NCM 101 Midterm Notess

NCM 101 Health
Assessment
Lectured by: Mr. Bornie Baguio RN, MAN
Topic Coverage this week:
Holistic Nursing Assessment
1.General status and vital signs
2.Mental status
• Children and adolescent
• Adult
3.Psychosocial, cognitive and moral development
4.Pain
5.Violence
6.Culture and ethnicity
7.Spiritual and religious practices
8.Nutritional status 2
General status
and vital signs
The General Survey
First encounter-
obvious physical
characteristics
It’s an introduction to
prepare for the
physical assessment
Gives an overall
impression
3
Level of consciousness
✓ Vigilant – hyperalert, overly sensitive to environmental stimuli, startled very easily
✓ Alertness – awake, aware of self and environment. When spoken to in a normal
voice, patient looks at you and responds fully and appropriately to stimuli
✓ Lethargy – when spoken to in a loud voice, patient appears drowsy but opens
eyes and looks at you, responds to questions, then falls asleep
✓ Obtundation – when shaken gently, patient open eyes and looks at you but
responds slowly and is somewhat confused. Alertness and interest in environment
are decreased.
✓ Stupor – arouses from sleep only after painful stimuli. Verbal responses are slow
or absent. Lapses into unresponsiveness when stimulus stops. Has minimal
awareness of self or environment.
✓ Coma – despite repeated painful stimuli, patient remains unarousable with eyes
closed. No evident response to inner need or external stimuli is shown
4
Temperature
Pulse
Respiration
Blood pressure 5
Vital signs- Definitions
Temperature, pulse, blood pressure, respiratory rate
Indicate the effectiveness of circulatory, respiratory, neural and endocrine body
functions.
• These measures referred to vital signs because of their importance as

indicators of body’s physiological status.
• Any difference between normal baseline measurement and present may
indicate the need for nursing and medical interventions
• Pain- considered to be the 5th vital sign
(Potter & perry,2010).
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• Vital signs show an individual is alive.
They include heart beat, breathing rate,
temperature, and blood pressure. These
signs may be watched, measured, and
monitored to check an individual's level
of physical functioning. Normal vital
signs change with age, sex, weight,
exercise tolerance, and condition.
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Guidelines in Taking Vital Signs:
1.The nurse caring for the client measures vital signs.
– Give important information about the client’s health status.
2.Equipment should be functional and appropriate.
– To ensure accurate findings.
3.Know the normal range of vital signs.
– Helps the nurse in detecting abnormalities.
4.Know the client’s normal range of vital signs.
– A nurse can detect a change in condition overtime.
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5. Know the client’s medical history and any therapies or
medications prescribed.
6. Control or minimize any environmental factors that may affect
the vital signs.
– Temperature of the environment, physical activity and effects of illness
cause vital signs to change.
7. Use an organized, systematic approach when taking vital signs.
– Measure temperature first, and then check the pulse, respirations and
blood pressure.
8. Decide the frequency of vital sign assessment on the basis of
client’s condition.
9. Analyze the results of vital sign measurement.
10.Record or document the results of vital signs measured
10
Frequency of Vital Signs
Nurses should take a patient’s vital signs:
• Upon admission to a facility
• Before and after any surgical procedure
• Before, during, and after administration of medications that
affect vital signs
• As per the institution’s policy or physician orders
• Any time the patient’s condition changes
• Before and after any procedure affecting vital signs
11
Mental status
• a structured assessment of client’s behavioural and cognitive
functioning—is a vital component of nursing care that assists
with evaluation of mental health conditions.
• The MSE is analogous to the physical examination and is
used to evaluate an individual’s current cogitative, affective
and behavioural functioning (Varcarolis, 2014).
• Specifically, the MSE assesses a client’s current state
including general appearance, mood and affect, speech,
thought process and content, perceptual disturbances,
impulse control, cognition, knowledge, judgment and insight
(Lasiuk, 2015). 12
MSE Elements
The acronym BEST PICK can assist with learning the main elements of
an MSE (Carniaux-Moran, 2008). A brief description of the elements that
are assessed includes:
• Behaviour and general appearance - age, sex, gender, cultural background,
posture, dress/ grooming, manner, alertness, as well as agitation,
hyperactivity, psychomotor retardation, unusual movements, catatonia, etc.
• Emotions: mood and state, emotional state and visible expression (state)
including description and variability.
• Speech—rate, amount, style and tone of speech.
• Thought content and processes—abnormalities, obsessions, delusions and
suicidal and homicidal thoughts and thought process as well as loose
associations, tangential thinking, word salad, and neologisms, circumstantial
thought, and concrete versus abstract thought. 13
MSE Elements
• Perceptual disturbances—illusions and hallucinations.
• Impulse control—ability to delay, modulate or inhibit
expressions or behaviours.
• Cognition—consciousness, orientation, concentration and
memory.
• Knowledge, insights and judgment—the capacity to identify
possible courses of action, anticipate consequences, and
choose appropriate behaviour, and extent of awareness of
illness and maladaptive behaviours.
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A. Children and adolescent
1. Focus on health promotion and illness prevention, particularly for care of well children with
competent parenting and no serious health problems (Hockenberry and Wilson, 2011). Focus on
growth and development, sensory screening, dental examination, and behavioral assessment.
2. Children who are chronically ill, disabled, in foster care, or foreign-born adopted may require
additional assessments because of unique health needs.
3. When obtaining histories of infants and children, gather all or part of the information from parents or
guardians.
4. Children who are chronically ill, disabled, in foster care, or adopted from a foreign country may
require additional assessment because of their unique health risks.
5. Parents may think that the examiner is testing or judging them. Offer support during examination
and do not pass judgment.
6. Call children by their preferred name and address parents as “Mr. and Mrs. Cruz” rather than by
first names.
7. Open-ended questions often allow parents to share more information and describe more of the
child’s problems.
8. Older children and adolescents respond best when treated as adults and individuals and often can
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provide details about their health history and severity of symptoms.
Psychosocial, cognitive and moral development
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17
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19
20
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• A personal & subjective experience w/ few or no
objective measurements.
• Nursing Definition (McCaffery) – “Whatever the
experiencing person says it is, and existing whenever
the person says it does.”
• Int. Assoc. for study of Pain (IASP)- “Unpleasant,
subjective sensory & emotional experience assoc. with
actual or potential tissue damage, or described in terms
of such damage.”
• Multidimensional phenomenon
• Viewed as an experience, not merely a symptom and not
a disease entity. 22
THEORIES:
1. Specific – Theory (Descartes-17th century) – specialized
pathways for pain transmission exist. Free nerve endings
existed in periphery as pain receptors. g transmitted through
the dorsal horn & substantia gelatinosa g thalamus g upper
level of the cortices.
2. Gate Control Theory – controlled by the dorsal horn of the

spinal cord
– Substantia gelatinosa in the dorasal horn of the SC acts as a
gate mechanism that can close or open.
– Most pain impulses are conducted over small-diameter nerve
fibers (A-delta) 23
PROCESS :
1. Pain transduction – stimulation of the nociceptors
2. Pain transmission – discharged impulse travels as
electric activity to spinal cord gbrain = pain
sensation.
– A-beta – larger and carry other sensory info. such
as touch
– A-delta – transmit pain fast.
- C fibers – transmit pain more slowly / no myelin
sheath.
3. Pain modulation – variation in the way clients 24
perceive similarly painful stimuli.

Pain reception
pathway :
25
Perception of pain :
• Pain Threshold – lowest perceivable intensity
of stimuli that is transmitted as pain.
• Pain Tolerance – amount of pain the client is
willing to endure.
• Past experiences of pain.
26
Physiological Responses to pain:
Sympathetic Stimulation :
1. dilation of bronchial tubes & hresp. rate.
2. hheart rate
3. peripheral vasoconstriction (pallor, hBP)
4. hblood glucose level
5. diaphoresis
6. hmuscle tension
7. dilation of pupils
8. iGI motility
27
Parasympathetic Stimulation :
1. pallor
2. muscle tension
3. iHR & BP
4. rapid, irregular breathing
5. nausea & vomiting
6. weakness or exhaustion
28
Behavioral Response:
• Phases of pain experience:
–Anticipation – allows a person to learn about
pain & its relief.
–Sensation – pain is felt. Gauging tolerance
level of pain.
–Aftermath – pain is reduced or stopped.
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Behavioral Indicators of Effects of Pain
Vocalizations: moaning / crying / screaming / gasping /
grunting
Facial expressions : grimace / clenched teeth / wrinkled
forehead / tightly closed or widely opened eyes or mouth /
lip biting / tightened jaw
Body movement : Restlessness / immobilization / muscle
tension / hhand & finger movements / pacing activities /
rhythmic or rubbing motions / protective movement of body
parts.
Social Interaction : Avoidance of conversation / focus only on
activities for pain relief / avoidance of social contact /
reduced attention span.
30
Factors Influencing Pain :
a. Age f. Attention
b. Sex g. Anxiety
c. Culture h. Fatigue
d. Meaning of pain
e. Previous experience
f. Coping style
g. Family & social support
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Assess for :
• Onset / time of occurrence
• Duration – chronic or acute
• Severity or intensity – scale 0 – 10
• Mode of transmission – normal pain pathway vs referred
pain
• Location / source
• Causation
• Causative forces / agent – spontaneous / self-inflicted
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Pain Scale
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Types of Pain :
o Acute Pain
o Chronic Pain
o Cutaneous or superficial pain
o Deep somatic pain
o Visceral pain
o Referred pain
o Malignant pain
o Pain of Psychological origin
▪ Pretended pain
▪ Psychogenic pain 34
Nursing Intervention :
Alleviating Anxiety Meditation
Autogenic Training Accupressure
Guided Imagery Rhythmic Breathing
Operant Conditioning Biofeedback
Touch Cutaneous Stimulation
Hypnosis Music
Progressive Relaxation Training
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Pharmacology
Non-narcotic analgesics
‚ Acetaminophen (Tyenol, Datril)
‚ Acetylsalicylic acid (aspirin)
‚ Choline magnesium trisalicylate (Trilisate)
NSAIDS
‚ Ibuprofen (Motrin, Nuprin)
‚ Naproxen (Naprosyn)
‚ Naproxen sodium (Anaprox)
‚ Indomethacin (Indocin)
‚ Tolmetin (Tolectin)
‚ Piroxicam (Feldene) 36
Narcotic Analgesics Adjuvants
‚ Meperidine (Demerol) ‚ Amitriptyline (Elavil)
‚ Methylmorphine (Codeine) ‚ Hydroxyzine (Vistaril)
‚ Morphine sulfate (Morphine) ‚ Caffeine
‚ Fentanyl (Sublimaze) ‚ Chlorpromazine (Thorazine)
‚ Butorphanol (Stadol) ‚ Diazepam (Valium)
‚ Hydromorphone HCl (Dilaudid)
37
Violence
• Family violence can be defined as “a situation in which
one family member causes physical or emotional harm
to another family member. At the center of this violence
is the abuser’s need to gain power and control over
the victim” (Violence wheel, 2009).
38
The cycle of violence.
(From Varcarolis, E.,
Carson, V., &
Shoemaker, N. [2010].
Foundations of
psychiatric mental
health nursing [6th ed.].
St. Louis: Saunders.)
39
Description:
1. Violence begins with threats or verbal or physical minor
assaults (tension building), and the victim attempts to comply
with the requests of the abuser.
2. The abuser loses control and becomes destructive and
harmful (acute battering), while the victim attempts to protect
himself or herself.
3. After the battering, the abuser becomes loving and attempts
to make peace (calmness and defusing of tension).
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4. The abuser justifies that violence is normal and the
victim is responsible for the abuse.
5. Outsiders are usually unaware of what is happening
in the family.
6. Family members are isolated socially and lack
autonomy and trust among each other; caring and
intimacy in the family are absent.
7. Family members expect other members of the family
to meet their needs, but none are able to do so.
8. The abuser threatens to abandon the family.
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Types of Violence
1. Physical Violence - Infliction of physical pain or
bodily harm
2. Sexual Violence - Any form of sexual contact
without consent
3. Emotional Violence - Infliction of mental anguish
4. Physical Neglect - Failure to provide health care to
prevent or treat physical or emotional illnesses
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Types of Violence
6. Developmental Neglect - Failure to provide
physical and cognitive stimulation needed to
prevent developmental deficits
7. Educational Neglect - Depriving a child of education
8. Economic Exploitation - Illegal or improper exploitation
of money, funds, or other resources for one’s personal
gain
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The vulnerable person
1. The vulnerable person is the one in the family unit
against whom violence is perpetrated.
2. The most vulnerable individuals are children and
older adults.
3. The perpetrator of violence and the person targeted
by the violence can be male or female.
4. Battering is a crime.
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Characteristics of abusers
1. Impaired self-esteem
2. Strong dependency needs
3. Narcissistic and suspicious
4. History of abuse during childhood
5. Perceive victims as their property and believe
that they are entitled to abuse them
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Characteristics of victims
1. Victims feel trapped, dependent, helpless, and
powerless.
2. Victims of abuse may become depressed as they are
trapped in the abusers’ power and control cycle
3. As victims’ self-esteem becomes diminished with
chronic abuse, they may blame themselves for the
violence and be unable to see a way out of the
situation.
46
Interventions
1. Report suspected or actual cases of child abuse or abuse of
an older adult to appropriate authorities (follow state and
agency guidelines).
2. Assess for evidence of physical injuries.
3. Ensure privacy and confidentiality during the assessment and
provide a nonjudgmental and empathetic approach to foster
trust; reassure the victim that he or she has not done anything
wrong.
4. Assist the victim to develop self-protective and other problem-
solving abilities. 47
Interventions
5. Even if the victim is not ready to leave the situation,
encourage the victim to develop a specific safety plan (a fast
escape if the violence returns) and where to obtain help
(hotlines, safe houses, and shelters); an abused person is
usually reluctant to call the police.
6. Assess suicidal potential of the victim.
7. Assess the potential for homicide.
8. Assess for the use of drugs and alcohol.
9. Determine family coping patterns and support systems. 48
Interventions
10. Provide support and assistance in coping with contacting
the legal system.
11. Assist in resolving family dysfunction with prescribed
therapies.
12. Encourage individual therapy for the victim that promotes
coping with the trauma and prevents further
psychological conflict.
13. Encourage individual therapy for the abuser that focuses
on preventing violent behavior and repairing
relationships. 49
Interventions
14. Encourage psychotherapy, counseling, group
therapy, and support groups to assist family members
to develop coping strategies.
15. Assist the family to identify an access to community
and personal resources.
16. Maintain accurate and thorough medical health
records.
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Culture and ethnicity
• Culture - dynamic network of knowledge, beliefs,
patterns of behavior, ideas, attitudes, values, and
norms that are unique to a particular group of people.
• Ethnic group - people within a culture who share
characteristics based on race, religion, color, national
origin, or language.
• Ethnicity - an individual’s identification of self as part
of an ethnic group.
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Personal Cultural Assessment
Five areas to be examined in assessing one’s
own culture and the influence it may have on
personal beliefs about health care are:
– Influences from own ethnic/racial background.
– Typical verbal and non-communication patterns.
– Cultural values and norms.
– Religious beliefs and practices.
– Health beliefs and practices.
52
Client Cultural Assessment
Six categories of information necessary for a
comprehensive cultural assessment of a client
are:
– Ethnic or racial background.
– Language and communication patterns.
– Cultural values and norms.
– Biocultural factors.
– Religious beliefs and practices.
– Health beliefs and practices. 53
Culturally Appropriate Care
• Respect clients for their different beliefs.
• Be sensitive to behaviors and practices different from your
own.
• Accommodate differences if they are not detrimental to
health.
• Listen for cues in the client’s conversation that relay a
unique ethnic belief about etiology, transmission,
prevention, etc.
• Teach positive health habits if client’s practices are
deleterious to good health.
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Spiritual and religious practices
• A spiritual assessment assists the nurse in
planning holistic nursing care. Whether the
nurse is unclear about the patient's spiritual
belief or the patient has a spiritual belief
unfamiliar to the nurse, acronym models such
as FICA provide the basis for an organized,
open and non-biased assessment.
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FICA model
One popular acronym tool is the FICA model. These are the areas of
assessment and possible questions that could be asked:
• F-Faith or beliefs: What are your spiritual beliefs? Do you consider yourself
spiritual? What things do you believe in that give meaning to life?
• I-Importance and influence: Is faith/spirituality important to you? How has
your illness and/or hospitalization affected your personal practices /beliefs?
• C-Community: Are you connected with a faith center in the community? Does
it provide support/comfort for you during times of stress? Is there a
person/group/leader who supports/assists you in your spirituality?
• A-Address: What can I do for you? What support/guidance can health care
provide to support your spiritual beliefs/practices?
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Nutritional status
57
58
59
60
61
62
63
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References:
• Carniaux-Moran, C. (2008). The Psychiatric Nursing Assessement. In O’Brien, P.G., Kennedy, W.Z.,
Ballard, K.A. Psychiatric mental health nursing: an introduction to theory and practice.,Sudbury, MA: Jones &
Bartlett
• Weber, Janet R., Jane H. Kelley (2014); Health Assessment in Nursing; 5th Ed., Wolters Kluwer Health |
Lippincott Williams & Wilkins.
• Perry, A. G., (2014). Clinical Nursing Skills and Techniques. Mosby, Inc., an affiliate of Elsevier Inc., St.
Louis, Missouri 63043 ISBN 978-0-323-08383-6
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Question 1
Pain is:
- A strongly unpleasant bodily sensation caused by actual or potential injury
Question 2
The stage that occurs between 5 – 13 years of age is concerned with:
- Industry vs. inferiority
Question 3
Who among the following proposed that personality development in childhood takes
place during five psychosexual stages, which are the oral, anal, phallic, latency, and
genital stages and that during each stage, sexual energy (libido) is expressed in
different ways and through different parts of the body?
- sigmund
Question 4
Facial expression, physiological changes and behavioral changes are a part of direct
observation for pain assessment.
- true
Question 5
Failure to provide health care to prevent or treat physical or emotional illnesses is a
form of which type of violence?
- Physical neglect
Question 6
The amount of force exerted against the walls of the artery by the blood is commonly
referred to as:
Blood pressure
Question 7
One of your friends tells you to steal some sweets. You are in Level 1, why do you NOT
steal?
- I might get caught and get in trouble
Question 8
Direct methods of nutritional assessment are summarized as:
- abcd
Question 9
A technique that teaches your body to respond to your verbal commands. These
commands "tell" your body to relax and help control breathing, blood pressure ,
heartbeat, and body temperature to achieve deep relaxation and reduce stress is known
as:
- autogenic training
Question 10
The nurse is aware that the term bradycardia means:
- a heart rate of under 60 bpm
Question 11
At which phase of the cycle of violence does the abuser assumes a loving behavior,
contrite and makes promises to change?
- Honeymoon phase
Question 12
The capacity to identify possible courses of action, anticipate consequences, and
choose appropriate behaviour, and extent of awareness of illness and maladaptive
behaviours are assessments to identify which element of the patient’s mental status
- Knowledge, insight and judgement
Question 13
Kohlberg was concerned with what type of development?
- moral
Question 14
Obsessions, delusions and suicidal and homicidal thoughts and thought process
alterations are categorized under which element of Mental Status Examination?
- Thought content and processes
Question 15
A situation in which one family member causes physical or emotional harm to another
family member is known as:
- Family violence
Question 16
______________________ is the amount of time something lasts or continues.
- Duration
Question 17
Which of the following vital sign will reveal information about pyrexia is:
- Temperature
Question 18
You are about to take the baseline vital signs. Before doing this you should ensure that:
- You inform the patient
Question 19
A person is considered obese with a BMI of:
- BMI of 30 or higher
Question 20
Pain management for acute pain involves pharmacological approaches only.
- false
Question 21
Which of the following assessment is a component of a patient assessment that
observes the entire patient as a whole and begins with the initial patient contact and
continue throughout the helping relationship?
- General survey
Question 22
What is the name of Erik Erickson's development theory?
- Psycho-social
Question 23
________________ is a pain that lasting for more than 6 months.
- Chronic pain
Question 24
Which of the following Non-Steroidal Anti-inflammatory drug (NSAIDS) is prescribed for
mild to moderate pain?
- Ibuprofen motrin
Question 25
Which pain scale is used for children?
- Wong-bake faces pain scale
Question 26
Which of the following is a specific nerve receptor for pain?
- nociceptors
Question 27
BMI stands for:
- body mass index
Question 28
The height, weight, head circumference, body mass index (BMI), body circumferences
to assess for adiposity (waist, hip, and limbs), and skinfold thickness are the core
elements of:
- Antropometric assessment
Question 29
Which of the following refers to how much pain a person can reasonably endure?
- tolerance
Question 30
To assess for hypotension due to shock, the nurse would take which vital sign?
- Blood pressure
Question 31
Cindy understands her world primarily by grasping and sucking easily available objects.
Cindy is clearly in Piaget's ________ stage:
- Sensorimotor
Question 32
Pain that we experience it when our internal organs are damaged is related to:
- Visceral pain
Question 33
In which psychosexual stage of personality development does Oedipus and Electra
complexes become evident?
- Phallic
Question 34
Which of the following are the most vulnerable person for violence in the family unit?
- all
Question 35
An unresponsiveness from which a person arouses from sleep only after painful stimuli.
Verbal responses are slow or absent and lapses into unresponsiveness when stimulus
stops. Patient has minimal awareness of self or environment. This is known as:
- stupor
Question 36
The categories of information necessary for a comprehensive cultural assessment of a
client includes all of the following, EXCEPT:
- political affiliation
Question 37
Failure to provide physical and cognitive stimulation needed to prevent developmental
deficits is a form of which type of violence?
- Developmental neglect
Question 38
Factors influencing pain would include which of the following?
- all
Question 39
Characteristics of abusers includes all of the following, EXCEPT:
- high self esteem
Question 40
The people within a culture who share characteristics based on race, religion, color,
national origin, or language is known as:
- ethnic group
Question 41
Mental Status assessment is a structured assessment of client’s behavioural and
cognitive functioning—is a vital component of nursing care that assists with evaluation
of:
- mental health conditions
Question 42
Intimacy vs. Isolation occurs at what stage?
- Young adulthood
Question 43
As victims’ self-esteem becomes diminished with chronic abuse, they may blame
themselves for the violence and be unable to see a way out of the situation.
- true
Question 44
Which of the following is also known as the 5th vital sign?
- pain
Question 45
A description of pain is ______________________ when it is based on the individual’s
experience or perceptions.
- subjective
Question 46
Which assessment tool was developed to help health care professionals address
spiritual issues with patients?
- maslows
Question 47
What is Kohlberg's theory?
- People progress in their moral reasoning through stages
Question 48
- moral
Question 49
To assess the effectiveness of cardiac compressions during adult cardiopulmonary
resuscitation (CPR), the nurse should palpate which pulse site?
- Carotid
Question 50
Nurses should take a patient’s vital signs during all of the following, EXCEPT:
- During any surgical procedure
PHYSICAL EXAMINATION OF THE
EARS, NOSE, SINUSES, MOUTH
AND THROAT
JOSHUA D. VARGAS, RN, MD
The Ear
• The Auricle. Inspect the auricle and surrounding tissue for
deformities, lumps, or skin lesions.
• If ear pain, discharge, or inflammation is present, move the auricle
up and down, press the tragus, and press firmly just behind the ear.
Ear Canal and Drum
• To see the ear canal and drum, use an
otoscope with the largest ear speculum
that the canal will accommodate and the
brightest light.
• Position the patient’s head so that you can
see comfortably through the instrument.
• To straighten the ear canal, grasp the
auricle firmly but gently and pull it upward,
backward, and slightly away from the head.
• Caution the patient to remain still.
Ear Canal and Drum
• Insert the speculum gently into the ear canal about a quarter inch,
directing it somewhat down and forward and through the hairs, if any,
toward the eardrum.
• Inspect the ear canal, noting any discharge, foreign bodies, redness of
the skin, or swelling. Cerumen, which varies in color and consistency
from yellow and flaky to brown and sticky or even to dark and hard,
may wholly or partly obscure your view.
• Inspect the eardrum, noting its color and contour. The cone of light—
usually easy to see—helps to orient you.
Ear Canal and Drum
• Identify the handle of
the malleus, noting its
position, and inspect
the short process of
the malleus.
Auditory Acuity
• To estimate hearing, test one ear at a time. Ask the patient to occlude
one ear with a finger, or better still, occlude it yourself.
• When auditory acuity on the two sides is different, move your finger
rapidly, but gently, in the occluded canal.
• Then, standing 1 or 2 feet away, exhale fully (so as to minimize the
intensity of your voice) and whisper softly toward the unoccluded ear
• To make sure the patient does not read your lips, stand behind the
patient, cover your mouth or obstruct the patient’s vision.
Air and Bone Conduction
• If hearing is diminished, try to distinguish conductive from
sensorineural hearing loss.
• You need quiet room and a tuning fork, preferably of 512 Hz or
possibly 1024 Hz.
• Weber test
• Test for lateralization
• Place the base of the lightly vibrating
• tuning fork firmly on top of the
patient’s head or on the midforehead
• Ask where the patient hears it: on one
or both sides
• Normally the sound is heard in the
midline or equally in both ears.
Rinne test
• Compare air conduction (AC) and bone
conduction (BC)
• Place the base of a lightly vibrating tuning
fork on the mastoid bone, behind the ear
and level with the canal.
• When the patient can no longer hear the
sound, quickly place the fork close to the
ear canal and ascertain whether the sound
can be heard again.
• Normally the sound is heard longer
through air than through bone (AC>BC).
The Nose
The Nose
• Inspect the anterior and inferior surfaces of the nose. Gentle pressure
on the tip of the nose with your thumb usually widens the nostrils
and, with the aid of a penlight or otoscope light, you can get a partial
view of each nasal vestibule. If the tip is tender, be particularly gentle
and manipulate the nose as little as possible.
• Note any asymmetry or deformity of the nose.
• Test for nasal obstruction, if indicated, by pressing on each ala nasi in
turn and asking the patient to breathe in.
The Nose
• Inspect the inside of the nose with an
otoscope and the largest ear speculum
available.
• Tilt the patient’s head back a bit and
insert the speculum gently into the
vestibule of each nostril, avoiding
contact with the sensitive nasal
septum.
• By directing the speculum posteriorly,
then upward in small steps, try to see
the inferior and middle turbinates, the
nasal septum, and the narrow nasal
passage between them. Some
asymmetry of the two sides is normal.
The Nose
• Observe the nasal mucosa, the nasal septum, and any abnormalities.
The nasal mucosa that covers the septum and turbinates.
• Note its color and any swelling, bleeding, or exudate. If exudate is present,
note its character: clear, mucopurulent, or purulent. The nasal mucosa is
normally somewhat redder than the oral mucosa
• The nasal septum
• Note any deviation, inflammation, or perforation of the septum. The lower
anterior portion of the septum (where the patient’s finger can reach) is a
common source of epistaxis (nosebleed).
• Any abnormalities such as ulcers or polyps.
The Nose
• Inspection of the nasal cavity through the anterior naris is usually
limited to the vestibule, the anterior portion of the septum, and the
lower and middle turbinates.
• Examination with a nasopharyngeal mirror is required for detection of
posterior abnormalities. This technique is used by
otorhinolaryngologists (ear, nose, and throat [ENT] specialists).
• Make it a habit to dispose of all nasal and ear specula after use.
The Sinuses
• Palpate for sinus tenderness.
Press up on the frontal sinuses
from under the bony brows,
avoiding pressure on the eyes.
Then press up on the maxillary
sinuses.
The Mouth and Throat
• Inspect the following:
• The Lips.
• Observe their color and moisture, and
note any lumps, ulcers, cracking, or
scaliness.
• The Oral Mucosa.
• Look into the patient’s mouth and, with
a good light and the help of a tongue
blade, inspect the oral mucosa for color,
ulcers, white patches, and nodules. The
wavy white line on this buccal mucosa
develops where the upper and lower
teeth meet.
• Irritation from sucking or chewing may
cause or intensify it.
• The Gums and Teeth.
• Note the color of the gums, normally pink. Patchy brownness
may be present, especially but not exclusively in black people.
Inspect the gum margins and the interdental papillae for
swelling or ulceration.
• Inspect the teeth.
• Are any of them missing, discolored, misshapen, or abnormally
positioned? You can check for looseness with your gloved
thumb and index finger. Look for malocclusion of the teeth.
• The Roof of the Mouth.
• Inspect the color and architecture of
the hard palate.
• The Tongue and the Floor of the
Mouth.
• Ask the patient to put out his or her
tongue. Inspect it for symmetry—a test
of the hypoglossal nerve (cranial nerve
XII).
• Note the color and texture of the
dorsum of the tongue.
• Inspect the sides and undersurface of the
tongue and the floor of the mouth. These are
the areas where cancer most often develops.
• Note any white or reddened areas, nodules, or
ulcerations. Because cancer of the tongue is
more common in men older than 50 years,
especially in smokers and drinkers of alcohol,
palpation is indicated.
• Explain what you plan to do and put on gloves.
• Ask the patient to protrude his or her tongue.
• With your right hand, grasp the tip of the
tongue with a square of gauze and gently pull
it to the patient’s left.
• Inspect the side of the tongue, and then
palpate it with your gloved left hand, feeling
for any induration (hardness)
• Reverse the procedure for the other side.
The Pharynx
• Now, with the patient’s mouth open but the
tongue not protruded, ask the patient to say
“ah” or yawn. This action may let you see
the pharynx well. If not, press a tongue
blade firmly down upon the midpoint of the
arched tongue—far enough back to get
good visualization of the pharynx but not so
far that you cause gagging.
• Simultaneously, ask for an “ah” or a yawn.
Note the rise of the soft palate and the
uvula—a test of cranial nerve X (the vagal
nerve).
The Pharynx
• Inspect the soft palate, anterior
and posterior pillars, uvula,
tonsils, and pharynx.
• Note their color and symmetry and
look for exudate, swelling,
ulceration, or tonsillar enlargement.
Tonsils are graded based on size:
• 1: Tonsils are visible
• 2: Tonsils are between the tonsillar
pillars and the uvula.
• 3: Tonsils are touching the uvula.
• 4: Tonsils are touching each other.
PHYSICAL EXAMINATION OF
THE HEAD AND NECK
The Hair
• Note its quantity,
distribution,
texture, and
pattern of loss, if
any.
• You may see loose
flakes of dandruff.
The Scalp.
• Part the hair in

several places
and look for
scaliness, lumps,
nevi, or other
lesions.
The Skull.
• Observe the general size and
contour of the skull. Note any
deformities, depressions, lumps,
or tenderness.
• Learn to recognize the
irregularities in a normal skull,
such as those near the suture
lines between the parietal and
occipital bones.
The Face
• Note the patient’s
facial expression and
contours. Observe for
asymmetry, involuntary
movements, edema,
and masses.
The Skin.
•Observe the skin,

noting its color,
pigmentation,
texture, thickness,
hair distribution,
and any lesions.
The Neck.
• Observe the skin, noting its color,
pigmentation, texture, thickness,
hair distribution, and any lesions.
Inspect the neck, noting its
symmetry and any masses or scars.
• Look for enlargement of the
parotid or submandibular glands,
and note any visible lymph nodes.
The Lymph Nodes.
• Palpate the lymph nodes.
• Using the pads of your index and
middle fingers, move the skin over
the underlying tissues in each area in
a circular motion.
• The patient should be relaxed, with
neck flexed slightly forward and, if
needed, slightly toward the side
being examined. You can usually
examine both sides at once.
The Lymph Nodes.
Feel in sequence for the following nodes:
1. Preauricular—in front of the ear
2. Posterior auricular—superficial to the mastoid process
3. Occipital—at the base of the skull posteriorly
4. Tonsillar—at the angle of the mandible
5. Submandibular- midway between the angle and the tip of the
mandible. These nodes are usually smaller and smoother than
the lobulated submandibular gland against which they lie.
6. Submental—in the midline a few centimeters behind the tip of
the mandible
7. Superficial cervical—superficial to the sternomastoid
8. Posterior cervical—along the anterior edge of the trapezius
9. Deep cervical chain—deep to the sternomastoid and often
inaccessible to examination. Hook your thumb and fingers
around either side of the sternomastoid muscle to find them.
10.Supraclavicular—deep in the angle formed by the clavicle and
the sternomastoid
The Trachea and the Thyroid Gland.
• To orient yourself to the neck, identify

the thyroid and cricoid cartilages and
the trachea below them.
• Inspect the trachea for any
deviation from its usual midline
position. Then feel for any
deviation. Place your finger along
one side of the trachea and note
the space between it and the
sternomastoid. Compare it with
the other side. The spaces should
be symmetric.
The Trachea and the Thyroid Gland.
• Inspect the neck for the thyroid gland. Tip the patient’s head back a
bit. Using tangential lighting directed downward from the tip of the
patient’s chin, inspect the region below the cricoid cartilage for the
gland. The lower shadowed border of each thyroid gland shown here
is outlined by arrows.
The Carotid Arteries and Jugular Veins.
• Defer a detailed examination of
these vessels until the patient lies
down for the cardiovascular
examination.
• Jugular venous distention,
however, may be visible in the
sitting position and should not be
overlooked.
• You should also be alert to
unusually prominent arterial
pulsations.
Recording your findings
PHYSICAL EXAMINATION OF THE SKIN
Dermatological examination
• Before you can make a diagnosis of any skin lesion, it's important to
be able to accurately describe the skin lesion.
• A thorough examination of the whole skin is considered best
practice.
• First just look
• Note whether the patient looks ill or well. Note whether there any
clues as to systemic illness.
• Wipe off any creams, make-up or anything else that may obscure the
true nature of the lesions.
• Now focus on the lesion(s)
• Note the position of lesions:
• Consider whether the distribution is symmetrical or asymmetrical.
(Symmetrical distribution suggests an endogenous condition such as
psoriasis, while asymmetry is more typical of an exogenous condition such
as tinea.) Some rashes have a characteristic distribution such as with
shingles.
• Note whether flexor or extensor surfaces are involved.
• Establish whether there are areas of friction or pressure.
• Note whether sweaty regions are involved.
• Note whether exposed regions are involved.
• Consider whether sexual contact is a factor (consider genital lesions but also
the lower abdomen and upper thighs).
•Note the size of the lesion. Measure for accuracy.
•Establish whether it is single or multiple.
•If a rash exists, consider its morphology. Are individual lesions:
•Macular?
•Papular?
•Vesicular?
•Crusty?
•Urticarial?
•Note color, shape, regularity or irregularity.
•Note whether areas of inflammation around it exist.
•Consider whether the edge is clearly demarcated or poorly defined.
Now touch
• Tenderness. Warmth. Site within the skin. Thickness.
• Consistency (hard, soft, firm, fluctuant).
• Note whether firm pressure leads to blanching.
• Note whether it is friable and whether it bleeds easily.
• Scaling - disorders of the epidermis may produce scale, which may be
visible, or gentle scratching of the skin may make it apparent.
• If appropriate, look to see if there is any evidence of infestation - eg,
scabies' burrows.
• Note hair in the local skin and on the head.
• Look at the nails.
• Note whether mucous membranes are involved.
• Examine the genitals where appropriate.
• Note regional lymph nodes. This may be relevant for infectious or
malignant lesions.
Standard examination of the skin
without lesions
Setting up the examination
• Good lighting (daylight or its
equivalent)
• Good exposure (ask patient to
disrobe)
• Universal precaution
• Appropriate PPE
• No make up
Standard examination of the skin without
lesions
• Note basic demographics of the patient: age, sex, occupation,
nationality, country of origin.
• Past medical history.
• Family history.
• Personal and social history.
Standard examination of the skin without
lesions
• Focus on reviewing signs and symptoms related to the skin.
• Describe the skin:
• Color
• Moisture
• Temperature
• Texture
• Mobility and turgor
Describing color
Describing texture
Describing temperature
Describing moisture
Describing mobility and turgor
Sample Report
• No history of pigmentation changes, rashes, pruritus, brusing or
bleeding, changes in size and shape of moles, and previously
diagnosed skin disease.
• Dark brown skin appears smooth and supple, warm to touch, with
quick recoil after pinching. Nailbeds appear pinking and capillary refill
time is less than 2 secs. Moles appear with symmetric edges, regular
borders, no variation in color, all less than 0.5 cm. Tongue and
mucous membranes appear pinking and moist. Palpebral
conjunctivae appear pinkish. Hair is black and coarse, with no signs of
hair loss.
Patient with a skin complaint
Terminologies: Secondary Lesions
• Scale – flakes; accumulation of stratum corneum
• Crust – dried exudates
• Scar – fibrous tissue formed as part of wound healing
• Excoriation – erosion from scratching
• Lichenification – thickening, accentuated skin fold markings
• Depressed
• Atrophy (loss of substance, intract dermis)
• Erosion (epidermis)
• Fissure (linear)
• Ulcer (dermis)
History:
• Evolution of lesions
a. Site of onset
b. Manner in which the eruption progressed or spread
c. Duration
d. Periods of resolution or improvement in chronic eruptions
History:
• Symptoms associated with the eruption
a. Itching, burning, pain, numbness
b. What, if anything, has relieved symptoms
c. Time of day when symptoms are most severe
History:
• Current or recent medications
• Associated systemic symptoms
• Ongoing or previous illnesses
• History of allergies
• Presence of photosensitivity
• Review of systems
• Family history
• Social, sexual, or travel history
Sample History
A 56-year-old diabetic man presented erythematous papules and
pustules on the neck and face who had developed since 3 months. He
had been treated with topical corticosteroids for the same time
period that resulted in progressive exacerbation. He additionally
showed patches of hair loss in the beard area, erythema and scaling
of the ears.
Sample History
A 32-year-old woman had developed moderate swelling, erythema and
papules of the central part of her face for 8 weeks. She started to
apply various topical cosmetic products sold for acne that did not
help. As one of her hobbies was outdoor biking she noticed that sun
exposure aggravated her skin condition, also resulting in burning and
stinging sensations. She consulted her general practitioner who
prescribed prednicarbat cream for topical application on the affected
regions. Whereas she observed a slight improvement of the skin
condition during the first week, she later on suddenly developed a
severe worsening with erythema, papules and many pustules.
Sample History
A 29-year old man presented to a dermatology department because of
inflammatory papules and nodules on both cheeks and the chin. The
forehead was not much affected. He had noticed severe seborrhea
and a progressive increase of large pores with continuous thickening
of the skin for several years. There were no comedones. Some small
erythematous lesions and papules were also found on the chest. He
had been treated for acne for several months without any significant
improvement.
Physical Examination:
• the morphology of individual lesions
• the types of primary and secondary lesions
• the arrangement of the lesions.
• the distribution of the eruption
Examination of Hair
• Inspect hair quantity, texture and
distribution
Examination of Nails
•Inspect nail color, shape
and presence of lesions
1. Clubbing of fingers
2. Onycholysis
3. Paronychia
4. Terry’s nails
5. Beau’s lines
Psoriatic nails (“oil spots”,

pitting, onycholysis)
AIDS TO DERMATOLOGIC DIAGNOSIS
The examiner’s eye is the most important
instrument .
• Magnification
• Wood’s lamp
• Diascopy
• Patch testing
• Skin biopsy
Distribution
Distribution
Distribution
Distribution
THE EYE
Preparation of the Patient
• Preparation of the patient and the environment is crucial to obtain
correct findings during the eye examination. If the Snellen chart is
located outside the exam room, then the patient should do this
portion of the examination prior to changing into a patient gown if a
complete examination is being performed.
• The area should be well lit and free of distractions.
• The remainder of the examination will be in a quiet, well-lit room
with all necessary equipment in the room.
The components of the eye examination
include:
1. Vision tests: distal, near, and peripheral
2. Inspection of the eye, eyebrows, lids, conjunctiva and sclera, cornea,
lens, iris, and pupils
3. Inspection and palpation of the lacrimal apparatus
4. Extraocular movements: assessment of cardinal fields, convergence,
corneal light test, cover–uncover test
5. Inspection of the fundi including the optic disc and cup, retina, and
retinal vessels
Vision Tests
• Visual Acuity (Distal).
• To test the acuity of central
vision, use a Snellen eye chart,
if possible, and light it well.
• Position the patient 20 feet
from the chart.
• Patients who use glasses or
contacts other than for reading
should wear them for the
examination
Vision Tests
• Coaxing to attempt the next line
may improve performance.
• A patient who cannot read the
largest letter should be positioned
closer to the chart; note the
intervening distance.
• Determine the smallest line of
print from which the patient can
identify more than half the letters
• Record the visual acuity
designated at the side of this line,
along with use of glasses or
contacts, if any.
Vision Tests
• Visual acuity is expressed as
two numbers (e.g.,20/30).
• The numerator indicates the
distance of the patient from the
chart and this number should
always be 20 unless the patient
moved closer to see, and the
denominator is the distance at
which a normal eye can read
the line of letters.
Vision Tests
• Visual Acuity (Near Vision).
• Rosenbaum chart
• Newspaper
Vision Tests
• Peripheral Vision
• Peripheral Visual Fields by Confrontation
• Screening starts in the temporal fields because most
defects involve these areas. Imagine the patient’s visual
fields projected onto a glass bowl that encircles the front
of the patient’s head.
1. Ask the patient to look with both eyes into your
eyes.
2. While you return the patient’s gaze, place your
hands about 2 feet apart, lateral to the patient’s
ears.
3. Instruct the patient to point to your fingers as
soon as they are seen.
4. Then slowly move the wiggling fingers of both
your hands along the imaginary bowl towards the
line of gaze until the patient points to them.
5. Repeat this pattern in the upper and lower
temporal quadrants. Usually a person sees both
sets of fingers at the same time. If so, fields are
usually normal.
Vision Tests
• Peripheral Vision
• Peripheral Visual Fields by
Confrontation
• FURTHER TESTING. If you find a defect,
try to establish its boundaries. Test one
eye at a time. If you suspect a temporal
defect in the left visual field, for example,
ask the patient to cover the right eye and,
with the left one, to look into your eye
directly opposite.
• Then slowly move your wiggling fingers
from the defective area toward the
better vision, noting where the patient
first responds.
• Repeat this at several levels to define the
border.
External Eye
• Position and Alignment of the Eyes.
• Stand in front of the patient and survey the eyes for position and alignment. If one or
both eyes seem to protrude, assess them from above.
• Eyebrows.
• Inspect the eyebrows, noting their quantity and distribution and any scaliness of the
underlying skin.
• Eyelids.
• Note the position of the lids in relation to the eyeballs.
• Inspect for the following:
• Width of the palpebral fissures—open area between the upper and lower
• eyelids
External Eye
• Eyelids.
• Note the position of the lids in relation to the eyeballs.
• Inspect for the following:
• Width of the palpebral fissures—open area between the upper and lower eyelids Edema
of the lids
• Color of the lids
• Lesions
• Condition and direction of the eyelashes
• Adequacy with which the eyelids close. Look for this especially when the eyes are
unusually prominent, when there is facial paralysis, or when the patient is unconscious.
External Eye
• Conjunctiva and Sclera.
• Ask the patient to look up as you
depress both lower lids with your
thumbs, exposing the sclera and
conjunctiva. Inspect the sclera and
palpebral conjunctiva for color, and
note the vascular pattern against the
white scleral background. Look for any
nodules or swelling.
External Eye
• Cornea and Lens.
• With oblique lighting, inspect the cornea
of each eye for opacities and note any
opacities in the lens that may be visible
through the pupil.
• Iris.
• At the same time, inspect each iris. The
markings should be clearly defined. With
your light shining directly from the
temporal side, look for a crescentic
shadow on the medial side of the iris.
Because the iris is normally fairly flat and
forms a relatively open angle with the
cornea, this lighting casts no shadow.
External Eye
• Pupils.
• Inspect the size, shape, and symmetry
of the pupils. If the pupils are large ( 5
mm), small ( 3 mm), or unequal,
measure them. A pupil guide with
black circles of varying sizes facilitates
measurement.
External Eye
• Test the pupillary reaction to light.
• Ask the patient to look into the distance, and shine a bright
light obliquely into each pupil in turn. (Both the distant gaze
and the oblique lighting help to prevent a near reaction.) Look
for:
• The direct reaction (pupillary constriction in the same eye)
• The consensual reaction (pupillary constriction in the opposite
eye)
• Always darken the room and use a bright light before
deciding that a light reaction is absent. If the reaction to
light is impaired or questionable, test the near reaction in
normal room light.
• Testing one eye at a time makes it easier to concentrate on
pupillary responses, without the distraction of extraocular
movement.
• Hold your finger or pencil about 10 cm from the patient’s
eye.
• Ask the patient to look alternately at it and into the
distance directly behind it.
• Watch for pupillary constriction with near effort.
Inspection and palpation of the lacrimal
apparatus
• Lacrimal Apparatus.
• Briefly inspect the regions of the lacrimal gland and lacrimal sac for swelling.
• Look for excessive tearing, dryness, or crusting of the eyes. Assessment of
dryness may require special testing by an ophthalmologist.
Extraocular movements
• Assess the extraocular movements, looking for:
• The normal conjugate movements of the eyes in each direction, or any
deviation from normal
• Nystagmus, a fine rhythmic oscillation of the eyes. A few beats of nystagmus
on extreme lateral gaze are normal. If you see it, bring your finger in to within
the field of binocular vision and look again.
• Lid lag as the eyes move from up to down.
• Cardinal fields.
• To test the six extraocular movements (EOMs), ask the
patient to follow your finger or pencil as you sweep
through the six cardinal directions of gaze. Making a wide
H in the air, lead the patient’s gaze:
• (1) to the patient’s extreme right
• (2) to the right and upward
• (3) down on the right
• (4) without pausing in the middle, to the extreme left
• (5) to the left and upward
• (6) down on the left.
• Pause during upward and lateral gaze to detect

nystagmus. Move your finger or pencil at 12”–18” from
the patient. Because middle-aged or older people may
have difficulty focusing on near objects, make this
distance greater for them than for young people. Some
patients move their heads to follow your finger. If
necessary, hold the head in the proper midline position.
• Convergence.
• Finally, test for convergence. Ask the
patient to follow your finger or pencil as
you move it in toward the bridge of the
nose. The converging eyes normally follow
the object to within 5 cm to 8 cm of the
nose.
• Corneal light reflex.
• From about 2 feet directly in front of the
patient, shine a light onto the patient’s eyes
and ask the patient to look at it. Inspect the
reflections in the cornea. They should be
visible slightly nasal to the center of the
pupils.
• A cover–uncover test may reveal a slight
or latent muscle imbalance not
otherwise seen
Ophthalmoscopic examination
• The nurse would examine the
patients eyes without dilating
the pupils. The view is
therefore limited to the
posterior structures of the
retina. To see more peripheral
structures, to evaluate the
macula well, or to investigate
unexplained visual loss,
ophthalmologists dilate the
pupils with mydriatic drops
unless this is contraindicated.
THE THORAX AND LUNGS
INITIAL SURVEY OF
RESPIRATION AND
THE THORAX
• Observation and
documentation of the rate,
rhythm, depth, and effort
of breathing is the first step
of the respiratory
assessment.
General Survey
• Always inspect the patient for any signs of respiratory difficulty.
• Observe the patient’s facial expression—it should be relaxed and calm.
• Observe level of consciousness.
• Assess the patient’s color for cyanosis, especially the face, mucous membranes, and
nail beds. Recall any relevant findings from earlier parts of your examination, such as
the shape of the fingernails.
• Listen to the patient’s breathing.
• Are there any audible sounds (e.g.,wheezing or stridor)? If so, where do they fall in
the respiratory cycle?
• Inspect the neck.
• During inspiration, is there contraction of the accessory muscles, namely, the
sternomastoid and scalene muscles, or supraclavicular retraction? Is the trachea
midline?
General Survey
• Also observe the shape of the chest.
• The anteroposterior (AP) diameter may increase with aging, compared with
the lateral chest diameter.
• Usually there is a 2:1 ratio of transverse to anteroposterior diameters.
PHYSICAL EXAMINATION
POSTERIOR CHEST
Inspection
• From a midline position behind the patient, note the shape of the
chest and how the chest moves, including:
• Deformities or asymmetry
• Abnormal retraction of the intercostal spaces during inspiration.
• Retraction is most apparent in the lower intercostal spaces.
• Impaired respiratory movement on one or both sides or a unilateral
lag (or delay) in movement
Palpation
• Identify tender areas.
• Carefully palpate any area where pain
has been
• reported or where lesions or bruises are
evident.
• Assess any observed abnormalities
such as masses
• Test chest expansion.
• Feel for tactile fremitus.
Palpation
• Palpate and compare symmetric areas of
the lungs in the pattern shown in the
photograph. Identify and locate any
areas of increased, decreased, or absent
fremitus.
• Fremitus is typically more prominent in

the interscapular area than in the lower
lung fields and is often more prominent
on the right side than on the left. It
disappears below the diaphragm.
Percussion
AUSCULTATION
• Breath Sounds (Lung Sounds).
• Learn to identify patterns of breath sounds by their intensity, their pitch, and the
relative duration of their inspiratory and expiratory phases. Normal breath sounds
are:
• Vesicular, or soft and low pitched.
• They are heard through inspiration, continue without pause through expiration, and
then fade away about one third of the way through expiration.
• Bronchovesicular, with inspiratory and expiratory sounds about equal in
Length, at times separated by a silent interval.
• Detecting differences in pitch and intensity is often easier during expiration.
• Bronchial, or louder and higher in pitch, with a short silence between
inspiratory and expiratory sounds.
• Expiratory sounds last longer than inspiratory sounds.
AUSCULTATION
• Listen to the breath sounds with the diaphragm of a stethoscope
after instructing the patient to breathe deeply through an open
mouth.
• Use the pattern suggested for percussion, moving from one side to
the other and comparing symmetric areas of the lungs.
• If you hear or suspect abnormal sounds, auscultate adjacent areas so that you
can fully describe the extent of any abnormality.
• Listen to at least one full breath in each location.
• Be alert for patient discomfort resulting from hyperventilation (e.g.,
lightheadedness, faintness), and allow the patient to rest as needed
AUSCULTATION
• Note the intensity of the breath sounds.
• Breath sounds are usually louder in the lower posterior lung fields and
may also vary from area to area.
• If the breath sounds seem faint, ask the patient to breathe more deeply.
You may then hear them easily.
• When patients do not breathe deeply enough or have a thick chest wall, as
in obesity, breath sounds may remain diminished.
• Listen for the pitch, intensity, and duration of the expiratory and inspiratory
sounds. Are vesicular breath sounds distributed throughout the chest wall?
Or are there bronchovesicular or bronchial breath sounds in unexpected
places? If so, where are they?
AUSCULTATION
• Adventitious (Extra) Sounds.
• Listen for any extra, or
adventitious, sounds that are
superimposed on the usual
breath sounds.
• Detection of adventitious
sounds—crackles (sometimes
called rales), wheezes, and
rhonchi—is an important part
of your examination, often
leading to diagnosis of cardiac
and pulmonary conditions.
AUSCULTATION
• Adventitious (Extra) Sounds.
• Listen for any extra, or
adventitious, sounds that are
superimposed on the usual
breath sounds.
• Detection of adventitious
sounds—crackles (sometimes
called rales), wheezes, and
rhonchi—is an important part
of your examination, often
leading to diagnosis of cardiac
and pulmonary conditions.
AUSCULTATION
• Transmitted Voice Sounds.
• If you hear abnormally located bronchovesicular or bronchial
breath sounds or adventitious sounds, assess transmitted
voice sounds. With a stethoscope, listen in symmetric areas
over the chest wall as you:
• Ask the patient to say “ninety-nine.” Normally the sounds
transmitted through the chest wall are muffled and indistinct.
• Ask the patient to say “ee.” You will normally hear a muffled long E
sound.
• Ask the patient to whisper “ninety-nine” or “one-two-three.” The
whispered voice is normally heard faintly and indistinctly, if at all.
PHYSICAL EXAMINATION
ANTERIOR CHEST
Inspection
• Observe the shape of the patient’s chest and the movement
of the chest wall.
• Note:
• 1. Deformities or asymmetry
• 2. Work of breathing: abnormal retraction of the lower intercostal
spaces during
• inspiration. Supraclavicular or substernal retraction is often
present.
• 3. Local lag or impairment in respiratory movement
Palpation
1. Identification of tender areas
2. Assessment of observed
abnormalities
3. Further assessment of chest
expansion.
1. Place your thumbs along each costal
margin, your hands along the lateral
rib cage. As you position your hands,
slide them medially a bit to raise loose
skin folds between your thumbs. Ask
the patient to inhale deeply (as the
thorax expands
2. Observe how far your thumbs diverge
and feel for the extent and symmetry
of respiratory movement.
Palpation
Assessment of tactile fremitus.
Compare both sides of the
chest, using the ball or ulnar surface
of your hand. Fremitus is usually
decreased or absent over the
precordium. When examining a
woman, gently displace the breasts
as necessary.
Palpation
Assessment of tactile fremitus.
Compare both sides of the
chest, using the ball or ulnar surface
of your hand. Fremitus is usually
decreased or absent over the
precordium. When examining a
woman, gently displace the breasts
as necessary.
Percussion
• Percuss the anterior and
lateral chest, again comparing
both sides. The heart normally
produces an area of dullness
to the left of the sternum from
the 3rd to the 5th intercostal
spaces. Percuss the left lung
lateral to it.
Percussion
• In a woman, to enhance
percussion, gently displace the
breast with your left hand
while percussing with the right.
• Alternatively, you may ask the
patient to move her breast for
you.
• Identify and locate any area
with an abnormal percussion
note.
Percussion
• With your pleximeter finger above
and parallel to the expected upper
border of liver dullness, percuss in
progressive steps downward in the
right midclavicular line. Identify the
upper border of liver dullness. Later,
during the abdominal examination,
you will use this method to
estimate the size of the liver.
• As you percuss down the chest on
the left, the resonance of normal
lung usually changes to the
tympany of the gastric air bubble.
Auscultation
1. Listen to the breath sounds,
noting their intensity and
identifying any variations from
normal vesicular breathing.
Breath sounds are usually louder
in the upper anterior lung fields.
Bronchovesicular breath sounds
may be heard over the large
airways, especially on the right.
2. Identify any adventitious sounds,
time them in the respiratory cycle,
and locate them on the chest wall.
Do they clear with deep
breathing?
3. If indicated, listen for transmitted
voice sounds.
Vital Signs Taking
TEMPERATURE,
PULSE, RESPIRATION
AND BLOOD
PRESSURE
PREPARED BY:
JOBELLE GRACE H. MIRANDA, RN, MAN, USRN
TEMPERATURE, PULSE, RESPIRATION
AND BLOOD PRESSURE
DEFINITION:
Obtaining and recording of the vital signs (temperature, pulse,
and respiration) accurately and safely, recognizing deviation from
normal)
PURPOSES:
1. To determine the course of illness, this serves as a guide in
meeting the needs of the patient.
2. To afford an opportunity to observe the general condition of
the patient.
3. To aid the physician in making diagnosis and planning
patient’s care.
GENERAL CONSIDERATIONS:
- Make sure the patient has had

rested before taking vital signs.
- Remember that the frequency of

taking the TPR depends upon the
condition of the patient and the
policy of the agency.
- Inform the physician or head

nurse promptly for any significant
change in the vital signs.
- Explain the procedure to the

patient so that he/she feels at ease.
This Photo by Unknown Author is licensed under CC BY-SA-NC
A. TEMPERATURE
DEFINITION:
The balance between heat produced and heat loss.
SPECIAL CONSIDERATIONS:
- Stay with the patient while thermometer is in place.
- Provide individual thermometer for each patient.
- Use only rectal thermometer, for rectal temperature.
- When patient has diarrhea, do not take temperature by rectum.
- Using the axillary method, see to it that the axilla is dry, and the bulb of the thermometer is
within the hollow of the axilla.
- Remember that rectal temperature is taken to check the anal passage/opening of the newborn
baby.
A.1 USING
DIGITAL
THERMOMETER
EQUIPMENT:
• Digital Axillary Thermometer
• Cotton balls
• Paper tissue or wipes
• Soap solution/Petroleum Jelly
A.1.1 AXILLARY METHOD
STEPS RATIONALE
1. Rinse, dry, turn on, and read the digital
thermometer
2. Dry it with a cotton ball or a soft paper A cotton ball with the aid of friction helps in drying
tissue from the bulb toward the fingers the thermometer.
with a firm twisting motion.
3. Wipe the axilla in order to dry it without Friction may produce heat thereby resulting to
using friction (gently pat it). inaccuracy of recording of the body temperature.
4. Place the digital thermometer into the When the bulb rests against the superficial blood
axilla with the bulb directed toward the vessels in the axilla and the skin surfaces are
patient’s head, bring the patient’s arm brought together to reduce the amount of air
down close to his body and place his surrounding the bulb a reasonable reliable
forearm over his chests. measurement of body temperature can be
obtained.
5. Leave the digital thermometer in Allowing sufficient time for the axillary tissue
place until it beeps. (Approximately to reach its maximum temperature results in
1-3 minutes) a reasonable accurate measurement of
the body temperature.
6. Remove the digital thermometer Cleansing from an area where there are
and wipe from the fingertips to the few organisms to an area where there are
bulb in a firm twisting motion. numerous organisms minimizes the spread
of organisms to cleaner areas. Friction helps
to loosen matter from a surface.
7. Read the thermometer and then, Washing/alcohol swabs remove organisms.

wash it with soap and water for
waterproof digital thermometer or
else wipe it with alcohol swab.
8. Dispose the tissue used in wiping Confining contaminated articles helps

the thermometer in a receptacle prevents the spread of pathogens.
used for soiled items.
9. Return the clean digital Ensure safety of the digital thermometer
thermometer to its container.
A.1.2 RECTAL METHOD
STEPS RATIONALE
1. Place a small amount of petroleum jelly or Vaseline In preparation for lubricating the rectal
cream on a piece of tissue paper. thermometer.
2. Rinse, dry, turn on, and read the digital

thermometer
3. Lubricate the digital thermometer about 1 inch from Lubrication reduces friction and thereby facilitates
the bulb. insertion of the thermometer; this minimizes irritation
of the mucous membrane of the anal canal.
4. Place the patient in a side lying position and separate the If not placed directly into the anal opening,
buttocks so that the anal sphincter is seen. Insert the digital the bulb of the thermometer may injure the
thermometer for 1 ½ inches into the rectum. Permit buttocks sphincter.
to fall in place.
5. Leave the digital thermometer in place for 1-3 Allowing sufficient time for thermometer to
minutes or until it beep. Hold it in place if the patient is register results in a more accurate
irrational or a restless child. measurement of body temperature.
6. Remove, wipe and read the thermometer and Same principles as in oral method.
proceed with its after care as indicated in the axilla
temperature taking.
• A.2.1 TEMPORAL (FOREHEAD) METHOD - measuring the temperature of something without
having to touch it or even be near it.
• EQUIPMENT:
• Infrared Temporal Thermometer
The advantages of using a thermometer gun include:

• Ability to monitor the temperature without touching a contagious person/patients
• Can be used for various applications
• Lightweight, compact and easy to use
• Fast scanning of large crowds
• An important resource for many places like airports, hospitals, schools, etc.
• Great for taking temperatures of uncooperative patients– such as infants, small children, etc.
• Infrared thermometer on a baby saves time and relieves stress
The disadvantages of using a thermometer gun include:
• Inaccurate readings caused by operator error
• Unnoticed environmental conditions that skew readings
• Likelihood of causing false readings that can greatly inconvenienced people
• Possible quarantining of people who aren’t sick
STEPS RATIONALE
1. Set the Reading to Fahrenheit or To set the gun for proper scanning
Celsius
You can move the toggle switch
easily to change your measurement
to Fahrenheit or Celsius.
2. Set the Measurement Unit
Choose what kind of reading you’re
doing – food, body temperature, etc.
3. Aim the Gun Blocking the target can give inaccurate
Aim the gun towards the object or reading
person. Make sure there is nothing
blocking the gun and target/patient.
4. Get Close Far distance can alter the result of scan.
Get close to the object or person –
between one and two feet.
5. Pull the Trigger To assess the body temperature.
Pulling the trigger gives an instant
infrared reading on the gun’s display.
A.2.2 TYMPANIC (EAR) METHOD
- Taking temperature in the ear.
probe
CONSIDERATION:
• Always take the temperature in the
same ear, as the reading in the
right ear may differ from that in the
left ear. This is a physiological
difference which occurs naturally
and is important to keep this in
mind when taking a reading.
• Consider external factors.
EQUIPMENT:
• Infrared Ear Thermometer
• Cap or Probe
Ear temperature can be affected by things other than true body temperature, for
example when the person has been:
•
• 1. Wearing something over their ears
• 2. Lying on one ear or the other
• 3. Exposed to very hot or very cold temperatures
• 4. Recently swimming or bathing
• In these cases, remove the external factors and wait 30 minutes prior to taking a
temperature.
When not to use an ear thermometer

TYMPANIC (EAR) METHOD
STEPS RATIONALE
1. Make sure a new, clean Hygiene Ensure accurate measurement

cap is in place before each
measurement.
2. Place the ear probe snugly in ear

canal and direct towards opposite
temple.
3. Keep the thermometer steady in Inaccurate reading may result & health
the ear canal assessment will be incorrect
4. Take a measurement by pressing Assess accurate body temperature.

the "Measurement" button and wait
until you achieve the correct body
temperature
5. Dispose of the used hygiene cap Prevents cross contamination

properly
B. OBTAINING THE PULSE (RADIAL ARTERY)
DEFINITION:
• The expansion of the arterial walls occurring with each ventricular contraction.
PURPOSES:
• 1. To count the number of times that the heart beats per minute.
• 2. To obtain information regarding condition of the heart action and patient’s
general condition.
• Remember that one pulse or one complete rise and fall of the arterial wall is
considered as one beat or count.
• Take the pulse at a convenient site for the patient and the nurse.
• When taking the pulse, note the rate, rhythm, the volume and quality of the
arterial wall.
• Do not take pulse when the patient is restless or when a child is crying.
• If peripheral pulse is difficult to obtain, take the apical or cardiac rate.
EQUIPMENT:
• Watch with a second hand and stethoscope if needed (apical pulse).
OBTAINING THE PULSE (RADIAL ARTERY)
STEPS RATIONALE
1. Have the patient rest his arm alongside of This position places the radial artery on the inner aspect
his body with the wrist extended and the palm of the patient’s wrist. The nurse’s fingers rest
of the hand facing downward. conveniently on the artery with the thumb in a position
on the outer aspect of the patient’s wrist.
2. Place the 1st, 2nd, 3rd fingers along the radial The fingerprints, sensitive to touch, will feel the
artery and press it gently against the radius; pulsation of the patient’s radial artery.
rest the thumb on the back of patient’s wrist. If the thumb is used for palpitating the patient’s pulse
the nurse may feel her own pulse.
3. Apply only enough pressure so that you, can Moderate pressure allows the nurse to feel the superficial
feel the patient’s pulsating artery directly. radial artery expand and contract with each heartbeat;
too much pressure will obliterate the pulse. If too little
pressure is applied, the pulse will be imperceptible.
4. Using a watch with a second hand, count the Sufficient time is necessary to detect irregularities or
number of pulsation felt on the patient’s artery other defects.
for one full minute.
5. If the pulse rate is abnormal, repeat the Repeating the count is necessary to allow regular timing
counting in order to determine accurately the between beats.
rate, the quality and rhythm of the pulse.
C. OBTAINING THE RESPIRATORY RATE
DEFINITION:
• The process by which oxygen and carbon dioxide
are interchanged.
PURPOSES:
• 1. To obtain the respiratory rate per minute.
• 2. To obtain an information of the patient’s
respiratory status and condition.
- Note the rate depth and character of
respiration.
- Note the color of the patient and his act of
breathing while taking his respiration.
- The patient should not be made aware that his
respiration is being taken.
EQUIPMENT: Watch with second hand.

OBTAINING THE RESPIRATORY RATE
STEPS RATIONALE
1. While the fingertips are still in place Counting the respiration while presumably still
after counting the pulse rate, observe counting the pulse keeps the patient from
the patient’s respiration. becoming conscious of his breathing and
possibly altering his usual rate.
2. Note the rise and fall of patient’s A complete cycle of inspiration and expiration
chest with each inspiration and constitutes one act of respiration.
expiration. You can make observation
without disturbing the patient’s clothes
and bed.
3. Using a watch with a second hand, Sufficient time is necessary to observe rate,
count the number of respiration for one depth and other character of respiration.
full minute.
4. If respiration is abnormal repeat the Repeating the count is allowed.
count in order to determine accurately
the rate and characteristics of
breathing.
D. TAKING BLOOD PRESSURE
DEFINITION:
• To take systolic, diastolic and pulse pressure.
• To determine certain physiologic changes that may occur.
• To determine the pumping action of the heart.
• To aid in diagnosis.
• To evaluate the general condition of the patient.
• Keep patient physically and emotionally rested before taking the blood pressure.
• For required repeated reading take blood pressure in the same arm, in the same position and time.
• Take blood pressure reading as quickly as possible to prevent venous congestion.
• Allow 20-30 seconds for venous circulation to return to normal if repeated reading is necessary.
• Report promptly to the physician or head nurse any significant change in blood pressure.
• Size of cuff should be appropriate to the size of the patient’s arm.
EQUIPMENT:
• Sphygmomanometer
• Appropriately sized blood pressure cuff
• Stethoscope
TAKING BLOOD PRESSURE
STEPS RATIONALE
1. Place patient in a comfortable position with This position places the brachial artery so that the
the arm supported and palm upward. stethoscope can rest on it conveniently in the
antecubital area.
2. Roll patient’s gown above the elbows; Most measurement errors occur by not taking the time to
Choose the proper BP cuff size: place the cuff so choose the proper cuff size.
that the inflatable bag is centered over the Proper placement of the cuff pressure applied directly
brachial artery. The lower edge of cuff is 2cm. over the artery will yield most accurate reading.
Above the antecubital fossa.
3. Wrap the cuff smoothly around the arm and A twisted cuff and wrapping could produce unequal
tuck end of cuff securely under preceding pressure and an inaccurate reading.
wrapping.
4. Place yourself so that aneroid gauge can be If the eye level is above or below aneroid gauge,
read at eye level, and no more than 3 feet parallax will give an inaccurate reading.
away.
5. Use the fingertips to feel for a strong pulsation Accurate blood pressure readings are possible when the
in the antecubital, space. stethoscope is directly over the artery.
6. Place the bell of the stethoscope on the Sound transmission can be distorted when source
brachial artery in the antecubital space where and reception are misaligned.
the pulse was noted without causing too much
pressure.
7. Pump the bulb of manometer until the Pressure in the cuff prevents blood from flowing
mercury rises to approximately 20 to 30 mmHg. through the brachial artery.
Above the anticipated systolic pressure.
8. Using the valve on the bulb, release 2 to 3 mm Systolic pressure is that point at which the blood in
per heart-beat and note on the manometer the the brachial artery is first able to force its way
point at which the first sound is heard, record this through, against the pressure exerted on the vessel
figure as the systolic pressure. by the cuff of the manometer.
9. Continue to release the air in the cuff evenly The artery is open, but still partly occluded.
and gradually. Sounds may become a bit
“muffled”.
10. Note the reading on the manometer when Diastolic pressure is that point when blood flows
the last distinct loud sound is heard. Record this freely in the brachial artery and is equivalent to the
figure as the diastolic pressure. amount of pressure normally exerted on the walls
of the arteries when the heart is at rest.
11. Allow the remaining air to escape quickly, Parallax is the apparent change of position of an
remove the cuff and cleanse the equipment. object when seen from two different points.
Sample of Temperature, Pulse and Respiratory Graphing
Sheet
Behavior and general appearance
- congruent to the patient look like
- dress properly
- alertness
- stress/restless
- Catatonia – extreme restlessness or fixity sometimes awkward position for a long
time
- Reflective of a psychiatric problem
Emotions
- looks stress in
Volatile – any time burst into anger
- visible expression – smiling, angry, in fear
Speech
- spontaneous or logic
- connected to each other
- logical make sense
- stutter interference
- tone (monotonous only one tone of the voice)
- rise and a fall
Thought content and processes

- logical flow content conversation. Straight to the point. Wander away from the
conversation that maybe underlaying a mental condition
Hints of abnormalities or hints or perversion
- obsession – repetitive thought of someone. Intrusive thought of patient most
thinking of the time. Keeps talking, going back.
- delusions - is false representation of reality. Fixed false belief. Cannot be change
Delusion of divinity – he believe that e is god
Delusion of granger – rich or powerful
- illusions – is a stimulus but the person is misinterpreting the stimulus. The eye
glass looks like a snake or scorpion
- hallucination – there is no stimulus, but the person says something that wish may
be real. Example is there is no eyeglasses the but he see snake or scorpion
Suicidal - thought can be settle. Contemplating thought
Homicidal thoughts – killing somebody or causing harm
Loose associations – words are not connected to the next phrase. The flow of
thought is loose
Tangential thinking – gaps of memories things forget.
Word salad – one word to another
Neologisms – creation of new words. It is not found in the dictionary
Circumstantial thought – concrete verses abstract talk. Intellectual state of
conversation
Perceptual disturbances – illusions and hallucinations (visual hallucination and

auditory hallucination - somebody is whispering to them. Tactile hallucination –
there is inspect crawling in their skin)
Impulse control
- ability to delay or modulate expression or behaviors
Cognition
– orientation to person ability of patient to imply oriented to place
- concentration they may tell the weather
- Memory listen attentively or analyze
Knowledge, insights and judgement

- response how this person resolve day to day problem. Probable consequences to
their action
Children and adolescent

- use dolls to communicate with the children
- comfortable for the parent. Not to judge the parent
open ended questions - expansion of the thought. Elaboration
close ended questions - brief response / yes or no
Sigmund freud’s stages of psychosexual development
Psychosocial predominant
Each stage has a psychosocial task
Oral – 0-1.5 years - Communication comes from the mouth

id – primitive to satisfy oneself
Anal - 1.5-3 years – control being in anal or toilet training. Control bladder
Phallic - 3-6 years – genital region. Explorative in sexuality. Contradicting.

Superego emerges from interactions with parents. Oedipal (for males) and electra
(for females) complexes appear
Ego – is the no or conscience. Once in between to give in in id or superego
- Preschool stage
Temporary feelings that can be developed into constructive feelings
Latency - 6-11 years – school age. Abeyance of sexual urges as the child develops
more intellectual and social skills, hobbies, sports for developing friendship with
members the same sex. The superego continues to develop. Defense mechanisms
appear.
- denial. This does not happen
- blaming
- Substitute their conflict into solutions
Genital – adolescence – puberty allows impulses to reappear. Resolved and if no

major fixation have occurred, the individual will develop heterosexual attachments
outside of the family. Romantic love can lead to a successful marriage and
parenting
- regression. Example is crying
Erik Erikson stages Focuses in the psychosocial development
Each development of the child has a task to resolve. To grow up responsible
Infancy - trust satisfy with their oral needs and mistrust. Hard time strusting
Toddlerhood – autonomy
Adolescence – identity and role confusion ( develop identify crisis) . You know
who you are. According to your age
Young adulthood – intimacy (whom to commit yourself and intimate relationship

with) and isolation (live alone. Could not trust people. jealous). Testing roles and
then integrating them to form single identity, or they become confused
Middle adulthood – generativity ( ability to generate knowledge and experience

that could left behind to the next generation) and stagnation. People discover a
sense of contributing to the world, usually trough family and work, or they may
feel a lack of purpose.
Piaget’s stages of cognitive development

Sensorimotor – object permanence
Preoperational – grammar to express concepts, symbolic thinking. Imagination
and intuition are strong, but complex abstract thoughts are still difficult.
Conservation is developed.
Concrete operational – concepts attached to concrete situations. Time, space, and
quantity are understood and can be applied, but not as independent concepts
Formal operational – theoretical, hypothetical, and counterfactual thinking.
Abstact logic and reasoning. Strategy and planning become possible. Concepts
learned in one context can be applied to another
Kohlberg’s theory of moral development

Moral – is concept of what’s good and bad. What is acceptable and unacceptable
Level one preconventional
Step one – punishment and obedience orientation. Obey rules to avoid punishment
Step two - naïve hedonism. Conforms to get rewards and to have favors returned
Level two conventional

Step three – good boy/ good girl morality. Conforms to avoid disapproval or
dislike by others
Step four – conforms to avoid censure by authorities. Know the enforcement of the
law.
Level three postconventional

Step five – conforms to maintain communities. Emphasis on individual rights.
Step six – individual principles consciences. Guilty. Anchored in family
Pain – existing
- unpleasant
- personal subjective experience can test
- stimulated actual tissue damage
- anticipated damage
- state of inflammation. There maybe damage. Potential tissue damage
- multidimensional phenomenon - psychological pain,
- fifth vital signs
Theories
1. specific
Nausea ceptors – detect pain from stimuli
2. gate control theory
- close or open
2. pain transmission Afferent to the gate of control

A-beta and A-delta transmit pain very fast within a fraction of second
Myelin covering of the nerves. Fatty composition
Pain threshold –
Pain tolerance – how long can you endure the pain
Past experiences of pain - Interpretation of the pain
According to Hansel ye Fight and flight responses – is the primitive responses for
survival. Need action or flee from the conflict
Parasympathetic stimulation - Maintain balance. Opposite of sympathetic

stimulation
- the purpose is contradicted of sympathetic to back to normal
Anticipation –
Aftermath – you learned. No longer the same before
Vocalizations
Sometimes Pain is made up
Body Movement
Immobilization – cannot move
Muscle tension – contraction of the muscle
Factors influencing pain

Culture - stoic in pain
Quality of pain – knife or stabbing pain
Ideal relief – rest, sleeping, eating
Duration – few seconds, hours, or days
Chronic pain in less than six months
Ethnic group - Share common culture and tradition
Abuse occurs because the victim allows the Abuser to abuse them
Personality - values upbringing as a child
Narcissistic - person who inlove in themselves
Pain modulation – how we experience pain. Is it dull, sharp, low intensity or high
intensity
Pain threshold – intensity of pain how we experience pain
Pain tolerance – how long can you endure the pain. Dysmenorrhea
Past experiences of pain - Interpretation of the pain
Sympathetic stimulation
- is the activation of your hormone that elevate respiration and blood pressure.
- The purpose is increase blood distribution to the muscle for action. Fight or flight
response
- all vital signs are up
- Gastrointestinal tract and urinary tract will decrease function. All blood is
diverted to muscle
- prolonged
According to Hansel ye Fight and flight responses – is the primitive responses for
survival. Need action or flee from the conflict or to confront your stressor
Parasympathetic stimulation
- Maintain balance. Opposite of sympathetic stimulation
- the purpose is contradicted of sympathetic to back to normal to main homeostasis
imbalance
Phases of pain experience

Anticipation – to learn about pain and its relief. Expected pain
Sensation – feeling the pain, density
Aftermath – you learned. You’ll able to study the pain what’s it impact to you. No
longer the as same before
Behavioral indicators of effects of pain - Sometimes Pain is made up
Vocalizations –
Facial expression -
Body Movement –
Social interaction –
Immobilization – cannot move
Muscle tension – contraction of the muscle
Stress came the word istresse which means contraction. Tightening the muscle. An
involuntary
Factors influencing pain

Age – the younger you are the better to adopt your stress. Regression
Sex – male has higher threshold but women can tolerate pain longer than men
Culture - stoic in pain (different) example, tattoos, noble suicide, very dramatic to
pain
Meaning of pain – if you experience it before you were able to adopt the future
pain
Previous experience - if you experience it before you were able to adopt the future
pain
Coping style – warm compress, cold compress, distracting self, family support.
Attention, anxiety and fatigue
Assess for:
L – LOCATION. Ask question
I – intensity: how can you measure. Use a tool, pain scale. Pain cannot measure
can be only priximated
Q – quality of pain: make the patient describe the experience of pain. Knife like
pain or stabbing pain
U – usual chronology: pattern of occurrence of pain. In morning, night, afternoon,
after lifting object
I – ideal relief: what does the patient do to reduce pain. Relieve by Rest (decreases
the demand for oxygenated blood to the heart) “coronary heart disease”, sleeping,
eating
Example: if the patient exert effort the demand for oxygenated increases in the
blood but if it’s not enough blood pump to the coronary artery the heart of the
patient may suffer from hypoxia (acid creates irritation)
D – duration: how long is the pain. few seconds, hours, or days
- acute pain occurs in less than six months
Chronic pain in less than six months
PQRST – predisposing precipitating factor, quality, relief , severity, time

Cold spa – as a umonic. To identify symptoms and pain
Phases pain scale – use for children who cannot qualify and quantify the pain. We
uses the faces
Types of pain
Acute pain – high intensity but short duration pain. Wound
Chronic pain – gradual and progressive pain (small to bigger) last more than 6
months. Cancer
Cutaneous or superficial pain – emanating from the skin such lavation, liberation
Deep somatic pain – arising from muscles and bones. Actual or potential pain
Visceral pain – emanating from viscera (compartment contains organ, example:

the brain has viscera, the brain is a tissue have no nociceptors we don’t directly
feel pain from the brain tissues. Chest is another viscera that contains heart and
lungs. The abdomen serve as your GI tract, hips or reproductive system
Referred pain – arising from the periphery. The pain is on the hand but you detect
the pain from the heart
Radiating pain - from the source to the radiation. No pain from the source
Malignant pain – malignancy of cancer
Pain of psychological origin – pretended pain. The make up pain. To avoid

accountability
Psychogenic pain – is real to the patient but when they go to the doctor there is
nothing found link to their pain. It’s just a thought. Hallucination or delusion
NURSING INTERVENTION:
Alleviating anxiety – elevate anxiety
Autogenic training – control pain
Guided imagery – using image to distract the patient from the source of pain
Operant conditioning – telling yourself that the pain is not real, pain is temporary
Touch – establish a good relationship with them. The patient should trust you first
Hypnosis – putting patient into deep sleep. In a positive perspective
Progressive relaxation training – using muscle control and breathing exercitation
Meditation – is an introspection (looking into oneself)
Acupressure – using the finger pressure rather than needle. Form of relaxation
Rhythmic breathing – using breathing exercise using a metronome (pyramid needle)
to guide the rhythm
Biofeedback – use of gadget. An electrical device. Help you to control pain so that
the alarm goes off
Cutaneous stimulation – massage.
Music – is a good form pain relieving measures
Pharmacology
Non-narcotic analgesics – mild to moderate pain
Piroxicam – indicated for patient who have arthritis
Narcotic analgesics - Moderate to severe pain

- develop tolerance
Morphine sulfate – consideration check the respiratory rate

- causes respiratory rate depression
Adjuvants – support therapy to pain

- Physiciatric drugs
Violence - Form of aggression
Ethnic group - Share common culture and tradition

Abuse occurs because the victim allows the Abuser to abuse them
Personality - values upbringing as a child
Narcissistic - person who inlove in themselves
Sexual violence – perversion
Emotional violence - Threating to abandon or abandoning. Defaming family in

public
Physical neglect –
Developmental neglect – did not give opportunity for child to decide, choose
Educational neglect – education
Economic exploitation – did not give enough resources to develop normally or

progress normally
Vulnerable person – women and child, older people
Characteristics of abusers
1. impaired self-esteem - less
2. strong dependency needs – dependent to their family
3. narcissistic and suspicious – by aggression
4.
Interventions
Empathy – put yourself in a situation of the patient
They did not do wrong

Culture and ethnicity
Culture – exist because there is commonality between members
Ethnic group – share characteristics. Boundary
Ethnicity – share common tradition and culture and pass-through generation
Individuals practice their own belief
CLIENT CULTURAL ASSESSMENT
Ethnic or racial background – where the patient belong. Aeta
Language and communication patterns – own unique or dialect
Cultural values and norms – familiar rituals, the elder who makes the patients
decision
Biocultural factors – medical sciences, anthropological considerations. Living in

high how they perform rituals. Adaptive capability
Religious beliefs and practices – decision making process
Health beliefs and practices – traditional doctors (quack doctor)
Spiritual –
Nutritional status - To determine the health status of the patient. Quality and
quantity of food
External environmental factors like: Capacity to purchase food

Underfeeding and overfeeding considered malnourish
DIRECT METHODS OF NUTRITIONAL ASSESSMENT
These are summarized as ABCD
Anthropometric methods - From head to toe
Clinical methods -
Dietary evaluation methods – how many meals in a day
Biochemical, laboratory methods –
I. Anthropometric assessment
- BMI – body mass index
- mid upper and calf circumstances
- weight loss during the past 3
II. Global evaluation

- accommodation type
- ently or nnursing home
- taking more than 3 prescription
- psychological stress or acute disease in the past 3 months
- mobility
- neuropsychological problems
- pressure sores or skin ulcers
III. Dietetic assessment
- quantity and quality of eating meals
- loss of appetite
- digestive problems, chewing or swallowing difficulties causing decline in patient
food intake
- beverages consumed per day
- mode of feeding
IV. Subjective assessment

- does patient consider having any nutritional problems
- how would the patient consider his health status in comparison with other people
of the same age?
INDIRECT METHODS OF NUTRITIONAL ASSESSMENT

- ecological variables including agricultural crops production
- economic factors e.g. household income, per capita income, population density,
food availability and prices
- cultural and social habits
- vital health statistics: morbidity, mortality and other health indicaotrs e.g., infants
and under-fives mortality, utilization of maternal and child health care services,
fertility indices and sanitary conditions
Scarcity might result to malnutrition
Metric
BMI = kg/m2
Imperial
BMI = 703 x lbs/in2
Underweight - Below 18.5
Normal – 18.5 - 24.9
Overweight – 25.0 – 29.9
Obese – 30.0 and above
Question 1
Pain is:
- A strongly unpleasant bodily sensation caused by actual or potential injury
Question 2
The stage that occurs between 5 – 13 years of age is concerned with:
- Industry vs. inferiority
Question 3
Who among the following proposed that personality development in childhood takes
place during five psychosexual stages, which are the oral, anal, phallic, latency, and
genital stages and that during each stage, sexual energy (libido) is expressed in
different ways and through different parts of the body?
- sigmund
Question 4
Facial expression, physiological changes and behavioral changes are a part of direct
observation for pain assessment.
- true
Question 5
Failure to provide health care to prevent or treat physical or emotional illnesses is a
form of which type of violence?
- Physical neglect
Question 6
The amount of force exerted against the walls of the artery by the blood is commonly
referred to as:
Blood pressure
Question 7
One of your friends tells you to steal some sweets. You are in Level 1, why do you NOT
steal?
- I might get caught and get in trouble
Question 8
Direct methods of nutritional assessment are summarized as:
- abcd
Question 9
A technique that teaches your body to respond to your verbal commands. These
commands "tell" your body to relax and help control breathing, blood pressure ,
heartbeat, and body temperature to achieve deep relaxation and reduce stress is known
as:
- autogenic training
Question 10
The nurse is aware that the term bradycardia means:
- a heart rate of under 60 bpm
Question 11
At which phase of the cycle of violence does the abuser assumes a loving behavior,
contrite and makes promises to change?
- Honeymoon phase
Question 12
The capacity to identify possible courses of action, anticipate consequences, and
choose appropriate behaviour, and extent of awareness of illness and maladaptive
behaviours are assessments to identify which element of the patient’s mental status
- Knowledge, insight and judgement
Question 13
- moral
Question 14
Obsessions, delusions and suicidal and homicidal thoughts and thought process
alterations are categorized under which element of Mental Status Examination?
- Thought content and processes
Question 15
A situation in which one family member causes physical or emotional harm to another
family member is known as:
- Family violence
Question 16
______________________ is the amount of time something lasts or continues.
- Duration
Question 17
Which of the following vital sign will reveal information about pyrexia is:
- Temperature
Question 18
You are about to take the baseline vital signs. Before doing this you should ensure that:
- You inform the patient
Question 19
A person is considered obese with a BMI of:
- BMI of 30 or higher
Question 20
Pain management for acute pain involves pharmacological approaches only.
- false
Question 21
Which of the following assessment is a component of a patient assessment that
observes the entire patient as a whole and begins with the initial patient contact and
continue throughout the helping relationship?
- General survey
Question 22
What is the name of Erik Erickson's development theory?
- Psycho-social
Question 23
________________ is a pain that lasting for more than 6 months.
- Chronic pain
Question 24
Which of the following Non-Steroidal Anti-inflammatory drug (NSAIDS) is prescribed for
mild to moderate pain?
- Ibuprofen motrin
Question 25
Which pain scale is used for children?
- Wong-bake faces pain scale
Question 26
Which of the following is a specific nerve receptor for pain?
- nociceptors
Question 27
BMI stands for:
- body mass index
Question 28
The height, weight, head circumference, body mass index (BMI), body circumferences
to assess for adiposity (waist, hip, and limbs), and skinfold thickness are the core
elements of:
- Antropometric assessment
Question 29
Which of the following refers to how much pain a person can reasonably endure?
- tolerance
Question 30
To assess for hypotension due to shock, the nurse would take which vital sign?
- Blood pressure
Question 31
Cindy understands her world primarily by grasping and sucking easily available objects.
Cindy is clearly in Piaget's ________ stage:
- Sensorimotor
Question 32
Pain that we experience it when our internal organs are damaged is related to:
- Visceral pain
Question 33
In which psychosexual stage of personality development does Oedipus and Electra
complexes become evident?
- Phallic
Question 34
Which of the following are the most vulnerable person for violence in the family unit?
- all
Question 35
An unresponsiveness from which a person arouses from sleep only after painful stimuli.
Verbal responses are slow or absent and lapses into unresponsiveness when stimulus
stops. Patient has minimal awareness of self or environment. This is known as:
- stupor
Question 36
The categories of information necessary for a comprehensive cultural assessment of a
client includes all of the following, EXCEPT:
- political affiliation
Question 37
Failure to provide physical and cognitive stimulation needed to prevent developmental
deficits is a form of which type of violence?
- Developmental neglect
Question 38
Factors influencing pain would include which of the following?
- all
Question 39
Characteristics of abusers includes all of the following, EXCEPT:
- high self esteem
Question 40
The people within a culture who share characteristics based on race, religion, color,
national origin, or language is known as:
- ethnic group
Question 41
Mental Status assessment is a structured assessment of client’s behavioural and
cognitive functioning—is a vital component of nursing care that assists with evaluation
of:
- mental health conditions
Question 42
Intimacy vs. Isolation occurs at what stage?
- Young adulthood
Question 43
As victims’ self-esteem becomes diminished with chronic abuse, they may blame
themselves for the violence and be unable to see a way out of the situation.
- true
Question 44
Which of the following is also known as the 5th vital sign?
- pain
Question 45
A description of pain is ______________________ when it is based on the individual’s
experience or perceptions.
- subjective
Question 46
Which assessment tool was developed to help health care professionals address
spiritual issues with patients?
- maslows
Question 47
What is Kohlberg's theory?
- People progress in their moral reasoning through stages
Question 48
- moral
Question 49
To assess the effectiveness of cardiac compressions during adult cardiopulmonary
resuscitation (CPR), the nurse should palpate which pulse site?
- Carotid
Question 50
Nurses should take a patient’s vital signs during all of the following, EXCEPT:
- During any surgical procedure
Question 1
All are components of eye examination includes the following except:
Response: Test for lateralization
Correct answer: Test for lateralization
Score: 1 out of 1 Yes
Question 2
The following statements are true except:
I
Response: Anisocoria of 0.5mm is present in virtually all individuals
Correct answer: Anisocoria of 0.5mm is present in virtually all individuals
Question 3
The chief muscle for breathing is innervated by:Supraclavicular nerve
Response: Phrenic nerve
Correct answer: Phrenic nerve
Question 4
You are a nurse assigned in the OPD, a person from Kenya came in with a
chief complain of abdominal pain and fever and initial assessment was acute
cholecystitis vs hepatitis. in the case presented, how will you assess jaundice?
Response: Use a bright and examine the buccal mucosa for yellowish
discoloration of mucosa
Correct answer: Use a bright and examine the buccal mucosa for yellowish
discoloration of mucosa
Question 5
How to straighten the ear canal:
Response: Grab the pinna firmly but gently and pull it upward and
backward and slightly away from the head.
Correct answer: Grab the pinna firmly but gently and pull it upward and
backward and slightly away from the head.
Question 6
In testing the hearing, in order to minimize distractions by preventing lip
ready the examiner can do the one of the following measures:
Response: Use mask when speaking
Correct answer: Use mask when speaking
Question 7
Dryness of the skin can be associated in the following conditions except:
Response: None of the above
Correct answer: None of the above
Question 8
You’re the nurse assigned in the neuro ward and you are taking care of
patients who are suffering from stroke. You are assessing the cardinal
movements of the extraocular muscles and you know very well that they
are lateral rectus muscle is innervated by what cranial nerves?
Response: Abducens nerve

Correct answer: Abducens nerve
Question 9
A finding that may indicate CN XII damage:
Response: Deviation of the tongue
Correct answer: Deviation of the tongue
Question 10
Adventitious breath sound that may indicate upper respiratory tract
obstruction:
Response: Stridor
Correct answer: Stridor
Question 11
Correct order of physical examination of the chest and thorax:
Response: Inspection, palpation, percussion, auscultation
Correct answer: Inspection, palpation, percussion, auscultation
Question 12
Dullness during percussion may indicate the following except:
Response: COPD
Correct answer: COPD
Question 13
General term for enlarged thyroid gland
Response: Goiter
Correct answer: Goiter
Question 14
Hard and fixed lymph nodes suggest:
Response: Inflammation
Correct answer: Inflammation
Question 15
The following is true about the examination of the head and neck except:
Response: None of the above
Correct answer: None of the above
Question 16
In examining patient with a skin complain the following must be noted
except:
Response: the interruption of the eruption
Correct answer: the interruption of the eruption
Question 17
In disease conditions that causes narrowing of airways, what adventitious
breath sound you may expect to hear during auscultation?
Response: Wheezing
Correct answer: Wheezing
Question 18
The following are types of secondary skin lesions except
Response: Papule
Correct answer: Papule
Question 19
Correct pairing of tonsil grading:
Response: Grade 2 – tonsils are between pillars and uvula
Correct answer: Grade 2 – tonsils are between pillars and uvula
Question 20
True of Webers test, except:
Response: Sound normally lateralize
Correct answer: Sound normally lateralize
Question 21
The nerve that innervates all the intrinsic tongue muscles
Response: Hypoglossal nerve
Correct answer: Hypoglossal nerve
Question 22
The following are symptoms of pulmonary tuberculosis, except:
Response: Bulimia
Correct answer: Bulimia
Question 23
A patient in the community approached you and told you that she has
been suffering from a vesicular skin lesion in her back on a which is very
painful and upon inspection you suspected that she might be suffering from
shingles. What is the distribution of the abovementioned lesion?
Response: Dermatomal
Correct answer: Dermatomal
Question 24
You noted a septal perforation upon examining a 32-year old male patient
in the ORL OPD. The causes of this finding are the following except:
Response: Intranasal influenza vaccine
Correct answer: Intranasal influenza vaccine
Question 25
One of the two common techniques in holding the otoscope:
Response: Pencil grip
Correct answer: Pencil grip
Question 26
A patient diagnosed with neurofibromatosis 1 came in your primary care
clinic and noted several café au lait spots in his skin. The above-mentioned
lesion is an example of:
Response: Patch
Correct answer: Patch
Question 27
In assessing the skin, the following are described except:
Response: Thermometer
Correct answer: Thermometer
Question 28
Functions of the nose, except
Response: Aesthetic functions
Correct answer: Aesthetic functions
Question 29
During otoscopy, what landmark you need you look for to orient yourself
on the structures you need to examine:
Response: Cone of light
Correct answer: Cone of light
Question 30
A simple test to check the acute inflammation of the external ear.
Response: Tug test
Correct answer: Tug test
Question 31
Contact lenses and eyeglasses must be removed when testing the distal
visual acuity.
Response: False
Correct answer: False
Question 32
Asymmetric chest expansion can be in one of the following conditions:
Response: Flail chest
Correct answer: Flail chest
Question 33
The skin’s ability to return to its place when pinched or lifted up:
Response: Turgor
Correct answer: Turgor
Question 34
The following are risk factors for melanoma except:
Response: Younger age group
Correct answer: Younger age group

Question 35
A primary lesion that is usually seen in patient with acne;
Response: Nodule
Correct answer: Pustule
Score: 0 out of 1 No
Question 36
You are a nurse assigned in the ENT OPD and you are assessing a senile
client. You are suspecting hearing loss what should you do next?
Response: Do tonoscopy
Correct answer: Distinguish between conductive and sensorineural hearing loss

using air and bone conduction test
Score: 0 out of 1 No
Question 37
All are true except:
Response: Adventitious breath sounds are seen in almost all normal

individuals
Correct answer: Adventitious breath sounds are seen in almost all normal
individuals
Question 38
The anterior-posterior chest diameter may increase with aging:
Response: True
Correct answer: True
Question 39
Arrange the sequence in examining the cervical lymph nodes:
i.Supraclavicular
ii.Posterior cervical
iii.Tonsillar
iv.Preauricular
v.Occipital
vi.Submental
vii.Posterior auricular
viii.Deep cervical chain
ix.Submandibular
x.Superficial cervical
Response: iv, vii, v, iii, ix, vi, x, ii, viii, i
Correct answer: iv, vii, v, iii, ix, vi, x, ii, viii, i
Question 40
What disease condition that has small and large plaque with silvery scales?
Response: Psoriasis
Correct answer: Psoriasis
Question 41
Landmark of the thyroid ithmus:
Response: 3rd and 4th tracheal rings
Correct answer: 3rd and 4th tracheal rings
Question 42
Functions of the skin except:
Response: Synthesize calcium
Correct answer: Synthesize calcium
Question 43
The following are needed in setting up the following are needed except:
Response: Make up
Correct answer: Make up
Question 44
Normal diaphragmatic excursion
Response: 3-7 cm
Correct answer: 3-7 cm
Question 45
Accurate description of the skin lesion is very important in making a
dermatologic
Response: True
Correct answer: True
Question 46
In cranial nerve X paralysis, what finding you may expect see when
assessing the pharynx?
Response: Soft palate fail rise
Correct answer: Soft palate fail rise

Question 47
Direct and consensual reaction are done to test__________.
Response: Pupillary reaction
Correct answer: Pupillary reaction
Question 48
Inspiratory and expiratory sounds that are equal in length
Response: Bronchovesicular
Correct answer: Bronchovesicular
Question 49
Test for lateralization:
Response: Weber test
Correct answer: Weber test
Question 50
Considered the best practice in examining the skin:
Response: Thorough observation
Correct answer: Thorough observation
Score: 1 out of 1

NCM 101 Midterm Notess

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NCM 101 Health

• These measures referred to vital signs because of their importance as

2. Gate Control Theory – controlled by the dorsal horn of the

perceive similarly painful stimuli.

- I might get caught and get in trouble

• Part the hair in

•Observe the skin,

• To orient yourself to the neck, identify

Psoriatic nails (“oil spots”,

• Pause during upward and lateral gaze to detect

• Fremitus is typically more prominent in

- Make sure the patient has had

- Remember that the frequency of

- Inform the physician or head

- Explain the procedure to the

7. Read the thermometer and then, Washing/alcohol swabs remove organisms.

8. Dispose the tissue used in wiping Confining contaminated articles helps

2. Rinse, dry, turn on, and read the digital

The advantages of using a thermometer gun include:

When not to use an ear thermometer

1. Make sure a new, clean Hygiene Ensure accurate measurement

2. Place the ear probe snugly in ear

4. Take a measurement by pressing Assess accurate body temperature.

5. Dispose of the used hygiene cap Prevents cross contamination

EQUIPMENT: Watch with second hand.

Thought content and processes

Perceptual disturbances – illusions and hallucinations (visual hallucination and

Knowledge, insights and judgement

Children and adolescent

Oral – 0-1.5 years - Communication comes from the mouth

Phallic - 3-6 years – genital region. Explorative in sexuality. Contradicting.

Genital – adolescence – puberty allows impulses to reappear. Resolved and if no

Young adulthood – intimacy (whom to commit yourself and intimate relationship

Middle adulthood – generativity ( ability to generate knowledge and experience

Piaget’s stages of cognitive development

Kohlberg’s theory of moral development

Level two conventional

Level three postconventional

2. pain transmission Afferent to the gate of control

Parasympathetic stimulation - Maintain balance. Opposite of sympathetic

Aftermath – you learned. No longer the same before

Factors influencing pain

Ethnic group - Share common culture and tradition

Pain threshold – intensity of pain how we experience pain

Past experiences of pain - Interpretation of the pain

Phases of pain experience

Sensation – feeling the pain, density

Factors influencing pain

PQRST – predisposing precipitating factor, quality, relief , severity, time

Visceral pain – emanating from viscera (compartment contains organ, example:

Malignant pain – malignancy of cancer

Pain of psychological origin – pretended pain. The make up pain. To avoid

Piroxicam – indicated for patient who have arthritis

Narcotic analgesics - Moderate to severe pain

Morphine sulfate – consideration check the respiratory rate

Adjuvants – support therapy to pain

Violence - Form of aggression

Ethnic group - Share common culture and tradition

Sexual violence – perversion