, aphasic, confused or disoriented, nonverbal expressions may be the only means of
communicating pain. Facial expression is often the first indication of pain and it may be
the only one. Clenched teeth, tightly shut eyes, open somber eyes, biting the lower lip,
and other facial grimaces may be indicative of pain. Vocalizations like moaning and
groaning or crying and screaming ate sometimes associated with pain.
It is important to note that behavioral responses can be controlled and so may not
be very revealing. When pain is chronic there are rarely overt behavioral responses
because the individual develops personal coping styles for dealing with pain, discomfort
or suffering.
Physiologic responses vary with the origin and duration of the pain. Physiologic
responses are most likely to be absent in people with chronic pain because of central
nervous system (CNS) adaptation. Thus, it is important that the nurse assess more than
only physiologic responses because they may be poor indicators of pain.
Daily Pain Diary
For clients who experience chronic pain, a daily diary may help the client and the
nurses identify pain patterns and factors that exacerbate or mediate the pain experience.
In home care the family or other caregiver can be taught to complete the diary. The
record can include: time or onset of pain, activity before pain, pain-related positions or
behaviors, pain intensity level, use of analgesics or other relief measures, duration of pain
and time spent in relief activities.
Recorded data can provide the basis for developing or modifying the plan for
care. For this tool to be effective, it is important that the nurse educate the client and
family about the value and use of the diary in achieving effective pain control
Strategies of Pain Relief
Pharmacologic Pain Management
Pharmacologic pain management involves the use of opioids (narcotics),

nonopioids/ nonsteriodal anti-inflammatory drugs (NSAIDS), and adjuvants, or
coanalgesic drugs.
Categories and Examples of Analgesics
Opioid Analgeics
• Butorphanol (Stadol)
• Fentanyl citrate (Sublimaze)
• Hydrocodone (Lortab, Vicodin)
• Hydromorphone hydrochloride (Dilaudid)
• Meperidine hydrochloride (Demerol)
• Codeine (Tylenol 3, Empirin 3)
• Morphine sulfate (morphine)
• Propoxyphene napsylate (Darvon-N, Dravocet-N)

Nonopioid Analgesics/ NSAIDs
• Acetaminophen (Tylenol, Datril)
• Acetylsalicylic acid (aspirin)
• Choline magnesium trisalicylate (Trilisate)
• Diclofenac sodium (Voltaren)
•Ibufrofen (Motrin, Advil)
• Indomethacin sodium trihydrate (Indocin)
• Naproxen (Naprosyn)
• Naproxen sodium (Anaprox)
• Piroxican (Feldene)
• Tolmetin sodium (Tolectin)
Adjuvant Analgesics
•Amitriptyline (Elavil)
• Chlorpromazine (Thorazine)
• Diazepam (Valium)
• Hydroxyzine (Vistaril)
Opioid Analgesics
It includes opium derivatives, such as morphine and codeine. McCaffery and

Pasero state that the term opioid is now used rather than narcotic, which has become an
obsolete term. Narcotic is used primarily in a legal context to refer to a wide variety of
substances of potential abuse.
Opioids relieve pain and provide a sense of euphoria largely by binding to opiate
receptors and activating endogenous pain suppression in the CNS. There are several types
of opiate receptors, including mu, delta, and kappa receptors. The mu receptor is the most
commonly associated with pain relief. Changes in mood and attitude and feelings of well
being make the person feel more comfortable even though the pain persists.
There are three primary types of opioids:
1. Full Agonists
These pure opioid drugs bind tightly to mu receptor sites, producing

maximum pain inhibition, an agonist effect. There is no ceiling on the
level of analgesia from these drugs; their dose can be steadily increased to
relieve pain. There is also no maximum daily dose limit.
2. Mixed agonists-antagonists
It can act like opioids and relieve pain when given to a client who has not
taken any pure opioids. However, they can block or inactivate other opioid
analgesics when given to a client who has been taking pure opioids. They
block the mu receptor site and activate a kappa receptor site. These drugs
also have a ceiling dose level. They are not recommended for use with
terminally ill clients.
3. Partial Agonist
Partial agonists have a ceiling effect in contrast to a full agonist. These

drugs block the mu receptors or are neutral at that receptor but bind at a
kappa receptor site.
When administrating any analgesic, the nurse must review side effects. All
opioids result in some initial drowsiness when first administered, but with regular
administration, this side effect tends to decrease. Opioids also may cause nausea,
vomiting, constipation and respiratory depression. Opioids must be used cautiously in
clients with respiratory problems.
Older clients are particularly sensitive to the analgesic properties of opioids and
often require less medication than younger clients. This sensitivity may be related to
reduced excretion of the drug in elderly clients.
Nonopioids/NSAIDs
Nonopioids include acetaminophen and nonsteroidal anti-inflammatory drugs

(NSAIDs) such as ibuprofen. NSAIDs have anti-inflammatory, analgesic and antipyretic
effects, whereas acetaminophen has only analgesic and antipyretic effects. They relieve
pain by acting on peripheral nerve endings at the injury site and decreasing the level of
inflammatory mediators and interfering with the production of prostaglandins at the site
of injury. Analgesia appears to result primarily from a central mechanism rather than a
peripheral one.
Individual drugs in this category vary widely in their analgesic properties,
metabolism, excretion and side effects.
The most common side effect of nonopioid analgesics is gastrointestinal, such as

heartburn or indigestion. Most NSAIDs interfere with platelet aggregation.
Acetaminophen, on the other hand, does not affect platelet function and rarely causes
gastrointestinal distress. It can, however, cause hepatotoxity and should be used
cautiously in clients with liver problems.
Adjuvant Analgesics
It is a medication that was developed for a use other than analgesia but has been
found to reduce chronic pain and sometimes acute pain, in addition to its primary action.
For example, mild sedatives or tranquilizers may help reduce anxiety, stress, and tension
so that the client can obtain a good night sleep. Antidepressants are used to treat
underlying depression or mood disorders but may also enhance other pain strategies.
Anticonvulsants, usually prescribed to treat seizures, can be useful in controlling painful
neuropathies such as herpes zoster (shingles) and diabetic neuropathies.
WHO Three-Step Ladder Approach
The World Health Organization (WHO) recommends a three-stepladder approach

to manage chronic cancer pain. This approach focuses on the intensity of the pain and
clients do not necessarily progress through the three steps. Step 1 of the analgesic ladder
suggests a nonopioid analgesic and the possibility of an adjuvant analgesic. If the client
receives the maximum recommended dose of nonopioids and continues to experience
pain, step 2 recommends adding an opioid. It appears that there is no difference between
steps 2 and 3; however, in practice the difference is in the choice of analgesic. For
example, opioid analgesics at step 3 should be available by a variety of routes (e.g. oral,
rectal, and subcutaneous). They should also have a short half-life in order to increase the
dosage for severe, escalating (increasing) pain.
Some medications (e.g. Vicodin) contain both opioids and nonopioids. Nurses
need to be aware of this in order to administer them safely and to complete proper
discharge instructions related to these combination medications.
Administration of Placebos
A placebo is “any medication or procedure including surgery , that produces an

effect in a client because of its implicit or explicit intent and not because of its specific
physical or chemical properties.” Placebos can be used as an effect in research to study
the effects of a new medication. A positive response to placebo dose is not indicative of
lack of real pain but only of the reality of the placebo effect, which can be expected in
30% or more of any population. Because placebos fail to relieve pain for many people, it
is recommended that the deceptive use of placebos be considered unacceptable in the
management of pain.
Routes for Opiate Delivery
Opioids have traditionally been administered by oral, subcutaneous, intramuscular

and intravenous routes. In addition, newer methods of delivering opiates have been
developed to circumvent potential obstacles that occur with these traditional routes.
Oral- remains the preferred route of delivery because of ease administration.
Nasal- transnasal administration has the advantage of rapid action of the

medication because of direct absorption through the vascular nasal mucosa. A commonly
used agent is a mixed agonist-antagonist butorphanol (Stadol) for acute headaches.
Transdermal- it is advantageous in that it delivers a relatively stable plasma drug

level and is noninvasive.
Rectal- several opiates are now available in suppository form. The rectal route is
particularly useful for clients who have dysphagia (difficulty of swallowing) or nausea
and vomiting.
Subcutaneous- although the subcutaneous (SC) route has been used extensively to
deliver opioids, another technique uses subcutaneous catheters and infusion pumps to
provide continuous subcutaneous infusion (CSCI) of narcotics. CSCI is particularly
helpful for clients (a) whose pain is poorly controlled by oral medications, (b) who are
experiencing dysphagia or gastrointestinal obstruction, or (c) who have a need for
prolonged use of parenteral narcotics. CSCI involves the use of a small, light, battery-
operated pump that administers the drug through a 23-or-25- gauge butterfly needle. The
needle can be inserted into the anterior chest, the subclavicular region, the abdominal
wall, the outer aspects of the upper arms, or the thighs.
Intramuscular- it is the least desirable route for opioid administration because of

variable absorption, pain involved with administration, and the need to repeat
administration every 3 to 4 hours.
Intravenous- it provides rapid and effective pain relief with few side effects. The
analgesic can be administered by IV bolus or by continuous infusion controlled by the
client using a patient controlled analgesia (PCA) machine at the bedside.
Intraspinal- an increasing popular method of delivery is the infusion of opiates

into the epidural or intrathetical (subarachnoid) space. Intraspinal analgesics act directly
on opiate receptors in the dorsal horn of the spinal cord. The major benefit of intraspinal
drug therapy is that it exerts a lesser sedative effect than do systemic opiates. The
epidural space is most commonly used because the dura mater acts as a protective barrier
against infection, including meningitis. Because the epidural catheter is in a space and not
a blood vessel, a continuous epidural infusion may be stopped for hours and restarted
without concern that the catheter has become occuled.
Intraspinal analgesia can be administered by three methods:
1. Bolus
For some surgical procedures, a single bolus may provide sufficient pain
control for up to 24 hours. After this time, the client may be given oral or
IV analgesics. Some agencies allow only the anesthesiologist or nurse
anesthetist to initiate an epidural infusion or administer a bolus.
2. Continuous infusion administered by pump
The pump may be external (for acute or chronic pain) or implanted (for
chronic pain).
3. Patient –controlled epidural analgesia (PCEA)
Patient –controlled epidural analgesia is administered by the client using a

pump. This is similar to patient-controlled analgesia in which a basal rate
may meet the client’s analgesic needs. If not, the client can push a button
to deliver a preset dose. PCEA is often used to manage acute postoperative
pain, chronic pain, and intractable cancer pain.
Nonpharmacologic Pain Management
Nonpharmacologic pain management consists of variety of physical and

cognitive-behavioral pain management strategies. Physical interventions include
cutaneous stimulation, immobilization, transcutaneous electrical nerve stimulation
(TENS), and acupuncture. Mind-body (cognitive-behavioral) interventions include
distraction activities, relaxation techniques, imagery, meditation, biofeedback, hypnosis
and therapeutic touch.
Physical Interventions
The goals of physical intervention include providing comfort, altering

physiologic responses, and reducing fears associated with pain-related immobility or
activity restriction.
Cutaneous Stimulation
Cutaneous stimulation can provide effective temporary pain

relief. It distracts the client and focuses attention on the tactile stimuli, away from
the painful sensations, thus reducing pain perception. Cutaneous stimulation is
also believed to (a) create the release of endorphins that block pain stimuli
transmission and (b) stimulate large diameter Abeta sensory nerve fibers, thus
decreasing the transmission of pain impulses through the smaller A –delta and C
fibers. Cutaneous stimulation techniques include the following:
•Massage
•Application of heat and cold
• Acupressure
• Contralateral stimulation
Cutaneous stimulation can be applied directly to the painful area, proximal

to the pain, distal to the pain and contralateral (opposite side) to the pain.
Cutaneous stimulation is contraindicated in areas of skin breakdown.
Massage
Is a comfort measure that can aid relaxation, decrease muscle

tension and may ease anxiety because the physical contact caring. It can also
decrease pain intensity by increasing superficial circulation to the area. The use of
ointments or liniments may provide localized pain relief with joint or muscle pain.
Heat and Cold Application
A warm bath, heating pads, ice bags, ice massage, hot or cold
compresses, and a warm or cold sitz baths in general relieve pain and promote
healing of injured tissues.
Acupressure
Developed from the ancient Chinese healing system of

acupuncture. The therapists applies finger pressure to points that corresponds to
many of the points used in acupuncture.
Contralateral Stimulation
Can be accomplished by stimulating the skin in an area opposite to

the painful area. The contralateral area may be scratched for itching, massaged for
cramps, or treated with cold packs or analgesic ointments. This method is
particularly useful when the painful area cannot be touched because it is
hypersensitive, inaccessible by a cast or bandages, or when the pain is felt in a
missing part (phantom pain).
Immobilization
Immobilizing or restricting the movement of a painful body part may help
to manage episodes of acute pain. Splints or supportive devices should hold joints in the
position of optimal function and should be removed regularly in accordance with agency
protocol to provide range of motion exercises. Prolonged immobilization can result in
joint contracture, muscle atrophy, and cardiovascular problems. Therefore, clients should
be encouraged to participate in self-care activities and remain as active as possible.
Transcutaneous Electrical Nerve Stimulation (TENS)
It is a method of applying low voltage electrical stimulation directly over

identified pain areas, at an acupressure point, along peripheral nerve areas that innervate
the pain area, or along the spinal column. The TENS unit consists of a portable, battery-
operated device with lead wire and electrode pads that are applied to the chosen area of
skin. Cutaneous stimulation from the TENS unit is thought to activate large diameter
fibers that modulate the transmission of the nociceptive impulse in the peripheral and
central nervous system, resulting in pain relief.
Distraction
It draws the person’s attention away from the pain and lessens the
perception of pain. In some instances, distraction can make a client completely unaware
of pain.
Nonpharmacologic Invasive Therapies
A nerve block is a chemical interruption of a nerve pathway, effected by injecting

a local anesthetic into the nerve. Nerve blocks are widely used during dental work. The
injected drug blocks nerve pathways from the painful tooth, thus stopping the
transmission of pain impulses to the brain. Nerve blocks are often used to relieve pain of
whiplash injury, lower back disorders, bursitis, and cancer. Sometimes alcohol blocks are
used. These, however, destroy nerve fibers and as a result are generally used only for
peripheral blocks, because peripheral nerve fibers regenerate.
Pain conduction pathways can be interrupted surgically. Because the distraction is

permanent, surgery is performed only as a last resort, generally for intractable pain. A
cordotomy obliterates pain and temperature sensation below the level of the
spinothalamic portion of the anterolateral tract severed, and is usually done for pain in
legs and trunk. Rhizotomy interrupts the anterior or posterior nerve root between the
ganglion and the cord. Interruption of anterior motor nerve roots stops spasmodic
movements that accompany paraplegia. Interruption of posterior sensory nerve roots
eliminates pain in areas innervated by that specific nerve root. Rhizotomies are generally
performed on cervical nerve roots to alleviate pain of the head and neck from cancer or
neuralgia.
In neurectomy, peripheral or cranial nerves are interrupted to alleviate localize

pain, such as pain in the lower leg or foot arising from a vascular occlusion. In a
sympathectomy, pathways of the sympathetic division of the autonomic nervous system
are severed. This procedure eliminates vasospasm, improves peripheral blood supply, and
thus is effective in treating painful vascular disorders such as angina and Raynard’s
disease.
Spinal cord stimulation (SCS) is used with nonmalignant pain that has not been
controlled with less invasive therapies. SCS involves the insertion of a cable that allows
the placement of an electrode directly on the spinal cord. The cable is attached to a device
that sends electric impulses to the spinal cord to control pain.
Nursing Process
Assessment
Mnemonics
OLDCART mnemonics
O- onset
L-location
D-duration
C-characteristic
A-aggravating factors
R- radiation
T-treatment ( what was previously ineffective and what has alleviated the pain)
PQRST mnemonic
P- provoked (what brought about pain)
Q-quality
R-region/ radiation
S-severity
T-timing
Diagnosing
NANDA includes the following diagnostic labels for clients experiencing pain or
discomfort:
• Acute pain
•Chronic pain
When writing the diagnostic statement, the nurse must specify the location (e.g.
right ankle pain, or left frontal headache). Related factors, when unknown, must also be
part of the diagnostic statement and can include both physiologic and psychologic
factors. For example, in addition to the injurious agent, related factors may include
deficient knowledge of pain management techniques or fear of drug tolerance or
addiction.
Examples of these diagnoses using NANDA, NOC and NIC designations are
shown in Identifying Nursing Diagnoses, Outcomes and Interventions.
Because the presence of pain can affect so many facets of a person’s functioning,
pain may be the etiology of other nursing diagnoses. Examples of such nursing diagnoses
follow:
• Ineffective airway clearance related to weak cough secondary to

postoperative incisional abdominal pain.
• Hopelessness related to feelings of continual pain.
•Ineffective Health Maintenance related to chronic pain and fatigue.
•Disturbed Sleep Pattern related to increased pain perception at night.
Planning
Planning Independent of Setting
When planning, nurses need to choose pain relief measures appropriate for the
client, based on the assessment data and input from the client or support persons. Nursing
interventions may include a variety of pharmacologic and nonpharmacologic
interventions. Developing a plan that incorporates a wide range of strategies is usually
most effective. Whether in acute care or in home care, it is important for everyone
involved in pain management to understand the plan of care. The plan should be
documented in the client’s record; in home care, a copy needs to be made available to the
client, support persons, and care givers. Involvement of the client and support persons is
essential in pain management.
Planning for Home Care
In preparation for discharge, the nurse needs to determine the client’s and
family’s needs, strengths, and resources. The accompanying Home Care Assessment
describes the specific assessment data required when establishing a discharge plan. Using
the assessment data, the nurse tailors a teaching plan for the client and family.
Implementing
Pain management is the alleviation of pain or a reduction in pain to a level of

comfort that is acceptable to the client. It includes two basic types of nursing
interventions: pharmacologic and nonpharmacologic. Nursing management of pain
consists of both independent and collaborative nursing actions. In general, noninvasive
measures may be performed as an independent nursing function, whereas administration
of analgesic medications requires a physician’s order. However, the decision to
administer the prescribed medication is frequently the nurse’s often requiring judgment
as to the dose and the limit of administration.
Generally speaking, a combination of strategies is best for the client in pain.

Sometimes strategies need to be tried and changed until the client obtains effective pain
relief.
Barriers to Pain Management
Misconceptions and biases can affect pain management. These may involve
attitudes of the nurse or the client as well as knowledge deficits. Clients respond to pain
experiences based on their culture, personal experiences and the meaning of pain for
them. Another barrier to effective pain management is the fear of becoming addicted,
especially when long-term opioid use is prescribed. This fear is often held by both nurses
and clients. It is important that all individual know the difference between tolerance,
dependence, and addiction.
Key Factors in Pain management
Acknowledging and Accepting Client’s Pain
Basic to all strategies for reducing pain is that nurses convey to clients that they
believe the client is having pain.
Assisting Support Persons
Support persons often need assistance to respond positively to the client

experiencing pain. Nurses can help by giving them accurate information about the pain
and providing opportunities for them to discuss their emotional reactions, which may
include anger, fear, frustration, and feelings of inadequacy. Support persons also may
need the nurse’s verbal recognition of their concern and participation in the client’s care.
Reducing Misconceptions about Pain
Reducing a client’s misconceptions about pain and its treatment will often avoid
intensifying the pain. The nurse should explain to the client that pain is a highly
individual experience and that it is only the client who really experiences the pain,
although the others can understand and emphasize. Misconceptions are also dealt with
when nurse and client discuss why the pain has increased or decreased at certain times.
Reducing fear and Anxiety
It is important to help relieve the emotional component, that is anxiety and fear,
associated the pain. When clients have no opportunity to talk about their pain and
associated fears, their perceptions and reactions to the pain can be intensified. The client
may become angry or complain about the nurse’s care when the problem really is a belief
that the pain is not being treated. If the nurse is honest and sincere and promptly attends
to the client’s needs, the client is much more likely to know that the nurse does believe
the client is in pain.
Preventing Pain
A preventive approach to pain management involves the provision of measures to

treat the pain before it occurs or before it becomes severe. Preemptive analgesia is the
administration of analgesics prior to an invasive or operative procedure in order to treat
pain before it occurs.
Evaluating
The goals established in the planning phase are evaluated according to specific
desired outcomes, also established in that phase. To assist in the evaluation process,
flowsheet records or a client diary may be helpful. A weekly log or diary can be
structured in a similar fashion for the individual client. If outcomes are not achieved, the
nurse and client need to explore the reasons before modifying the care plan.
E. SLEEP
Definition of Sleep and Rest

• Sleep- An altered state of consciousness of an individual in which the
person’s perception of and reaction to environment are decreased.
-A cyclical physiological process that alternates with longer period of
wakefulness.
• Rest-implies calmness, relaxation without emotional stress, and freedom
from anxiety.
Physiology of Sleep
Biorythms (Rhythmic Biologic clocks) exist in plants, animals and humans. The
most familiar example of this is circadian rhythm.
▪ Circadian Rhythm (derived from the latin word, circa, “about”, and
dies, “day”)
-coincides with sleep-wake pattern,
-predictable changing of body temperature, heart rate, BP,
hormone secretion, sensory acuity, and mood depend on the
maintenance of 24-hour circadian cycle.
Sleep Regulation
▪ Sleep involves a sequence of physiological states maintained by highly
integrated central nervous system (CNS) activity. This is associated
with changes in the peripheral nervous, endocrine, cardiovascular,
respiratory and muscular systems.
▪ Current theory suggests that sleep is an active multiphase process. The

major sleep center in the body is the hypothalamus. The hypothalamus
secretes hypocreatins (orexins) that promote wakefulness and rapid
eye movement in sleep. Prostaglandin D2 and, L-tryptophan and growth
factors control sleep.
▪ Researchers believe the ascending reticular activating system (RAS)

located in the upper brain stem to contain special cells that maintain
alertness and wakefulness. The RAS receives visual, auditory, pain
and tactile sensory stimuli. Activity from the cerebral cortex (e.g.
emotions or thought process) also stimulates the RAS. Arousal,
wakefulness and maintenance of consciousness results from neurons in
the RAS that release catecholamines such as norepinephrine.
▪ Researchers hypothesize that the release of serotonin from specialized

cells in the rapher nuclei sleep system of the pons and medulla
produces sleep. This area of the brain is also called bulbar
synchronizing region (BSR). Whether a person remains awake or falls
asleep depends on a balance of impulses received from higher centers
(e.g., thoughts), peripheral sensory receptors (e.g., sound or light
stimuli) and the limbic system (emotions).
Stages of Sleep
▪ Different brain-wave, muscle, and eye activity are associated with
different stages of sleep (Izac, 2006)
▪ Two phases: Nonrapid eye movement (NREM) sleep and rapid eye
movement (REM) sleep.
▪ Electrocephalogram (EEG) provides a good picture of what occurs
during sleep. It measures electrical activity in the cerebral cortex.
* NREM Sleep
- Referred as slow-wave sleep because the brain waves of a sleeper are
slower than alpha and beta waves of a person who is awake or alert.
- Deep, restful sleep and brings a decrease in some physiologic functions.
- All metabolic process including VS, metabolism and muscle action is
slow. Even swallowing and saliva production are reduced.
- There are physiologic changes during NREM sleep.
- Occurs 90-100 minutes.
- NREM usually progresses from stage 1 through stage 4 of a period of
REM sleep, followed by a reversal from stage 4 to 3 to 2, ending a period of REM sleep.
* REM Sleep
-Occurs 90 minutes and lasts 5 to 30 minutes.
- Dreams are usually takes place and usually remembered.
- Muscle tone is depressed, gastric secretions increase and heart and
respiratory rates often are irregular.
Physiologic Changes during NREM Sleep

▪ Arterial blood pressure falls.
▪ Pulse rate increases.
▪ Peripheral blood vessels dilate
▪ Cardiac output decreases.
▪ Skeletal muscles relax
▪ Basal metabolic rate decreases 10% to 30%
▪ Growth hormone levels peak.
▪ Imtercranial pressure decreases
Stages of Sleep Cycle
Stage 1: NREM
▪ Includes lightest level sleep.
▪ Stage lasts a few minutes.
▪ Decreased physiological activity begins wit gradual fall in vital signs and
metabolism.
▪ Sensory stimuli such as noise easily arouses person.
▪ Awakened, person feels as though daydreaming has occurred.
Stage 2: NREM
▪ Period of sound sleep.
▪ Relaxation progresses.
▪ Arousal remains relatively easy.
▪ Stage lasts 10 to 20 minutes.
▪ Body functions continue to slow.
Stage 3: NREM
▪ Involves initial stages of deep sleep.
▪ Sleeper is difficult to arouse
▪ Muscles are completely relaxed.
▪ Vital signs decline but remain regular.
▪ Stage lasts 15-30 minutes.
Stage 4: NREM
▪ Deepest stage of sleep
▪ Very difficult to arouse and rarely moves.
▪ If sleep loss has occurred, sleeper will spend considerable portion of night this
stage.
REM Sleep
▪ Vivid, full color dreaming occurs.
▪ Less vivid dreaming occurs in other stages.
▪ Stage usually begins about 90 minutes after sleep has begun.
▪ Typified by autonomic response of rapidly moving eyes, fluctuating heart and
respiratory rates, and increased or fluctuating blood pressure.
▪ Loss of skeletal muscle tone occurs.
▪ Gastric secretions increase.
▪ Very difficult to arouse sleeper.
▪ Duration of REM sleep increases with each cycle and averages 20 minutes.
Functions of Sleep
- Contributes in physiological and psychological restoration.

- NREM sleep contributes to body restoration (McCance and Huether, 2006)
- Body needs to sleep to routinely restore biological processes.
- Another theory states that the body needs sleep to conserve energy.
- REM sleep is necessary for brain tissue restoration and appears to be important
for cognitive restoration (Buysse, 2005).
▪ Dreams - is a succession of thoughts, images, sounds or emotions which

the mind experiences during sleep
- Occur during both REM and NREM, dreams of REM sleep are
more vivid and elaborate and some believe they are functionally important
to learning, memory processing, and adaptation to stress. REM dreams
progress in content throughout the night from dreams about current events
to emotional dreams of childhood or the past.
- Personality influences the quality of dreams.
▪ Normal Sleep Patterns and Requirements

It has been suggested that maintaining a regular sleep wake
rhythm is more important than the number of hours actually slept.
Factors Affecting Sleep

▪ Illness- Illness that can causes pain or physical distress can result in sleep
problems. People who are ill require more sleep than normal and the
normal rhythm of sleep and wakefulness is often disturbed.
▪ Environment- The presence of unfamiliar stimuli can prevent people
from sleeping.
▪ Lifestyle- A person who does shift work and changes shifts frequently
must arrange activities to be ready to sleep at the right time.
▪ Emotional Stress- A person preoccupies with personal problems may be
unable to relax sufficiently to get sleep. Anxiety and depression frequently
disturb sleep.
▪ Stimulants and Alcohol- Caffeine-containing beverages act as stimulants
of the CNS, thus interfering sleep. Excessive alcohol disrupts REM sleep,
although it may hasten the onset of sleep.
▪ Diet- Weight loss has been associated with reduced total sleep time as
well as broken sleep and earlier awakening. Weight gain, on the other
hand, seems to be associated with an increase in total sleep time, less
broken sleep and later waking.
▪ Smoking- Nicotine has a stimulating effect on the body. Smokers are
usually aroused and often describe themselves as light sleepers.
▪ Motivation-The desire to stay awake can often overcome person’s fatigue.
▪ Medications-The box below states the drugs that disrupt sleep.
Drugs that Disrupt Sleep and Their Effects
▪ Hypnotics
-Interfere with reaching deeper sleep stages
-Provide only temporary (1 week) increase in quantity if sleep
- Eventually cause “hangover” during day; excess drowsiness,
confusion, decreased energy.
- Sometimes worsens sleep apnea in the older adults.
▪ Antidepressants and Stimulants
- Suppress REM sleep
- Decrease total sleep time
▪ Alcohol
- Speeds onset of sleep
- Reduces REM sleep
- Awakens person during night and causes difficulty returning
to sleep.
▪ Caffeine
- Prevents person from falling asleep
- Causes person to awake during night
- Interferes with REM sleep
▪ Diuretics
- Nighttime awakenings caused by nocturia.
▪ Beta-Adrenergic Blockers
- Cause nightmares, insomnia, awakening from sleep
▪ Benzodiazepines
- Alter REM sleep
- Increase sleep time
- Increase daytime sleepiness
▪ Narcotics
- Suppress REM sleep
-Cause increased daytime drowsiness
▪ Anticonvulsants
-Decrease REM sleep time
- Causes daytime drowsiness
Common Sleep Disorders
▪ Parasomnias- behavior that may interfere sleep.
Parasomnias
▪ Bruxism- grinding of teeth; occurs during Stage II NREM sleep.
▪ Nocturnal Enuresis- Bed-wetting during sleep can occur in children 3 years
old. More males than females are affected. Often occurs 1-2 hrs after falling
asleep.
▪ Nocturnal erections- Emission and erections during REM sleep.
▪ Periodic Limb movements disorder (PLMD)- In this condition, the legs jerk
twice of three times per minute during sleep and is most common among elders.
▪ Sleeptalking- Occurs during NREM sleep before REM sleep. It presents a
problem to the person unless it becomes troublesome to others.
▪ Somnambulism- Sleepwalking occurs during stage III and IV of NREM sleep.
Usually occurs 1-2 hours after falling asleep. They tend not to notice dangers
(e.g stairs).
Primary Sleep Disorders- are those in which the person’s sleep problem is the main
disorder. These disorders include insomnia, hypersomnia, narcolepsy, sleep apnea
and sleep deprivation.
1. Insomnia- inability to obtain an adequate amount or quantity of sleep.

There are three types of insomnia:
o Difficulty in falling asleep (initial insomnia)
o Difficulty in staying asleep because or prolonged waking.
(intermittent insomnia)
o Early morning or premature waking (terminal insomnia)
2. Hypersomnia- opposite of insomnia,; excessive sleep, particularly in
daytime.
3. Narcolepsy- (from the greek word, narco, meaning “numbness”, and
lepsis, meaning “seizure”) a sudden wave of overwhelming sleepiness that
occurs during the day; thus its is referred to as “sleep attack”. Onset
symptoms occur between ages 15 to 30. The narcoleptic attacks sleep
starts with the REM phase.
4. Sleep Apnea- periodic cessation of breathing during sleep. Most frequent
in men over 50 and in postmenopausal women. It lasts 10 second to 2
minutes; occur during REM or NREM sleep. Episodes range from 50-600
per night.
There are three common types of sleep apnea: obstructive
apnea, central apnea, and mixed apnea.
o Obstructive apnea occurs when the structures of the
pharynx or oral cavity block the flow of air. The person
continues to breathe; that is, the chest and abdominal
muscles move.
o Central Apnea is thought to defect in the respiratory center
of the brain. All actions involved in breathing, such as chest
movement and airflow, cease.
o Mixed Apnea combination of obstructive and central apnea.
5. Sleep Deprivation- a prolonged disturbance in amount, quality, and
consistency of sleep may lead to this disorder. It is not a disorder itself but
a result of sleep disturbances. Two major types of sleep deprivation are
REM deprivation and NREM deprivation.
Type Causes Clinical signs

REM Deprivation Alcohol, barbiturates, shift • Excitability,
work, jet lag, extended ICU, restlessness, irritability
hospitalization, morphine, and increased sensitivity
meperidine hydrochlorine to pain
(Demerol) • Confusion and
suspiciousness
• Emotional lability
NREM Deprivation All the above plus diazepam • Withdrawal, apathy,
(Valium), flurazepam hyporesponsiveness
hydrochlorine (Dalmane), • Feeling physically
hyoothyroidism, depression, uncomfortable
respiratory distress • Lack of facial
disorders, sleep apnea, and expression
age (common in the elderly) • Speech deterioration
• Excessive sleepiness
Both REM and NREM As above • Decreased reasoning
Deprivation ability (judgment) and
ability to concentrate
• Inactiveness
• Marked Fatigue: blurred
vision, itchy eyes,
nausea, headache
• Difficulty performing
activities of daily living
• Lack of memory, mental
confusion, visual or
auditory hallucinations,
illusions
▪ Second Sleep Disorders- are sleep disturbances caused by clinical conditions.

NURSING PROCESS AND SLEEP
• ASSESSMENT
Sleep is a subjective experience. Only the client is able to describe his sleep
whether it is sufficient, restful or not. If the client is satisfied with his sleep you will
consider it as normal.
▪ Sleep Assessment
Aim your assessment at understanding characteristics of the
client’s sleep problem and the usual sleep habit so that you incorporate
ways for promoting sleep into nursing care.
▪ Sources for Sleep Assessment
o Client- resource for describing sleep problems and
how these problems are a change from their usual
sleep and waking patterns.
o Bed Partners- able to provide sleep patterns that
help reveal the nature of certain sleep disorder.
o Parents- usually reliable source of information
about how their child is having trouble sleeping.
Parents need to describe infant’s eating pattern and
sleeping environment because these influence
sleeping behavior.
▪ Tools for Assessment of Sleep
o Visual Analog Scale (Lashley, 2004)- A drawing
with a straight horizontal line 100mm (4 inches)
long. Opposite statements such as “best night’s
sleep” and “worst night’s sleep” are at the opposite
ends of the line.
o Numeric Scale- with a 0-10 sleep rating. Ask
individuals to separately rate their quantity and
quality of sleep on the scale. 0 being worst and 10
being the best sleep.
▪ Sleep History- When a client report having adequate sleep, a sleep
history is usually brief. Assess the quality and characteristics of sleep
in greater depth asking the client to describe the sleep problem.
o Describing of Sleeping Problems-
- This ensures therapeutic care is
approximately provided. Open-ended questions
help a client to describe a problem more fully.
To begin, you need to understand the nature of
the sleep problem, its signs and symptoms, its
onset and duration, its severity, any
predisposing factors or causes, and the overall
effect on the client.
Nursing Assessment Questions
Nature of the Problem

• What type of problem are you having with
your sleep?
Effect on Client
• Why do you think your sleep is inadequate?
• How has the loss of
• Describe for me a recent typical night’s sleep.
How is this sleep different from what you are sleep affected you?
used to? • Do you feel
excessively sleepy,
Signs and Symptoms irritable, or have
• Do you have difficulty falling asleep, staying trouble concentrating
asleep, or waking up? during waking hours?
• Have you been told you snore loudly? • Do you have trouble
staying awake or have
• Do you have headaches when awakening?
you fallen asleep at
Does your child awaken from nightmares?
inappropriate times,
for example, while
Onset and Duration
driving, sitting quietly
• When did you notice the problem?
in a meeting, or
• How long has this problem lasted? watching TV?
Severity
• How long does it take you to fall asleep?
• How often during the week do you have
trouble falling asleep?
• How many hours of sleep a night did you get
this week?
• How does this compare to what is usual for
you?
• What do you do when you awaken during the
night or too early in the morning?
Predisposing Factors
• What do you do just before you go to bed?
• How is your mood, and have you notices any
changes recently?
• What medications or recreational drugs do you
take on a regular basis?
• Are you taking any new prescription or over-
the-counter medications?
• Do you eat food (spicy or greasy foods) or
drinks substances (alcohol or caffeinated
beverages) that interfere with your sleep?
• Do you have a physical illness that interferes
with your sleep?
• Does anyone in you family have a history of
sleep problems?
As an adjunct to the sleep history, have the client and bed partner keep a
sleep-wake log for 1-4 weeks (Lashley, 2004). The client completes the sleep-wake
pattern log daily to provide information on day-to-day variations in sleep-wake patterns
over extended periods.
▪ Usual Sleep Pattern- Normal sleep is difficult to define because

individuals vary in perception of adequate quantity and quality of
sleep.
Ask the following questions to determine a client’s sleep pattern:
1. What time do you usually get in bed each night?
2. What time do you usually fall asleep? Do you do
anything special to help you fall asleep?
3. How many times do you awaken during the night?
Why?
4. What time do you typically wake up in the
morning?
5. What is average number of hours you sleep each
night?
▪ Physical and Psychological Illness- Determine whether the client has
preexisting health problems that interfere with sleep. A history of
psychiatric problems also makes difference. Also access medication
history, including the description of over-the-counter and prescribed
drugs.
▪ Current Life Events- Learn whether the client is experiencing any
changes in lifestyle that disrupt sleep.
▪ Emotional and Mental Status- Clients with psychiatric disorders may
need mild sedation for adequate rest. Client’s emotions and mental
status affect the ability to sleep.
▪ Bedtime Routines- Ask client what they do to prepare for sleep. Assess
habits that are beneficial compared with those that disturb sleep. Pay
some attention to a child’s rituals.
▪ Bedtime Environment- Ask the client to describe preferred bedroom
conditions. Some children require the company of a parent to fall
asleep. Identify factors to reduce or control the environment.
▪ Behaviors of Sleep Deprivation- Some clients are unaware of how
their sleep problems are affecting their behavior. Observe for
behaviors such as irritability, disorientation (similar to a drunken
state), frequent yawning, and slurred speech.
Physical Examination
Observe client’s facial appearance, behavior, and energy level. Darkened areas
around ayes, puffy eyelids, reddened conjunctiva, glazed or dull-appearing eyes, and
limited facial expressions are indicative of sleep sufficiency.
Diagnostic Studies:
Sleep is measured objectively in a sleep disorder laboratory by
Polysomnography: an electroencephalogram (EEG), electromyogram (EMG), and
electro-oculogram.
• DIAGNOSING
Disturbed Sleep Pattern, the NANDA (2003) diagnosis given to clients
with sleep problems, is usually made more elicit with description such as “falling
asleep” or “difficulty staying asleep”. Sleep pattern disturbances may also be
stated as the etiology of another diagnosis, in which case the nursing interventions
are directed toward the sleep disturbance itself. Examples include the following:
o Risk for Injury related to somnambulism
o Ineffective Coping related to quantity and quality of
sleep
o Fatigue related to insomnia
o Risk for Impaired Gas Exchange related to sleep apnea
o Deficient Knowledge (Nonprescription remedies for
insomnia) related to misinformation
o Disturbed Thought Process related to chronic insomnia
o Anxiety related to sleep apnea and threat of death
o Activity Intolerance related to sleep deprivation
• PLANNING
MAIN GOAL: Maintain (or develop) a sleeping pattern that provides
sufficient energy for daily activities.
Improve quantity and quality of the client’s sleep. The goal
based on the etiology of each nursing interventions to reach the goal based on the
etiology of each nursing diagnosis.
• IMPLEMENTING
Nursing interventions to enhance the quantity and quality of clients’ sleep
involve largely nonpharmacologic measures.
• Client Teaching-Clients need to learn (a) the conditions that

promote sleep and those that interfere with sleep, (b) safe use of
medications, (c) effects of other prescribed medications on sleep,
(d) effects of their disease states of sleep.
• Supporting Bedtime Rituals- Common prebedtime activities of
adults include an evening stroll, listening to music, watching
television, taking a soothing bath, and praying.
• Creating a Restful Environment- Minimal noise, a comfortable
room temperature, appropriate ventilation and appropriate lighting
(see the box below). The environment must also be safe so that the
client can relax. People who are the unaccustomed to narrow
hospital beds may feel more secure with side rails.
▪ Placing beds in low positions
▪ Using night-lights
▪ Placing call beds within easy reach
Reducing Environmental Distractions in Hospitals
• Close window curtains if street lights shine

through
• Close curtains between clients in semiprivate and
larger rooms
• Reduce or eliminate overhead lighting; provide a
night-light at the bedside or in the bathroom.
• Close the door of the client’s room
• Adhere to agency policy about times to turn off
communal televisions or radios
• Lower the ring tone of nearby telephones
• Discontinue use of the paging system after a
certain hour (e.g., 2100 hours) or reduce its
volume
• Keep required staff conversations at low levels;
conduct nursing reports or other discussions in a
separate area or away from the client rooms
• Wear rubber-soled rubber shoes
• Ensure that all cart wheels are well oiled
• Perform only essential noisy activities during
sleeping hours
• Promoting Comfort and Relaxation- A controlled, caring attitude,

along with the following interventions, can significantly promote
client comfort and sleep:
▪ Provide loose-fitting nightwear
▪ Assist clients with hygienic routines
▪ Make sure the bed linen is smooth, clean, and dry
▪ Assist or encourage the client to void before
bedtime
▪ Offer to provide back massage before sleep.
• Effleurage- is a type of massage consisting
of long, gliding strokes. Research
demonstrates that back massage has the
ability to elicit a relaxation response. A
simple 3-minute back rub can enhance client
comfort and relaxation and have a positive
effect on cardiovascular parameters such as
BP, HR, and RR.
• Purposes:
-To relieve muscle tension
-To promote physical and mental
relaxation
- To relieve insomnia
▪ Position dependent clients approximately to aid
muscle relaxation and provide supportive devices to
protect pressure areas.
▪ Schedule medications especially diuretics, t prevent
nocturnal awakenings.
▪ For clients who have pain, administer analgesics 30
minutes before sleep.
▪ Listen to the client’s concern and deal with
problems as they arise.
• Enhancing Sleep with Medications

Sleep medications often prescribed on a prn (as
needed) basis for clients include the sedative-hypnotics which
induce sleep, and antianxiety drugs or tranquilizers, which
decrease anxiety and tension.
Although medications vary in their activity and
effects, considerations include the ff:
▪ Sedative-hypnotic medications produce a general
central nervous system (CNS) depression and
unnatural sleep.
▪ Antianxiety medications decrease levels of
arousal by facilitating the action of neurons in
the CNS that suppress responsiveness to
stimulation.
▪ Sleep medications vary in their onset and
duration of action and will impair waking
function as long as they are chemically active.
▪ Sleep medication affect REM sleep more than
NREM sleep
▪ Initial doses of medications should be low and
increases added gradually, depending on the
client’s response.
▪ Regular use of any sleep medication can lead to
tolerance over time (e.g. 4 weeks) and rebound
insomnia.
▪ Abrupt cessation of barbiturate sedative-
hypnotics can create withdrawal symptoms.
Selected Sedative-Hypnotic Medications Used for
Insomnia
Medication Half-Life
• Chloral Hydrate (Noctec) 7-10 hrs
• Ethchlorvynol (Placidyl) 10-20 hrs
• Flurozepam (Dalmane) 47-100 hrs
• Gluthemide (Doriden) 1-12 hrs
• Lorezepam (Ativan) 10-20 hrs
• Melatonin 1 hr
• Temazepam (Restoril) 9-15 hrs
• Triazolam (Halcion) 1.5-5.5 hrs
• Zaleplon (Sonata) 1 hr
• Zolpidem (Ambien) 2.6 hrs
The half-life represents how long it takes for half of the medication to be metabolized and
eliminated by the body; hence, those with shorter half-life are less likely to cause residual
drowsiness after administration.
• EVALUATING
Data collection may include (a) observations of the duration of the
client’s sleep and the presence of REM and NREM sleep and (b) questions about how the
client feels on awakening, or about the effectiveness of specific interventions.
If the desired outcomes are not achieved, the nurse, client and support
people if appropriate should explore the reasons which may include answers to the ff
questions:
• Were etiologic factors correctly identified?
• Has the patient’s physical condition or medication therapy
changed?
• Did the client comply with instructions about establishing a
regular sleep wake pattern?
• Did the client avoid ingesting caffeine?
• Did the client participate in stimulating daytime activities to
avoid excessive daytime naps?
• Were all possible measures taken to provide a restful
environment for the client?
• Were bedtime rituals supported?
• Were the comfort and relaxation measures effective?

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What are the different positions used during a physical examination?

What are the different positions used during a physical examination?

What are some factors to consider when positioning a client for examination?

What are some factors to consider when positioning a client for examination?

ASSESSMENT

Physical health assessment is done to:

The nurse should:

It is important to determine in advance any positions that are contraindicated for a

In assessing adults, it is important to recognize that they differ markedly.

Health assessment of the Adult

• Be aware of normal physiologic changes that occur with age

Preparing the Environment

Several positions are frequently required during physical examinations. It is important to

Position Description Areas Assessed Cautions

Equipment and Supplies Used for a Health Examination

Laryngeal or dental mirror To observe the pharynx and oral cavity

To permit visualization of the lower and

Ophthalmoscope A lighted instrument to visualize the

Otoscope A lighted instrument to visualize the

Percussion Hammer An instrument with a rubber head to test

Vaginal Speculum To assess the cervix and the vagina

Cotton Applicators To obtain specimens

Disposable Pads To absorb liquid

Gloves To protect the nurse

Tongue blades (depressors) To depress tongue during the assessment of

General guidelines for palpation:

Two types of palpation:

b. Deep – bimanual or one hand

Palpation is used to determine the size and shape of internal organs by

b. Indirect – is the striking of an object held against the body area

Five types of sound:

Assessing Appearance and Mental Status

5. Observe the client’s Relaxed, erect posture; Tense, slouched, bent

9. Note obvious signs of Healthy appearance Pallor; weakness;

11. Note the client’s Inappropriate to

Illogical sequence; flight

14. Document findings

Height and Weight

Pallor is the result of inadequate circulating blood or hemoglobin and subsequent

Localized areas of hyperpigmentation (increased pigmentation) and hypopigmentation

Primary Skin Lesion

Secondary Skin Lesions

Examples: Striae, aged skin Examples: Decubitus ulcers (pressure

Scales Shedding flakes of greasy,

Examples: Keloid from ear piercing or

Crust Dry blood, serum, or pus left on the

Assessment Normal Findings Deviation from Normal

1+ Barely detectable (2 mm)

4+ Indentation of more than 7

8. Inspect, palpate and Freckles, some

9. Observe and palpate Moisture in skin folds Excessive moisture;

10. Palpate skin

12. Document findings

• Configuration. Refers to the arrangement of lesions in relation to each other.

Assessing the Hair

6. Inspect hair thickness Thick hair Very thin hair

7. Inspect hair texture Silky, resilient hair Brittle hair; excessively

8. Note presence of No infection or Flaking, sores, lice, nits,

10. Document findings