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NCM 101 Endterm Notessss
NCM 101 Endterm Notessss
TO HEALTH
ASSESSMENT:
THE NURSING PROCESS
Lecturer: Jonnafe G. Gayatin, RMT, RN, MAN
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THE NURSING PROCESS
A systematic, rational method -Cyclical, follows a logical sequence
of planning and providing -Enables the nurse to respond to the
individualized nursing care. changing status of the client
-An individual
-Family
The client may be:
-Community
-Group
CYCLIC AND DYNAMIC
• Data from each phase provide input to the next
phase
CLIENT CENTERED
• Plan of care is according to client’s
CHARACTERISTICS problems/needs
OF THE NURSING
FOCUS ON PROBLEM SOLVING AND
PROCESS DECISION MAKING
• Identifying possible solutions and choosing the
best one to implement
• Approaches include trial and error, intuition
and research
• Directed towards client’s responses to real or
potential disease/illness.
INTERPERSONAL AND
COLLABORATIVE
• Communicating with clients, significant others
and support groups
• Collaborating with the health care team
UNIVERSAL APPLICABILITY
CHARACTERISTICS
OF THE NURSING • Nursing process is used as a framework for
PROCESS nursing care for all types of settings with clients
from all age groups
DEVELOPING RATIONALES
COMPONENTS • Explanations of priority setting and nursing
OF CLINICAL interventions
• Acts as a check for potential errors, justifies
REASONING nursing actions and contributes to client safety
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COLLECTING, ORGANIZING, VALIDATING AND
DOCUMENTING CLIENT DATA
PURPOSE:
• To establish a database about the client’s response to
health concerns or illnesses and the ability to manage
healthcare needs
ACTIVITIES:
INITIAL PROBLEM-FOCUSED
ASSESSMENT ASSESSMENT
Performed within a specified time Ongoing process integrated with
after admission to a health care nursing care
agency Purpose: to determine the status
Purpose: to establish a complete of a specific problem identified in
database problem identification, an earlier assessment
reference and future comparison
TYPES OF ASSESSMENT
EMERGENCY TIME-LAPSED
ASSESSMENT ASSESSMENT
Done during any physiological or Done several months after
psychological crisis of the client initial assessment
Purpose: To identify life- Purpose: To compare the
threatening problems / To client’s current status to
identify new or overlooked baseline data previously
problems obtained
Nurse’s Role in Health
Assessment
• obtaining the patient’s health history
• performing a physical assessment
• Nursing assessment focuses not only on
physiological and psychological responses to
The goal of medical
practice is to diagnose and
actual or potential health problems but also on
treat disease. The goal of
the psychosocial, cultural, developmental and
nursing is to diagnose and spiritual dimensions.
treat human responses to • Compliment medical assessments to ensure
actual or potential health best possible care for patients
problems.
COLLECTING DATA
CLIENT RECORDS
Sources • Demographic profile
• Medical records
BODY
STAGES OF • Client communicates what he/she thinks, feels, knows
CLOSING
INTERVIEW • Offer to answer questions
• Conclude
• Provide a summary to verify accuracy and agreement
• Thank the client
• Express concern for the person’s welfare and future
• Plan for the next meeting
EXAMINING
Physical Examination or Physical Assessment
INSPECTION
Techniques used to conduct the AUSCULTATION
examination: PALPATION
PERCUSSION
INTRODUCTION TO
HEALTH ASSESSMENT
(PART 2)
Jonnafe G. Gayatin, RMT, RN, MAN
ORGANIZING DATA
Also referred to as nursing health history, nursing assessment
or database form
ASSESSMENT FORMATS
Gordon’s Functional Health Patterns
Conceptual Models or Orem’s Self-Care Model
Frameworks Roy’s Adaptation Model
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Developmental Theories
VALIDATING DATA
VALIDATING
Double check data that are extremely abnormal
ASSESSMENT
DATA Determine the presence of factors that may interfere with
accurate measurement
Record – also called chart or client record; a formal legal document that
provides evidence of client’s care; can be written or computer based
Accepted
Date and Time Timing Legibility Permanence
terminology
Correct
Signature Accuracy Sequence Appropriateness
Spelling
TIMING
• Documenting should be done as soon as possible after an
DOCUMENTATION assessment or intervention. (Do not document before assessment
or intervention is done)
GUIDELINES LEGIBILITY (FOR WRITTEN DOCUMENTATION)
• Must be legible or easy to read. Hand-printing or easily understood
handwriting is permissible. (avoid script or shorthand)
PERMANENCE
• Written in “dark ink or permanent pen”
• For Electronic Records, changes are made in accordance with
software guidelines
DOCUMENTATION
GUIDELINES
ACCEPTED TERMINOLOGY
• Use only commonly accepted
abbreviations, symbols and terms. Refer
to approved list given by the institution.
CORRECT SPELLING
• Incorrect spelling gives a negative
impression to the reader and decreases
the credibility of the nurse
SIGNATURE
• Includes name and title of the nurse
• For electronic records each nurse has his
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DOCUMENTATION GUIDELINES
• ACCURACY
• Client’s name and identifying information should be stamped or written on each page of the
clinical record. Do not identify charts by room number. Special care is needed when caring for
clients with the same last name.
• Accurate notations consist of fact or observations not opinions or interpretations.
• Avoid general words (e.g. large, good, normal). Chart specific data (e.g. exact measurement)
• Write on every line, never between lines.
• If there is a blank space, draw a line through the blank space so that no additional information
can be recorded at any other time or by any other person. Then sign the notation
• When recording a mistake – draw a single line, indicate your name or initials above or near the
line (depending on agency policy). Avoid writing the word “error” when recording a mistake (it
may be interpreted as a “red flag” and lead to an assumption that a clinical error has caused
client injury). DO NOT ERASE, BLOT OR USE CORRECTION FLUID. Original entry must remain
visible. For computerized entry, follow agency protocol.
SEQUENCE
• Document events in the order in which they occur.
DOCUMENTATION APPROPRIATENESS
• Record only information that pertains to client’s health problems and care.
Recording irrelevant information may be considered invasion of client’s
privacy and/or libelous.
COMPLETENESS
GUIDELINES
• Not all data that a nurse obtains about a client can be recorded. However,
the information that is recorded needs to be complete and helpful to the
client and the health care team.
• Record all assessments, dependent and independent nursing
interventions, client problems, client comments and responses to
interventions and tests, progress toward goals and communication with
other members of the health care team.
• Care that is omitted because of the client’s condition or refusal of
treatment must also be recorded. Document what was omitted, why it
was omitted and who was notified. (Remember, what is not documented is
NOT DONE.)
CONCISENESS
LEGAL PRUDENCE
Data Collection
- the process of gathering information about a client’s health status
-must be both systematic and continuous in order to prevent omission of significant data.
Data base
-are information that are found about the patient and the history of the patient.
- contains all the information about a client includes:
• nursing health history
• physical assessment
• primary care provider’s history and physical examination
• result of laboratory and diagnostic tests
• material contributed by other health personnel
Kinds of Data
Constant Data – is the information that does not change over time. Ex. Race, blood type
Variable Data- can change quickly, frequently or rarely over time. Ex. us, age, level of pain.
Types of Data
Subjective – symptoms, covert data, only known to client, sensations, feelings, values, beliefs, attitudes
and perceptions.
Objective- signs, overt data (visible/can be seen or detected) detectable by observer or the nurse or can
be measured or tested, obtained by observation or physical examination. Include lab values (can be
seen, measured or tested and are not felt).
Sources of Data
Primary – client, best source of data
Secondary – all other (family, friends, other HCU and/or records)
The Client- can provide subjective data that no one else can offer
Support People – family members, friends and care givers
Client Records- include information documented by various healthcare professionals, include medical
records, records of therapies and laboratory records and must be taken in consideration of current
situation.
Health Care Professionals- verbal reports from other health care professionals serve as other potential
sources of information, promotes continuity of care
Literature- standards or norms against which to compare findings, cultural and social health practices,
spiritual beliefs, and assessment data needed for specific client conditions, nursing interventions and
evaluation criterial relevant to a client’s health problems.
CHADVASC – evaluation criteria for the use of anticoagulant, part of your assessment depending upon
the needs of the patients, information about medical diagnoses, treatment, prognoses, current
methodologies and research finding.
Closed questions- used in directive, usually yes/no questions, what, when, where and who
Open minded questions- used in nondirective interview, allows discovery, exploration, elaboration,
clarification and illustration, provides long answer, may start with what or how.
Neutral questions- closed, used in a directive interview, and directs the client’s answer
Leading questions- closed, used in a directive directs the client’s answer and avoid asking why
Video #2
Aggravating factors- any situation or action that will worsen the symptoms ex. Headache that is
worse with bearing down or with bending down, dyspnea that is worse when a pt is in a
particular place (work)
Relieving factors- any situation or action that will make the symptom better
>opposite of the aggravating factors ex. Abdominal pain of appendicitis is better in a fetal
position or leg pain in PAD that is better when the leg is dangled.
Timing- when the symptoms occur
>associated with a specific event, time of the week, time of the day.
>doesn’t have to be a specific time ex. Some fevers only occur in the late afternoon or night as
in IB or some that only occurs after every meal in some types of ulcers.
Treatments- include any medication or herbal drugs or home remedies that were taken for the
problem whether received or not.
Setting- in what situations dues the symptoms occur.
>happens only in certain situation
Video #3
Data Collection (Making a Comprehensive Health History)
Past history
Childhood Illness – include disease such as measles, rubella, mumps, whooping cough, chicken fox,
rheumatic fever, scarlet fever and polio
-Also includes all immunizations received tetanus, pertussis, diphtheria, polio, measles, rubella, mumps,
influenza, varicella, hepatitis B virus (HBV) human papilloma virus (HPV), memingococcal disease,
haemophilus in influenza type b, pneumoccocci and herpes zoster.
Adult Illness
Medical
Comorbids: diabetes, hypertension, hepatitis, asthma and HIV, allergies, other chronic illness
• Hospitalization
Ex. Date Institution Reason 10x Duration of the day
May 2020 Riverside Cholecystitis 5 days
Medication currently being taken
Ex. Generic Dose Tabs Timing
Apixaban 5 mg ½ tab BID
Surgical – all surgical procedures including dates what procedure and for what reason
Ex. Date Institution Procedure Reason
May 2020 Riverside Hemicolectomy Colon Cancer
Psychiatric – includes all psychiatric illness and time frame, diagnoses, hospitalizations and treatment.
OB/GYN: MIDAS CPCS, LMP, GP (TPAL)
• Menarche: age> of when the first menstruation occurred
• Interval of Menstruation: regular or irregular or number of cycle days if regular
• Duration of menstruation
• Amount of bleeding during menstruation
• Symptoms associated
Family history – to ascertain risk factors for certain diseases, the ages of siblings, parent, and
grandparents and their current state of health or if they are deceased, the cause of death are
obtained.
- hypertension , coronary artery disease, elevated cholesterol level, stroke,
diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease,
headache, seizure disorder, mental illness, suicide, substance abuse, and
allergies, cancers as well as symptoms reported by patient.
Personal and social history – lifestyle and psychological history
- includes occupation; sources of stress, both recent and long-term, leisure
activities; religious affiliation and spiritual beliefs.
Baseline level of function
• Activities of daily living and instrumental activities of daily living
Activities of Daily Living (ADLs)
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
Development level- usually best used in pediatric patients with regards to their developmental level
Video #4
Data Collection (Physical Assessment)
Types of Physical Examination
Comprehensive- complete
Focused- body system/ area
Functional- abilities
• General survey
• Vital signs
• Head
-hair, scalp, face
-eyes and vision
- nose
- mouth and oropharynx
• Neck
-muscles
-lymph nodes
-trachea
-thyroid gland
-carotid arteries
-neck veins
• Upper extremities
-skin and nails
- muscle strength and tone
- joint range of motion
- brachial and radial pulses
-sensation
• Cheek and back
-skin
-thorax
-lungs
-heart
-spinal column
-breast and axillae
• Abdomen
-skin
-abdominal sounds
-femoral pulses
• External genitals
• Anus
• Lower extremities
-skin and toenails
-gait and balance
-joint range of motion
-popliteal, posterior tibial, and dorsalis pedis pulses
Shift assessment- in order to use as a baseline in order to compare the later data focused on the
immediate needs and problems
Observe
• level of consciousness
• skin color
• respiratory effort
• nutritional status
• body position
• speech
• hygiene and grooming
• Check vital signs including pain
• Auscultate lungs and apical pulse Can point to a life- threatening condition
• Check capillary refill and peripheral edema
• Auscultate bowel sounds
• Observe skin turgor and surfaces for lesions
• Observe mobility
• Examine drains, catheters, wound dressings, or tubes: location, patency, and description of
drainage, if any.
• Convenient time
• Well lighted
• Organized equipment
• Warm room for the patient to be comfortable
• Private
PROPER POSITIONING
SUPPLIES PURPOSE
Flashlight or penlight To assist viewing of the pharynx or to determine
the reactions of the pupils of the eye.
Opthalmoscope anyway A lighted instrument to visualize the interior of
the eye.
Otoscope A lighted instrument to visualize the eardrum and
external auditory canal. (a nasal speculum may
be attached to the otoscope to inspect the nasal
cavities)
Percussion (reflex) hammer An instrument with a rubber head to test
reflexes.
Tuning Fork A two-pronged metal instrument used to test
hearing acuity and vibratory sense.
Gloves To protect the nurse.
Tongue blades (depressors) To depress the tongue during assessment of the
mouth and pharynx.
METHODS OF EXAMINING
• Inspection
• Palpation
• Percussion
• Auscultation
1. Inspection
- Through a visual examination which uses assessment using light, sense of light or eyes.
- Celiberate, purposeful and systematic.
- Moisture, color, and texture of body surfaces as well as shape position size, color and
symmetry.
- Sufficient lighting (natural or artificial lighting)
- Can be combined with other assessment techniques in order to perform the assessment
simultaneously in an efficient amount of time.
2. Palpation
- Examination of the body using the sense of touch.
- Texture, temperature, vibration, position, size, consistency and mobility of organs or
masses, distention, pulsation, tenderness or pain.
TWO TYPES:
Light
Deep
PALPATION: LIGHT
PALPATION: DEEP
- Not done during routine examination and will require a significant skilled practitioner.
- Requires significant practitioner skill.
- Extreme caution: can cause damage.
- Not indicated in clients: can cause damage
- Not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed
- Is done with 2 hands or can be one hand.
* The nurse’s hands should be clean and warm and the fingernails short.
3. PERCUSSION
- Act of striking the body surface to elicit sounds that can be heard or felt.
- Determine the size and shape of internal organs by establishing their borders
- Indicates: fluid filled, air filled, or solid
TYPES
- Direct
- Indirect
PERCUSSION: DIRECT
- Strikes the area with the pads of two, three, or four fingers or with the pad of the middle
finger.
- Movement is from the wrist.
PERCUSSION: INDIRECT
PERCUSSION: SOUNDS
4. AUSCULTATION
- Process of listening the sounds produced within the body.
- describe according to their pitch, intensity, duration and quality
PITCH- frequency of the vibrations
INTENSITY (amplitude)- loudness or softness of a sound
DURATION OF A SOUND- length (long or short)
QUALITY OF SOUND- subjective description of a sound, for example, whistling, gurgling, or
snapping.
DIRECT AUSCULTATION
INDIRECT AUSCULTATION
DATA COLLECTION
• OTHER SOURCES
• DIAGNOSTICS
• MEDICAL CHARTS
Diagnostics and Procedures- will yield important data for the diagnosis and management of the patient.
Intraop Record- can get a lot of information it could have a bearing with the care plan.
• Vital signs
• Blood or fluid loss
• Devices
• Procedure
• Final diagnosis
Intraop Technique
FORM INFORMATION
Admission (Face) Sheet legal name, birth date, age, gender, Social
Security number, address, marital status, closest
relatives or individual to notify in case of
emergency.
Date, time, and admitting diagnosis
Food or drug allergies
Name of admitting (attending primary care
provider)
Insurance information
Any assigned diagnosis related group (DRG)
Initial nursing assessment Findings from the initial nursing history and
physical assessment.
Graphic record body temperature, pulse rate, respiratory rate,
blood pressure, daily weight, and special
measurements such as fluid intake and output
and oxygen saturation
Daily Care Record Activity, diet, bathing, and elimination records
Special Flow Sheets Examples: fluid balance record, skin assessment
Medication record Name, dosage, route, time, date or regularly
administered medications
Name or initials of individuals administering the
medication.
Nurse’s notes Pertinent assessment of client
Specific nursing care including teaching and
client’s responses.
Client’s complaints and how the client is coping.
Medical history and Physical Examination Past and family medical history, present medical
problems. Differential of current diagnoses,
findings of physical examination by the primary
care provider.
Physician’s order form Medical orders for medication, treatments, and
so on.
Physician’s Progress Notes Medical observations, treatments, client progress
and so on.
Consultation records Reports by medical and clinical specialists.
Diagnostic reports Examples: laboratory reports, x-ray reports, CT
Scan reports.
Consultation reports Physical therapy, respiratory therapy
Client discharge plan and referral summary Started on admission and completed on
discharge: includes nursing problems, general
information, and referral data.
That's what we do with the data we have So what this organizing data it's also referred to as of course
processing of data in an organized fashion or in a systematic fashion OK so it's place already in a way
that they are clustered no according to a certain criteria so assessment formats a very from institution
to institution and we could make use of certain models or frameworks to organize the data that we have
collected the first model not our framework examples of this are your good dogs functional health
pattern yourself care model by Dorothy Oregon now and calista Roy's adaptation model are you still
familiar with this honestly
they are saying clear risks right so unsexual models or frameworks would help us get close to the top
that are related to each other OK so we can make use of this conceptual models or frameworks to
organize gate to cluster the data that are related to each other and will later on guide us to have a
clinical picture not of a certain aspect of our patient another assessment format is your Wellness model
it includes factors that influence levels of Wellness further examples of the Wellness models for example
one example of a Wellness model is the lifestyle OK what are the lifestyle collectivistic Sabha certain
patient press source a health risks another example would be the nutritional characteristics of the
patient so these fat words influence the Wellness of our patient along the continuum of health OK so we
can make use of these models full cluster and lifestyle practices what are the what is the common dying
of your patient what are the common stresses or health risks that your patient is presented do so these
are different factors and attitudes that influence the level of Wellness of our patient debug stress buying
lifestyle beliefs and practices not like for example they believe in organic king among a food or they
believe in nonmedical therapies Gaelic for example a few fresh or acupuncture so those are certain
models that we can use now to determine not the Wellness of our patient and of course last but not the
least are your non nursing models so not nursing models examples of these are but these systems model
your maslow's hierarchy of needs and the different developmental theories have you learned already
the developmental theories in your 100 yes or no
guys I'm not yet so I think you'll be learning it in your phone and of course part of your pediatric nursing
in your second year you will learn these different humans are developmental theories or theories of
development so again not as a summary so we make use of assessment for months such as conceptual
models or frameworks Wellness models and non nursing models to organize or cluster not related
information from the assessment that we have made not by collecting your subjective and objective
views so here is an example of organizing data affording to Gordon's functional health patterns OK so
the first column indicates the functional health pattern OK so let's take for example health perception
and management So what are now the different patterns now of health and well being and how is
health managed by the lion examples of the data that you put in here are compliance to medication red
chimneys is the client is the client what is Shane shoes thinking his or her maintenance medication is the
fly as does the fly and abide by the die yet or the exercise pattern or regular check up perception health
management so next is your nutritional and metabolic pattern so here we cluster no pattern of food and
fluid consumption related to the clients consumption so in relation to that so we check aside from the
diet patient we also check the condition of the steam thief here nails because my brains as well as the
height and weight so quickly pointed at my enclosed I mean if I was not BMI now of the patients end
nutritional metabolic our height and weight is a reflection of our nutrition
when it comes to physical activity guess activities of daily living because the activity and exercise of our
patient affects not our cardiovascular and respiratory status from The Walking Dead by these are Arabic
exercises that of course keep our heart and loves healthy so those are examples or another example is
the role relationship pattern of your patient and yellow mulation ships with a significant others and your
major roles and responsibilities as a mother as a father as students not as children OK so mega affect
applenet condition some patient remember the patient is not just a fishel logic being my psycho
emotional my spiritual my cultural my social aspect activation so we organize this data according to the
garden so mccluster similarly have another example Royce adaptation model so the roys adaptation
model our partner aspect now the fish ological functions the self concept the role function and the
interdependence of all these functions to each other low students
sorry we had a glitch so I had the glitch here with my Internet connection can you already hear me this
means OK thank you so let's proceed
Feedback exercise for example you took the blood pressure of your patient to which aspect
physiologique self concept role function or interdependence new chelis section app did you say become
blood pressure are very good so that's an example a self concept unbold should be for example like I am
a I am a mother of two kids visual logics of concept role function are interdependent I really function so
those are examples not of clustering data not according to this model let's proceed with your human by
the organ system so this this is an example already of your non nursing model see so let's take for
example the WBC count of your patient the initial look back among the different human body systems
there presented WBC count circulatory ZWB circulatory so then WBC is is responsible for what pretty
good immunity lymphatic system how about blood sugar not really very good in the crane system OK
exercise and activity pattern muscular means they're very good muscular let's give them an abnormal
body weakness you can give me actually two systems for body weakness they include well very good
nervous system and muscular system how about heart treat very good circulatory system how about
diarrhea diarrhea patient very good they just give system up skeem furger so very good menstrual cycle
email very good your female reproductive system chest X ray result of your patient very good yard
respiratory system actually played it line some heart so mobile and when I search as X ray couldn't
enlarged our heart so uh there and then additional national later on but basically just X ray would reflect
the condition of the lungs of your patient respiratory system OK so just a little tip from this woman
budget problems of your patient OK now meet the meet born no model not for organizing your data is
the body organ systems model we shall logic problem sufficiently how about can psychologic or psycho
emotional usually we make use of the Gordon's functional health patterns OK so I'm not sure guys
importance of organizing your data OK so let's proceed
this is another example of your non nursing models that different developmental series you will learn
more about this not as you go along and these for me have this is one of the very interesting topics not
when you are already in your SIM because you begin to understand no why you are thinking that way
why well your relationship with other people the ideology Sigmund Freud for psychosocial development
Erik erikson for psychosocial development Jean piaget for cognitive development and Lawrence
kohlberg for moral reasoning OK so now maybe check my Skype did you know many mention behind or
this is how you will cluster your data especially if you are assessing no the stages of growth and
development of your patient OK so for example your patient is a priest school child OK so I know
normally gay I initiative versus guilt OK so preschool age are afraid to be scolded no they are afraid of
punishment not so I'm not sure and of course for the phallic stage they are now becoming interested no
of there being male or female huh somebody sting wished I I'm a girl well I'm a boy OK how about
adolescence to adulthood or so so cognitive development changing this is how you will approach or you
will approach the lessons and adults for most thinking that so they could already explain things they can
already give rationale for their actions now so those are the different developmental theories that will
guide us on what are the normal OK behaviors of our patients as a search at a certain age so during
assessment normally I'm young last psychosocial development as psychosocial is normal OK so those are
the developmental series models that you can use to cluster data I normally and young thinking normal
reasoning OK or we keep development open in front or this is how they move this is how they interact
with equal gay so Nicola I don't trust versus mistrust not on backpack in the shop some other person I'm
gonna get there so yeah Bruce so I'm gonna get my trust there is still mistrust so I'm not sure adapter
mean that when we are assessing our patients with regards to what is normal and what is abnormal
following the different developmental OK so this is this model will help us organize not data that are
related to each other and these data will reflect a certain aspect of the client OK he didn't wanna class
my determann later on I'm normal abnormal during your analysis and sentences in the diagnostic page
or the nursing diagnosis face so that is why assessment is very very important as the first phase of the
nursing process OK so after you gather you organize your data OK because organizing your data will
make it easier for you to go on to the next phase which is diagnose now after organizing the data we
need to validate it what is the purpose of validation to verify data or to confirm data if it is complete if it
is factual and if it is accurate we don't just list right away because there are certain data subjective and
objective data that are fun flick Ting not malicious she feels warm she feels hot clear temperature
normal so I need to validate the feeling of the patient can develop on mug menopause I'm patient OK so
when you when the patient tells you I feel hot I feel warm it doesn't me right away that the patient has
fever OK that's because of the effect of the hormones gonna give time information OK so after
organizing your data you validate the data you double check you very fight to make sure that what we
the data that we have collected or gathered is complete factual and accurate OK So what are our
guidelines number one ensure that the assessment information is complete this is very very simple just
make sure that your history taking information sheet as well as your physical assessment data sheet is
complete OK my template number two we need to ensure that the subjective and objective data agree
with each other what do we mean by this inside OK for example patient tells you not gingka lot injury is
but upon your assessment you notice that it's not an insect bite it is a cigarette burn if we did and then
you could ask to verify now when did the when the when did the insect bite you OK then better mean if
the patient is really telling the truth by uh reviewing no this stages of the inflammatory process but we
need to ensure that the subjective and the objective data go inside another is full for example manner of
the fracture or manner of the dislocation does not go inside with the way the patient is you can find
notion who gay or not gay for example but yes so that pallab Bruce why is it not no so there are certain
things that we need to verify so we have further questions not like the manner of the injury next is we
need to obtain additional information that may have been overlooked so as we as you go along now as
studying the different assessment of our patient from head to toe now to be discussed in your midterms
and your finals you will be able to learn further no information that needs to be gathered for each part
of the body or for each system of the body OK next is we need to differentiate between cues and
inferences OK subjective or objective data that can be directly observed is known as your cues and
infrared is the interpretation of the nurse or conclusion based on the cues for example the patient has
LVM queue patient has sunken eyeballs that's a cute patient has sunken one panels that's a cute what is
an inference the patient may be dehydrated that's an inference because that's already the nurses in
interpretation or conclusion based on documents OK so that's the difference between a Q and an
infrared OK I know there example the patient is walking through and fro OK that's a cute the patient is
walking to and fro what's an inference the patient is agitated Speech OK that's an inference already so
we need to differentiate now our own interpretation from what is factual what is happening with
suppression OK and last minute they least avoid jumping into conclusion and focusing in the wrong
direction to identify problems I will not shop now we always look at the patient objectively and all
subjectively throughs are taken as is OK patient right so remember it now I'm critical thinking and bias
OK so that's part of critical thinking when you are gonna be playing so points to remember not all data
requires validation OK like laboratory studies OK when I'm with the result celebratory see that's what is
the reflection based on the machines not the termination of the for example the CBC the blood levels of
your patient I'm like wait maybe sharing tools and that height and weight is standardized already so
quote 555 no need to validate again I will tell you what type then what we have they're nice instruments
OK so just make sure that it is well calibrated and at weighing scale for the week OK next is the nurse
validates data when there are discrepancies between the data obtained in the interview and the
physical assessment similar to the example I said earlier I'm just need I got called West gay I was like the
temperature it's normal OK I feel feverish don't feel good are normal that's what I felt last week yes yes
last week booster feeling you need to validate now if there are discrepancies next is you need to be
aware of your own biases values and beliefs and separate facts from inference interpretation and
assumption gay So what we always make sure is what we are documenting and what we are stating in
the database of our patients are facts interpretation we do not say their patient is agitated no patient is
walking to and fro so move you are making inferences already if you are diagnosing you are patient but
not yet in assessment gay you don't put there in your assessment patient is anemic no what we put
there is RBC count I'm moving my 12 patient is fail there is fire there is sweetness we don't put their
patient is anemic that way they don't make inference or interpretation OK patient is paralyzed patient
and able to move extremities patient is paralyzed because it's already interpretation McGee who I'm
able to move right arm unable to move left leg so I'm looking at Next is to build an accurate database we
must validate our assumptions regarding clients cycle and emotional behavior OK must difficult to
validate can psycho emotional because it is body to given to you is subjective no no it's quite difficult to
validate it it is subjective data because subjective data is the clients own opinion of a certain condition
of himself or herself yeah so we take it patient we write it verbatim Lauer clear email check the
feedback temperature 36.9 degrees Celsius eight delete oil you will make use of this data to analyze and
this synthesize when you're already buying the client feels warm they don't normally when I meet young
temperature so you analyze one and yes unmixed face that's why I cannot learn accurate unpacked
document assessment feedback So what are the different guidelines that we need to follow and validity
OK first is to compare subjective and objective data not to verify client statements with observation
client feels warm check them clarify any ambiguous or vague statements for example client tells you I
feel sick I feel sick general OK so you need to clarify what are you feeling is there any pain do you have
any business comforts did you have any injury no Superman put on motion to clarify who are sick I know
probably take shot I feel sick some bolka I feel sick simply vicious psychologically sick or physically sick
be sure that your data consists of cues not inferences yeah it's working all and fro why can't yes Sir
patient is agitated because it's already an inference a patient is walking to and fro center not keep still
that's cute OK so that's how you takedown your notes huh assessment findings next double check the
data that are extremely abnormal example patient is sitting down very calm pillow on blood pressure
200 / 120 asking how are they laugh they check or request another nurse check you want abnormal
needed another example are great yeah pretty long what's the normal heart rate it's 60 to 130 heart
rate so when extremely abnormal very high or very low data OK so they didn't sign up the five owners
no would would exercise now how many extremely abnormal just to make sure I did laugh dating is
double checking extremely abnormal with it next is better in presence of factors that may interfere with
accurate measurement for example bug hi leans they have full health hey Helen I never spirit for you
read yeah of course if the factor that the patient has just arrived the patient walked no or ran on to say
we affect of course the accuracy of the respiratory care taking from your patient another would be
blood fresh word so of course 130 vital signs taking now but prior to taking the blood pressure patient
should be rested correct do you agree with me students guys are you still there can you give me some
some reactions there
signs not discussion they knew anything 101 our skills lab enter back in your vital signs I someone that
shut well so another example is italianissimo movies great well now it's a CG OK when taking the ECG
stop will appoint no Julie remove so gonna remove that cell phones or metals like coins and jewelry
from the patient because taking the ECG took my metal somebody will have an erratic result because of
the static cost by metals and magnetic magnetic media vices gay kiss on patient and come with update
I'm underside real some bad method no remove the heart attack the patient the interference accurate
measurement so that means proper positioning of the patient now and taking a CG as well as proper
placement of the program or of course removal of metals in the body OK so these are this is just an
example Thursday meeting for fear with after eight measurements OK and of course last look at the
least use references to explain phenomena go back to the books that is normal what is subnormal what
are the updated information that may help explain the condition of our patient examples I'm I'm go back
now to references so these are some of the guidelines that will help us validate our assessment the OK
check and compare check OK before you document your assessment data so we organize then we
validate our assessment feedback after organizing and validating we document documenting is the
recording taking down notes of all the assessment findings that we have gathered through interview
huh physical examination and of course our assessment So what is a report not a report is an oral
written or computer based communication intended to convey information to others so our report we
do it through our endorsement underreport is to an endorsement so we convey information to the next
shipment runners we convey information to the physician when we are documenting all when we are
making reports right doctor patient has not eaten the whole morning since Aretha that's an oral report
also the chart or clients records is a formal legal document that provides evidence of client care it can be
written or for people take note here that they have underline formal document and I placed aye aye aye
made the evidence no word read one yes I want that the chart or the client report is a formal legal
document that's why we ask ourselves should be very careful and we should follow guidelines and
policies when documenting data even just for assessment they will just formal especially in assessment
and of course all client care activities the whole of the patients chart is considered as a legal document
and when legalities matter it can serve as evidence in court and that I needed next I see you reach
second year after your capping you will be already hopefully not having your exposure in the hospital
beside McGrath balance and temperature some patient OK it should be accurate it should be
documented correctly and accurately in the patient chart in chapter word 8 inch in temperature wipe it
high temperature low my shop temperature is very very important than the woman to support
unfamiliar it can serve as evidence so very very carefully when document so the process of making an
entry is but of course recording charting or documenting so Mama let's start with that and here please
take note the nurses accountable and should document according to organizational policies and
universal standards so the main basis for documentation organizational policies and universal standards
so even just know what our student nurse final, you're already part of the health care team if you are
there having your RLE exposures in the hospital so left align I also intake and output accurate take one
100CC again in Rome with that 1000CC where did the 900CC come from or be it will matter later on
especially if it will be used as evidence in court no someone left here next word with make short supply
ads hey it's remember accurate documentation is essential and should include all data collected about
the client's health status and still the same data are reported in a factual manner not based on the
interpretation of the nurse also avoid restating or fire freezing clients subjective feedback it should be
documented in verbatim in quotation marks with lab you are thought was a subjective data quotation
mark I feel sick I feel sick I feel like I'm going to harm it I feel like I'm going to vomit when patient is not
cheated interpretation but I feel no shame no I feel like I'm going to vomit not the interpretation that no
patient is no sheated analysis later on but what you will need to document is the patient said I feel like
I'm going to vomit OK because saying no patient saying I feel like I'm going to vomit doesn't necessarily
mean nanosheet patient expression or for example yeah interpretation so it should be documented in
pay fine Pena has many other interpretations aside from being machine that's why when we record top
one but end we don't have money patient subjective data listed the best chance not avoid judgment or
conclusions example normal appetite what is normal for you may not be normal for the patient how do
you document it properly ate half of the rice consume one glass of milk and one apple and one whole
egg OK so one apple half cup of rice one glass of milk you don't put their normal appetite so that's an
example now document what is factual what really happened what the patient is we don't document
the normal appetite heavy I'm gonna no you document what has been functional huh so clear that that's
how we document no when we are assessing our patients game able to walk four steps without
assistance nothing about I did not get any patient has is paralyzed or patient has a para pleasure a
patient has muscle pain before steps gay so I think it back make judgments or conclusions OK so that's
how we document the fact accurate and batch OK so there are 13 main guidelines for recording patients
data OK we'll discuss them one by one let's start with your date inside OK when you're documenting
make sure that you have stated the date and time for each recording hey I'm the arrest Michigan
interview I know my date so not last charts on patient not name of the patient my baby not that time so
time can be documented in 12 hours now clock AM PM or it could be a 24 hour military flag on 24 hours
not signing OK so timing documenting should be done as soon as possible after an assessment or doctor
intervention do not document before you have done the assessment or intervention and the after hey
this way when you are in the clinical area you are required to have a small multiple alright you know
why some vital signs my notebook they pause are both substation igrafx patients chart you don't bring
and graft beside the patient so the last small notebook so last small notebook vital signs station
graphing hey so do not draft before assessment is done next legibility for written documentation so for
written documentation your penmanship should be legible and easy to read hand printing or easily
understood handwriting is permissible so use always now we avoid script or shorthand we might seem
what's not shorthand now so we don't make use of that one one word short long abbreviation gay boy
I'm because because we are very right now huh we are very adjusted that with text messaging my short
and I need uh online Bible way BTW I know but not usually now we avoid those things damn pause no
I'm big like an awkward messy so legibility should be very important now class we are different from
physicians OK so the documentation legible and he knows this notes Or success meant sheet so I can
match question next for recent documentation it should be written in ink or permanent pin one last
time add it's short boil pin not sentence now invent mega blocks stop Ben and usually client records in
the chart are double sided so bullpen no sign for electronic records changes are made in accordance
with software guidelines OK got under that device within some program that you cannot change the
information OK when you type something to change that are red shirt so you will learn more of those in
your nursing informatics such OK so again I'm finding a firmer right after and we do not document on
the next day OK so that part well once again access to the moment document do not have that habit
tomorrow so let me know right after that assessment so legibility practitioner proper handwriting for
those now maybe fakulty when it comes to 10 month ship it I'm gonna say remanent next would be
accepted terminology we make use of commonly accepted abbreviations symbols and curves you will be
fought with regards to the symbols and terms let me give you an example in the comments among us a
symbols I'm with Nathan is C with a bar on top and without ass with a bar on top so call 1 with those
without so uh those are just examples that I am sharing with you that why not you will be taught in your
fundamentals in nursing of the common abbreviations symbols and things you can also refer to the bold
examples of hey correct spelling please take notes in spelling gives a negative impression to the reader
and decreases the credibility of the nerves so make sure that when you are writing you are writing with
correct spelling signature it should include the mean and the title of the nurse so call me OK for example
when word art in yeah I still did 1S N CS that means student nurse got from CSD so for electronic records
of course you will have your own code or password not word my school my number or some boy for the
nurse that is unique to you for electronic records right so here based on the joint permission this is
established worldwide a here are the do not use list of symbols and units huh do not use you for unit
because it can be mistaken for zero or #4 or Sissy my balangir so word name where I used it can be
misinterpreted as intravenous or #10 the printer so right give international you me QD QD qod every
other day right get daily or every other day gay are you that but my zero open my zero or leaving 0
decimal point is mixed well who are Latin zero bye bye 10 milligrams study by 100 milligrams so one
whole number numb and long in the .0 gay solid 0 Norman leading zero popping decimal so when
decimal 0.25 ML beat song give after 70.25 ML bye see Abby Mila 25 MLK in Mesquite so when my when
does emotional fraction 0.25 and end so 0.25 one whole number misinterpret it is open yo hey
magnesium sulfate morphine sulfate magnesium sulfate it can be confused for one another so right my
long I'm more painful feet with magnesium sulfate OK so please take note of this multi very cool and
may the misinterpretation may affect not your care for your patience so please take note he shall not
lose my list OK so basically right now I've been talking to clamp row it could matter no.25 zero point
25ML it's way smaller than 25 10ML big difference man 110. Soldner document that accurately
especially on numbers terminology correct spelling and of course proper signature that's move on to the
next one you receive now we gonna see a curacy first reminder the clients name end identifying
information should be stamped or written on each beach of the client record every pitch so cut the
document my so let them mean supplier number date today time today special gear is needed when
clients have the same last name twins baby eight baby patient will BB8 baby be like the world is my you
wanna see you silly apellido Ruiz baby baby be similar OK my junior and senior in one syllable father and
son lucila my junior amazing you're my junior my daughter did forgive so special theory is needed
specially if not so clear we carefully must recheck give up you're holding the correct chart no not now it
could happen huh next would be I create locations consists of facts or above our observations not
opinions or interpretations again avoid your own interpretation I have given examples that earlier I
don't need elaborate on that now avoid general words like large board normal not because what is large
for you may not be large for others what is good for you may not be good for others like appetite
normal appetite normal weight measurement OK so short the clients ossific data the exact measure
when it comes to appetite when it comes to weight when it comes to height wrong when it comes to
size measure get 20 by 30 by 70 centimeters large it's not measurement shooting placement right on
every light never between lights so some idling yeah that's in between lines blocker no one and three for
each line on the chart again one and P for each line on the chart I know to building increases one entry
or one sentence well well we always remember that if there is a blank space draw a line through the
blank space so that no additional information can be recorded at any other time or by any other person
and then sign the notation what do I mean by this right remove make it 9 I swear so this is sample this is
one night my end vehicle blue for example of your writing I'm entry here Internet edge open end 39.
Hey so team So what do I do by Mary mean a blank space they didn't mention that yeah and then you
sign at the end I partner in Vietnam so and treat that is your protection asked the nurse now again
Wednesday night my line then they blank space add or draw a line on the blank space and then sign up
the end the game clear the bat so I the up went and tree I will put a line to complete that total to
complete the blank space and then I will sign and that is what is meant by this diagram that that will be
legally implicating on you good luck to you someone protection our entry in there is so next when we
draw a single line in the paper name and initials above or near the line depending on agency policy in
Chandler because it may be interpreted as a red flag not not follow my errors appear some patient no so
do not put the word error so the original entry must be visible so crash out one line laugh but I'm
intrigued playing the original entry should be visible for computerized entry follow the agency profile so
it depends you will learn it for your during your nursing informatics here I have also placed in all caps do
not erase do not block or do not news for action fluid for correction in our patients sharp mortal sin my
blood or my gamut correction loaded while lap hey goodnight again but highlight so here like increase
maybe for example so let me get intrigued what do I do please align insert that shot I will put my initials
here and then of course enter the entry I am sorry with the correct entity after how many inches my red
line and then my signature going up that means get delete for not sure I am the one in the Panama
shopper momo I am the one who deleted it and this is my correct entry and then in playing again delete
gay in in sign language not OK so that's how we make corrections if we have entered a mistake not are
my errors but as much as possible yeah writing and erroneous data on the patient chart I know love
much quote brass much as possible in Hawaii and madelung before check see patient is with me I can't
get my patience I'm gonna give me alright I'm gonna give me a call along about Ben sleeping my blow
my black and my red and she's depending on your ship mice scratch so let me check my email when
insert for now right Lena or Romeo notebook correctly section so I'm gonna eat that remove also left so
scratch rewrite rewrite miss transferring sharp or my hand hey so that is what happens OK OK so that's
clear accuracy can I have a thumbs up if clear on accuracy
OK very good connection manager Wi-Fi man OK so we're done with accuracy OK so very important give
me accurate and of course please take note that we should know how to properly correct the data that
we have encoded and we always make sure that what we have encoded in our patients chart is correct
A and accurate 5th minutes right deafness when your document and how animal dilone relax make sure
that you are confident that you are doing it correctly winning short scratch on my back on 3rd check
things before entering the bases once in break on what you are doing You mean that give me classmate
some more then I got charging then I got graphing students with my mother graphing charting
Yeah and each word time you said they serve Goodman in I'm miss or I serve as Sir 100 10/5 I'm missing
OK indeed make erase a indeed yeah but then that first year is action and they have a thumbs up on that
yeah in the there is always the proper way to correct on this OK and don't be afraid to say your CI Sir but
then long OK people all the more again it is it is move that game let him in jail indeed how we will be
there to guide you and supervise you on how to do it and upgrade again mine and what you are hey
when you're already in bed I know my job if you're doing it correctly and the confidence that UCI is there
guiding you and do it properly it can be smooth on your own have that motivation I will do this properly
I will concentrate I will write OK so I'm gonna show they are coming that to guide you and that to school
you has to dance I'm gonna have I need that make you help you learn how to do it properly so in human
in human responsibility is to do it correctly and confidence hey no OK let's move on to sequence the
document the events in order in the order in which they Porsche because when we document it should
be in 859 no pick a weird man listen to Asha this one gives the soil gain gain miss if I did look really long
but I know trouble look so weird OK so that part according to the timeline in which sequence so my
documentary mobile charting hey according to the events as they work and according to the
interventions as you did in oral care unbold remove minutes next is appropriateness record only
information that pertains to client health problems and air recording of irrelevant information may be
considered as invasion of clients privacy or you will be accused of libel libel hey it's a boy I'm glad that
patient hey so you are recording now or you are assessing now the local discharges of your patient I'm
up at the and and fuller I got serious steaks or your mom with my things abdomen because you're
accessing expression and war city diner you don't need to document it cannot expression G because
that's relevant information to your client care and lab charges they're giving birth OK later on from the
list emotional I'm sorry please now subjektive Don or sing diagnosis listening or I'm ciety chart because if
he can be considered a flight now or it is already an invasion express that so appropriate client
physiological response after giving birth hypogastric theme local discharges so that's just an example
that the nurse should also consider the appropriateness of the information that he or she is
documenting in the chart OK want to give me information but we also consider appropriateness when
we are document especially patient know sometimes they're psycho emotional normal I know you
expressed that's good one next is complete not only fast but the nurse some things about the client can
be recorded whoever they information that is recorded needs to be complete and helpful to the client
and the help So what we need as I've given the example earlier complete this charges amount
defendants and independent nursing interventions client problems client comments and responses to
interventions and tests progress towards voice and communication with other members of the health
care team condition or what does this mean for example the client refused super thanks yeah used to be
intubated so document what was on mitted why it was omitted and he was not ified so for example
client refused integration Paris informed hey refusal form refusal form or be an art form sign in sign
sufficiently I'm using cell form they may receive cell form so that's why the client has the right to self
determination client has the right to open refuse in our client here yes document it so have the client
side I'm I'm sorry or that do not receive one so Please remember what is not documented is not bad
play document refusal if you're the best scared beginner document when it comes to port remember
next is so they should be lion's why is playing simply refuse intubation so no need client refused
intubation refused intubation if you sounds form sign that means inside my client and end each spot
with a period so very concise but so this is where your training in grammar and English comes in maybe
English because it will be applied in your documentation my my appreciate you amigo making 6 it is
applied in our you don't need to be alive document but basic English and proper so now it's not easy
sweet we need to make it the horse left but not the least is legal prudence since the chart is a formal
legal document that serves as evidence in case of legal problems how are you guys so after it incomplete
documentation we'll give perfection to the nurse the health care team and the institution so when you
are properly documenting you are not just protecting yourself you're protecting the holy healthcare
theme and of course the institution it is admissible in court as a legal document so the clinical record
provides proof of the quality of care given to the patient so proof that some quality some gear and no
completeness and care what are the management's given to the patient completing the chart I'm not
leaving avoid taking on any shores and we properly correct our mistakes or errors in the documentation
next documentation is usually viewed as the best evidence of what really happened to the client upon a
time line complete correct huh and reminder I'd hear the professional standards of nursing care and
follow agency policies and procedures for intervention and documentation in all situation so when
you're working now I center see you are oriented why you are being given orientation on what did you
and of course it is your responsibility to study the patients chart thing in the book and in ending the
colors unbold pan right now with the advancement of technology we already make use of electronic
records so I know your generation is attacking generation you are what do you call this digital natives
come here come here digital immigrants from paper to elect to digital generation generation from
Electro or from paper to digital so not migrate immigrant when you were born I saw OK someone got
Jack funny things not more generation so it's easier for you to uh but the adapt to the electronic world
but legally again now we follow always agency protocol when documenting care for our patients when
documenting assessment findings no to follow that one OK especially now legal food dance is a similar
cases make sure that you do not own legal prudence especially in cases of abuse I assessment wise very
important not in cases of abuse so this is just an example unconscious patients forget that is very very
important so let's now proceed ensuring confidentiality and security of computer records since now we
are in a generation or we are in a time where in digital records is very common and usually used in the
hospital we have several tips and such as sessions to ensure protection insecurity of both the nurse as
well as the record itself the client record so number one remember that a personal password is required
to enter & off computer files so what's the main tip never share your password gay with anyone
including other health team members last protection when I email password when you had that mobus
word southwood mold entries gay or Miley patch on my leg number or in my password need to send in I
will let you out email password I'm sure password more with my sword Nelly password move into your
password in multiple data signatures fear in your data Next up sister veena or not some fashion thing in
that in outlook in password so that could happen in the So what is this do not share your password with
anyone can imagine this you know by sometimes uncontrollable circumstances that could lead to an
error and that error maybe that hey the number 2 hey attended hey I do not know the soap opera
others may see it I'm gonna shop and I bring the money for his face strategically in the station gay they
may he says or my instances sometimes nothing more than some significant others or some other
people know that they are the different example of my information birthdate and everything or
commitment in imposing patient possibly so simple birthday now leepa careful that is why versus you
thought you named it you don't get that now area hey Shred all I needed computer generated
worksheets yes we print something we print a we print we have print outs OK so all I needed is red now
is shredded I was thinking to her boy you've seen it in movies you've seen it in soap operas that Sam not
information in the used later on so we shred it huh hey Quinn next no the facilities policies and
procedures for correcting an entry error so you will be oriented on the agency's policy file no the agent
policy went correcting and entry error hey follow agency procedures for documenting sensitive
materials such as diagnosis of aids sample it's a very sensitive topic you may invade privacy and
confidentiality of information if you do not follow agency protocol OK so if I log it so policies and
procedures can also be termed as as not a lot first hey I thi personnel must is called a firewall to protect
server from unauthorized course not shop sports no protect the data especially if it is already digital
information and we not know very advantageous month if you are taking at the same time you are also
a nurse OK is sending a single class area to hospital management information system or ID office let me
add it that numbers OK so context cervical at the same time you're also good nurse you are you can also
be employed as part of the I team or the information technology team like when I T language class and
ID language information in the beginning includes new season so one month create forms and
documents no a nurse is needed because the nurse understands how things are how things go about in
the clinical area OK so we begin class in duty as stuff nurse did I see office forms to go even get checked
some some entries no so another quality control in three someday 80 office cerner's is the fermentation
it got to the check on complete an entry some data some assessment form now I think digitally encoded
not hopefully not yeah yeah I'm gonna career OK so with advancement technology additional jobs and
expertise can also be a career path for the nurse OK so now we know you're a nurse also an IP expert
clear I'm not mine carrier flash meant to act as if you are dead so organizing validating and documenting
client data is an important part of assessment so after gathering information collecting data no we of
course a organize the data using the different models we validate the data by double checking and
verifying information and we document data properly so that concludes the first phase of the nursing
process you proceed with the diagnosis and that concludes my topic with you word assessment not
introductory fool assessment
Which of the following methods of data collection
-ECG tracing
-birthday
-blood pressure
-age#
-variable data
-overt data
-neutral data
-constant data#
-database #
-medical chart
-biographical data
-physical assessment
-observe
-interview
-examine
-examine
-observe#
- interview
-clients#
-mother
-dyspnea
-Pain
-Cyanosis#
-bloating
-bp 110/80#
-constant
-variable#
-covert
-neutral
Repetition of questions can breed mistrust and cause annoyance for the patient
-false
-true#
-neutral
-directive#
-nondirective
-open-ended
-neutral
-closed
-leading
-age
-sex#
-height
-weight
-directive#
-neutral
-nondirective
-open-ended
POST TEST 2
-chief complaint
-past history
-biographic data#
-biographic data
-date and time
-past history#
-chief complaints
THESE DESCRIBE ANY SITUATION OR ACTION THAT WILL MAKE THE SYMPTOM
-location
-timing
-setting
-relieving#
-fellow nurses
-friend
-clinical record
-present illness
-past history
-biographic data#
-chief complaints
ONE DAY PTA ,PATIENT EXPERIENCED SUDDEN ONSET, INTERMITTENT,STABBING EPIGASTRIC PAIN
RADIATING TO THE RLQ AND LLQ LASTING FOR 15MINS,PS 10/10,PARTIALLY RELIEVED BY KNEE CHEST
POSITION, WORSENED BY FOOD INTAKE ,WITH UNDOCUMENTED FEVER ,CHILL AND NAUSEA AND
VOMITING OF 5 TIMES ,APPROX.240ML PER EPISODE OF PREVIOUSLY TAKEN FOOD THAT IS PROJECTILE
AND COFFE COLORED. IN THIS HPI WHAT WERE THE ASSOCIATED SYMPTOM?
-fever
-vomiting
-nausea
INCLUDE ALL MEDICATIONS, HERBAL DRUGS, HOME REMEDIES AND EVEN TOPICS THAT WERE TAKEN
FOR THE PROBLEM
-setting
-relieving
-onset
-treatments#
SPEAKS OF WHAT OTHER SYMPTOMS ARE NOTED ASSOCIATED WITH THE MAIN PROBLEM
-location
-setting
-associated symptoms#
-character
-setting
-timing
-location
-duration#
-alleviating
-setting
-aggravating
-past illness
-chief complaint#
-biographic data
THIS ATTRIBUTE OF A SYMPTOM ANSWERS THE QUESTION CAN YOU POINT OUT WHERE IT HURTS?
-timing
-duration
-location#
-setting
-biographic data#
-chief complaints
POST TEST 3
-menarche#
-coitarche
-lmp
-puberty
-para
-preterm#
-live
-gravida
-institution admitted
-reason of admission
-date of admission
-menarche
-lmp
-puberty
-coitarche#
-lifestyle history#
-past history
-functional history
-medical history
-the patient story often unfolds in a similar sequence as the health history#
-it is the responsibility of the nurse to arrange patients information to fit the different components of
the health assessment
WHICH OF THE FOLLOWING INFORMATION IS THE BEST CATEGORIZED UNDER MEDICAL HISTORY
WHAT IMPORTANT INFORMATION MUST BE WRITTEN DOWN IN THE HISTORY WITH REGARD TO
MEDICATIONS EXCEPT
-dose
-brand names#
-preterm#
-grativa
-para
-live
WHEN ELICITING HISTORY OF CONTRACEPTIVE USE WHICH OF THE FOLLOWING QUESTIONS ARE
IMPORTANT TO ASK,EXCEPT?
-coitarche#
-pubertt
-menarche
-LMP
These are usually closed questions with short specific answer. This allows identification of the owner
of the information
- Present illness
- Past history
- Biographic data*****
- Chief complaints
- HR of 110bpm
- Crackles says he is sad all the time
- Report her son to be sad all the time
- Patient says he is sad all the time ******
Factors that may influence how comfortable the client will be and what special arrangements might
be needed.
Which of the following chronic diseases are important to note in the past medical history
- Timing
- Treatment
- Setting*******
- Onset
- Dullness
- Flatness
- Tympany
- Hyperresonance********
- Indirect*********
- Direct
- Light
- Deep
- Tympany*****SALA
- Flatness
- Dullness
- hyperresonance
What important information must be written down in the history with regard to surgical procedures,
except
- Institution admitted
- Date of admission
- Reason for procedure
- All of the choices are correct******
In this HPI what the quality of the symptom? One day PTA, patient experienced sudden onset,
intermitted, stabbing epigastric pain radiating to the RLQ and LLQ lasting for 15mins, PS 10/10,
partially relieved by knee chest position, worsened by food intake, with undocumented fever, chills
and nausea and vomiting of 5 times, approx.. 240ml per and coffee colored.
- Stabbing ********
- Insidious
- Epigastric
- Sudden
- True
- False*******
- Circular rash
- Tympanitic
- Hyperactive bowel sounds
- Soft abdomen, non tender*****
Which of the following diseases are important in an interview fir family history, except
- Hypertension
- All of the choices are correct******
- Tb
- Thyroid disease
Give 1 vial Diazepam IV now which are of the medical chart does this belong to?
Wala ang 16
- Sitting
- Supine
- Sims ******
- Semi-fowlers
Source of the data will help determine which of the following, except
- Quality
- All of the choices are correct******
- Reliability
- Correctness
I feel hot and sweaty every afternoon is a sentence that speaks to which attribute of a symptom?
- Timing *******
- Setting
- Relieving
- Onset
My mom gave me Vicks vapor rub when I had a stuffy nose is a sentence that speaks to which
attribute of a symptom?
- Timing
- Setting
- Onset
- Treatment******
- Cyanosis*****
- Nodular
- Fremitus
- Dullness
When preparing a client for PE this is an important way to maintain a client’s dignity and privacy
- Draping*****
- Isolation
- Confidentiality
- Single nurse
- Chief complaint
- All of the choices are correct*****
- Biographic data
- Data and time
- Wheezing of auscultation
- Increased JVP
- All of the choices are correct****
- Increased RR
This component of comprehensive health assessment is always important and allows your assessment
to be used by future providers
On eliciting smoking history of a 60yo pt. states, I used to smoke 10yrs ago. I usually smokes half a
pack a day since I was 18 what would be his pack yrs?
- 25 *********
- 21******ARIII
- 30
- 16
Nurse come assess lungs and heart of patient complaining of dyspnea. This describes which type of PE
- Functional
- Specific
- comprehensive
- focused******
In this HPI what was the character of the symptom? One day PTA, patient experienced sudden onset,
intermittent, stabbing epigastric pain radiating to the RLQ and LLQ lasting for 15mins, PS 10/10,
partially relieved by knee chest position, worsened by food intake, with undocumented fever, chills
and nausea and vomiting of 5 times, approx.,240ml per episode of previously taken food that is
projectile and coffee colored.
- Epigastric pain
- PS 10/10*********
- Gnawing
- Radiating
This component of a comprehensive health assessment is always important and allows your
assessment to be used by future providers
On eliciting smoking history of a 50yo pt. states I stated smoking when I 10yo, my uncle taught me
how. I could finish 30 sticks a day what would be his pack yrs.?
- 60*********
- Tympany
- Dullness
- Flatness
- Resonance*****
When eliciting history of contraceptive use which of the following questions are important to ask?
29yo female patient came into the ER due to dizziness and pallor. As the nurse in the ER you are
taking the health history. Which of the following components of the OB/GYN history may point to the
source of the problem
- Interval
- Menarche
- Symptom
- Amount ******
A distance that the most people are comfortable with during interview is
- 2-3m
- 2-4ft
- 2-4m
- 2-3ft*******
I noticed that I am having runny nose every morning is a sentence that speaks to which attribute of a
symptom?
- Timing**********
- Setting
- Relieving
- Onset
The review of nursing and related literature can provide additional information for the database.
Which part of literature review is involved when you research for alternatives for blood transfusion?
During the initial interview the client makes this statement I don’t understand why I have to have
surgery I’m really not that sick or in pain right now what is the nurses best response?
A patient came in to the ER and OB history revealed my first baby was born at 28wks and had to stay
in an incubator for long time …………..
- May show any drug interactions that may occur with medications given in the hospital
- All of the choices are correct ***********
- May show possible organ injury to watch out for
- Mat show possible increased risk of bleeding
Which of the following circumstances where open-ended questions would be best suited
- Character*******
- Aggravating******
- Location
- Associated symptoms
- Character
Which of the following information is best categorized under past history
- Relieving
- Location
- Setting
- Timing*******
This component of health assessment answers the question. Describe the reason you came to the
hospital or clinic today.
- My father brought me for a check up for a swollen nodule when I was a child
- I had a cyst removed last year****
- None of the choices are correct
- I had leukemia when I was 10yo
- Variable data*****
- Constant data
- Neutral data
- Overt data
The finger that strikes the nondominat hand in contact with the body surface in order to produce a
sound
- Direct
- Indirect
- Pleximeter
- Plexor *******
Most important in determining data that can be taken from an intraoperative technique that speaks
of what was seen while doing the procedure
- Blood loss
- Devices intraoperative findings****
- Vital sign
Which statement would be true regarding use of observing method of data collection?
On history taking pt. says the last day of her last menstrual period was on jan 10 and lasted only 5
days. What is her LMP?
- 6-jan*****
- 11-jan
- 10-jan
- 15-jan
I have vomiting and abdominal pain is a sentence that speaks to which attribute of a symptom?
- Associated symptoms********
- Setting
- Character
- Location
- Dullness
- Tympany
- Flatness
- Hyperresonance*****
- Peripheral edema
- HR 76
- O2sat 98%
- Pain*******
- Bloating
- Dyspnea
- Cyanosis*******
- pain
A patient come in to the ER complaining of abdominal pain, upon pregnancy test it was positive. Upon
OB history patient is adamant that she has never has sexual partner prior to her boyfriend whom she
met 3months before. What would be her OB history?
- G1P1(0000)
- G1P1(0010)
- G1P0(0000)*****
- G0P0(0000)
Which of the following information would be best categorized in the past illness
My stomach hurts and feel awful is a sentence that speaks to which component of the health
assessment?
- Dullness *****
- Tympany
- Flatness
- Hyperresonance
In this HPI what was the duration of the symptom? One day PTA experienced sudden onset,
intermittent, stabbing epigastric pain radiating to the RLQ and LLQ lasting for 15mins, PS 10/10,
partially relieved by knee chest position, worsened by food intake, with undocumented fever, chills
and nausea and vomiting of 5 times, aprrox 240ml per episode of previously taken food that is
projectile and coffee colored.
- Intermittent
- 15mins*****
- 5x
- None of the choices
- Birthday******8
On history taking pt. says the last day of her menstrual period was on jan 3 and lasted only 3 days.
What is her LMP?
- 6-JAN
- 1-jan********
- 3-jan
- 4-jan
A conscious, deliberate skill that is developed through effort and with an organized approach
- Examining
- All of the choices are correct
- Observing*********
- Interviewing
Which of the following is the part of the history involving literature review for information about
medical diagnoses, treatment and prognoses
- Refusal of chemotherapy*******SAL
- Female circumcision ****SALA
- Refusal of blood transfusion and other blood product******
- Cardiac aneurysmal rupture for Kawasaki patient
- Live
- Gravida
- Term
- Para********
- Leading
- Open-ended******
- Closed
- None of the choices are correct
- Immunization history*******
- Father dies of cancer
- Use of illicit drugs
- All of the choices are correct
The patient is vague when describing symptoms, and the details are confusing is a sentence that
speaks to which component of the health assessment?
- Reliability ********8
- Client
- Source
- Questions
- Inspection
- Auscultation
- Palpation********
- Percussion
My pain starts in the back and goes to the front is a sentence that speaks to which component of the
health assessment?
- Chief complaint
- Biographic data
- History of present illness******
- Past history
This attribute of a symptom is always important in diagnosis and therefore in determine urgency of
management and kind of management
- Duration******
- Timing
- Location
- Setting
Which of the following is the main reason for receiving verbal reports from other healthcare
professionals
- Accurate medical records
- Sharing of information
- Completeness of record
- Continuity of care********
- Time
- Language
- All of the choices are correct******
- Seating
It is a complete, clear and chronologic description of the problems prompting the patients visit
- Biographic data
- Past history
- Chief complaint
- History of present illness******
- Mother
- Chart
- All of the choices are correct*****
- Other healthcare workers
- Tuning fork
- Percussion hammer
- Otoscope******
- Ophthalmoscope
- Live
- Para
- Term****
- Gravida
Respiration
Blood pressure 5
Vital signs- Definitions
Temperature, pulse, blood pressure, respiratory rate
Indicate the effectiveness of circulatory, respiratory, neural and endocrine body
functions.
6
• 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.
7
8
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.
9
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.
14
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
15
provide details about their health history and severity of symptoms.
Psychosocial, cognitive and moral development
16
17
18
19
20
21
• 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.
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.
29
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
31
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
32
Pain Scale
33
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
35
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).
40
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.
41
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
42
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
43
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.
44
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
45
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.
50
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.
51
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.
54
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.
55
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?
56
Nutritional status
57
58
59
60
61
62
63
64
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
65
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?
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
Kohlberg was concerned with what type of development?
- 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.
Air and Bone Conduction
• 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.
Air and Bone Conduction
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
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 Mouth and Throat
• Inspect the following:
• 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 Mouth and Throat
• Inspect the following:
• 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.
The Mouth and Throat
• Inspect the following:
• 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
JOSHUA D. VARGAS, RN, MD
The Hair
• Note its quantity,
distribution,
texture, and
pattern of loss, if
any.
• You may see loose
flakes of dandruff.
The Scalp.
1. Clubbing of fingers
2. Onycholysis
3. Paronychia
4. Terry’s nails
5. Beau’s lines
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:
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.
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
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.
STEPS RATIONALE
3. Keep the thermometer steady in Inaccurate reading may result & health
the ear canal assessment will be incorrect
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.
SPECIAL CONSIDERATIONS:
• 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.
SPECIAL CONSIDERATIONS:
- 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.
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.
SPECIAL CONSIDERATIONS:
• 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
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
Anal - 1.5-3 years – control being in anal or toilet training. Control bladder
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
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
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
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
Anticipation –
Vocalizations
Sometimes Pain is made up
Body Movement
Immobilization – cannot move
Muscle tension – contraction of the muscle
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 tolerance – how long can you endure the pain. Dysmenorrhea
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
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
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
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
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
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
Physical neglect –
Developmental neglect – did not give opportunity for child to decide, choose
Characteristics of abusers
4.
Interventions
Cultural values and norms – familiar rituals, the elder who makes the patients
decision
Spiritual –
Nutritional status - To determine the health status of the patient. Quality and
quantity of food
Clinical methods -
I. Anthropometric assessment
- BMI – body mass index
- mid upper and calf circumstances
- weight loss during the past 3
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?
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
Kohlberg was concerned with what type of development?
- 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:
Question 2
The following statements are true except:
I
Question 3
The chief muscle for breathing is innervated by:Supraclavicular 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
Score: 1 out of 1 Yes
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:
Question 7
Dryness of the skin can be associated in the following conditions except:
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?
Question 9
A finding that may indicate CN XII damage:
Question 10
Adventitious breath sound that may indicate upper respiratory tract
obstruction:
Response: Stridor
Question 11
Correct order of physical examination of the chest and thorax:
Question 12
Dullness during percussion may indicate the following except:
Response: COPD
Question 13
General term for enlarged thyroid gland
Response: Goiter
Question 14
Hard and fixed lymph nodes suggest:
Response: Inflammation
Question 15
The following is true about the examination of the head and neck except:
Question 16
In examining patient with a skin complain the following must be noted
except:
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
Question 19
Correct pairing of tonsil grading:
Question 20
True of Webers test, except:
Question 21
The nerve that innervates all the intrinsic tongue muscles
Question 22
The following are symptoms of pulmonary tuberculosis, except:
Response: 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
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:
Question 25
One of the two common techniques in holding the otoscope:
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
Question 27
In assessing the skin, the following are described except:
Response: Thermometer
Question 28
Functions of the nose, except
Question 29
During otoscopy, what landmark you need you look for to orient yourself
on the structures you need to examine:
Question 30
A simple test to check the acute inflammation of the external ear.
Response: Tug test
Question 31
Contact lenses and eyeglasses must be removed when testing the distal
visual acuity.
Response: False
Question 32
Asymmetric chest expansion can be in one of the following conditions:
Question 33
The skin’s ability to return to its place when pinched or lifted up:
Response: Turgor
Question 34
The following are risk factors for melanoma except:
Response: Nodule
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
Score: 0 out of 1 No
Question 37
All are true except:
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
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
Question 40
What disease condition that has small and large plaque with silvery scales?
Response: Psoriasis
Question 41
Landmark of the thyroid ithmus:
Question 42
Functions of the skin except:
Response: Synthesize calcium
Question 43
The following are needed in setting up the following are needed except:
Response: Make up
Question 44
Normal diaphragmatic excursion
Response: 3-7 cm
Question 45
Accurate description of the skin lesion is very important in making a
dermatologic
Response: True
Question 46
In cranial nerve X paralysis, what finding you may expect see when
assessing the pharynx?
Question 47
Direct and consensual reaction are done to test__________.
Question 48
Inspiratory and expiratory sounds that are equal in length
Response: Bronchovesicular
Question 49
Test for lateralization:
Question 50
Considered the best practice in examining the skin:
Score: 1 out of 1
Question 1
It is a basic nursing tool in which the nurse ensures that the interaction
focuses on the patient and the patient’s concerns and can gather complete
information that can help improve the health of patients.
Question 2
It allows patients time to gather their thoughts and provide accurate
answers. Silence can be therapeutic, communicating nonverbal concerns.
Question 3
Which therapeutic communication technique is being used in this nurse-
client interaction?
Client: “My father spanked me often.”
Nurse: “Your father spanked you often, he was a disciplinarian.”
Response: A. Restatement
Question 4
These are sensitive, personal, and privileged information of patients:
Question 5
Students are permitted to perform controlled acts authorized to nursing if
they meet all three criteria:
Question 6
Under the Philippine Nursing Act of 2002 R.A. 9178, nursing students do
not perform professional nursing duties. They are to be supervised by their
clinical instructors.
Response: False
Question 7
It relates to the content of the communication. The nurse makes a simple
statement, usually using the same words as patients.
Response: Restatement
Question 8
When a patient goes to the laboratory and offers his or her arm for blood
extraction is an example of an Express onsent.
Response: False
Question 9
The nurse changes the topic when a situation is uncomfortable because of
personal experiences or coping mechanisms.
Question 10
A student nurse is learning about the appropriate use of touch when
communicating with clients during the health assessment. Which statement
by the instructor best provides information about this aspect of therapeutic
communication?
Question 11
These are the inherent factors of effective nursing care:
Response: All of the above
Question 12
It is a special agreement to allow something to happen such as a surgery
based on full disclosure of risks, benefits, alternatives, and consequences of
refusal.
Question 13
In 2012 the Philippines passed the Data Privacy Act 2012, comprehensive
and strict privacy legislation “to protect the fundamental human right of
privacy, of communication while ensuring free flow of information to
promote innovation and growth.” .” (Republic Act. No. 10273, Ch. 1, Sec.
2).
Response: False
Question 14
During the interview, when patients are angry, the nurse listens for
associated themes and avoids becoming defensive or personalizing the
situation.
Response: True
Question 15
“Don’t worry everything will be alright”, is an example of_____________.
Question 16
Obtaining valid nursing history and gathering information on the
physiologic, psychological, socio-cultural, and spiritual status. The nursing
role focuses on promoting health, screening for problems, and intervening to
restore or improve health or function as optimally as possible.
Response: Interview
Question 17
These are ethical considerations in conducting health assessments except for:
Response: Supervision
Question 18
The goal is to elicit as much data about health status including biographical
data, reasons for seeking care, and history of present concern.
Question 19
Avoid being at different levels from the patient like standing in front of
her/him. It makes the patient feels inferior, he/she may not share critical
information and may feel you are disinterested.
Response: True
Question 20
Is an agreement to a client to accept a course of treatment or procedure
after being provided complete information, including the benefits and risks
of treatment, alternatives to the treatment, and prognosis if not treated by
a health care provider.
Question 21
The closing phase is where the nurse ends the interview by summarizing
and stating what the two to three most important patterns or problems
might be and asking patients if they would like to mention or need
anything else.
Response: True
Question 22
All is true about non- verbal therapeutic communication except for:
Response: d. Posture: Nurse is standing in open posture, while the client is
sitting in a chair.
Correct answer: d. Posture: Nurse is standing in open posture, while the client
is sitting in a chair.
Question 23
It was mandated by Article III, Section 9 of R. A. 9173, promulgated by
the Philippine Regulatory Board of Nursing which serves as the ethical -and
legal basis in the practice of the nursing profession in the Philippines.
Question 24
It is the ability to focus on patients and their perspectives. Talking to
patients with eye contact.
Question 25
It helps to minimize uncomfortable feelings but may mislead a patient into
minimizing a health concern or neglecting to perform a needed health-
promoting activity.
Question 27
Choose the three guidelines to avoid mistakes for nursing students:
Question 28
Students are not permitted to:
Question 29
When the community health nurse visits a patient at home, the patient
states, “I haven’t slept the last couple of nights.” Which response by the
nurse illustrates a therapeutic communication response to this patient?
Question 30
It is the ability to perceive, reason, and communicate an understanding of
another person’s feelings without criticism.
Response: Empathy
Question 31
A nurse states to a client, “Things will look better tomorrow after a good
night’s sleep.” This is an example of which communication technique?
Question 32
In verbal Communication, all is correct except for:
Response: Tell your patient that everything will be alright after the surgery.
Correct answer: Tell your patient that everything will be alright after the
surgery.
Question 33
It is a phase where the nurse establishes rapport by introducing herself/
himself and explaining the purpose of the interview.
Question 34
It is the ability to connect with the patient and demonstrate compassion,
sensitivity, and patient-centered care.
Response: Caring
Score: 1 out of 1
LONG QUIZ 1
Question 1
It is a basic nursing tool in which the nurse ensures that the interaction focuses on the
patient and the patient’s concerns and can gather complete information that can help
improve the health of patients.
Response: Therapeutic Communication Skills
Correct answer: Therapeutic Communication Skills
Score: 1 out of 1 Yes
Question 2
It allows patients time to gather their thoughts and provide accurate answers. Silence
can be therapeutic, communicating nonverbal concerns.
Response: Purposeful silence
Correct answer: Purposeful silence
Score: 1 out of 1 Yes
Question 3
Which therapeutic communication technique is being used in this nurse-client
interaction?
Client: “My father spanked me often.”
Nurse: “Your father spanked you often, he was a disciplinarian.”
Response: A. Restatement
Correct answer: A. Restatement
Score: 1 out of 1 Yes
Question 4
These are sensitive, personal, and privileged information of patients:
Response: Social security I.D.
Correct answer: Social security I.D.
Score: 1 out of 1 Yes
Question 5
Students are permitted to perform controlled acts authorized to nursing if they
meet all three criteria:
Response: Have been taught by their faculty, preceptor or Nurse Educator.
Response: Have the knowledge, skill and judgment to perform them as determined by
their preceptor or faculty member.
Response: Are supervised by a member of the nursing staff at hospitals or the faculty
member.
Correct answer: Have been taught by their faculty, preceptor or Nurse Educator. ,
Have the knowledge, skill and judgment to perform them as determined by their
preceptor or faculty member. , Are supervised by a member of the nursing staff at
hospitals or the faculty member.
Score: 3 out of 3 Yes
Question 6
Under the Philippine Nursing Act of 2002 R.A. 9178, nursing students do not perform
professional nursing duties. They are to be supervised by their clinical instructors.
Response: False
Correct answer: False
Score: 1 out of 1 Yes
Question 7
It relates to the content of the communication. The nurse makes a simple statement,
usually using the same words as patients.
Response: Restatement
Correct answer: Restatement
Score: 1 out of 1 Yes
Question 8
When a patient goes to the laboratory and offers his or her arm for blood extraction
is an example of an Express onsent.
Response: False
Correct answer: False
Score: 1 out of 1 Yes
Question 9
The nurse changes the topic when a situation is uncomfortable because of personal
experiences or coping mechanisms.
Response: Changing the subject
Correct answer: Changing the subject
Score: 1 out of 1 Yes
Question 10
A student nurse is learning about the appropriate use of touch when communicating
with clients during the health assessment. Which statement by the instructor best
provides information about this aspect of therapeutic communication?
Response: A. "Touch carries a different meaning for different individuals." Always ask
permission.
Correct answer: A. "Touch carries a different meaning for different individuals."
Always ask permission.
Score: 1 out of 1 Yes
Question 11
These are the inherent factors of effective nursing care:
Response: All of the above
Correct answer: All of the above
Score: 1 out of 1 Yes
Question 12
It is a special agreement to allow something to happen such as a surgery based on full
disclosure of risks, benefits, alternatives, and consequences of refusal.
Response: Informed consent
Correct answer: Informed consent
Score: 1 out of 1 Yes
Question 13
In 2012 the Philippines passed the Data Privacy Act 2012, comprehensive and strict
privacy legislation “to protect the fundamental human right of privacy, of
communication while ensuring free flow of information to promote innovation and
growth.” .” (Republic Act. No. 10273, Ch. 1, Sec. 2).
Response: False
Correct answer: False
Score: 1 out of 1 Yes
Question 14
During the interview, when patients are angry, the nurse listens for associated
themes and avoids becoming defensive or personalizing the situation.
Response: True
Correct answer: True
Score: 1 out of 1 Yes
Question 15
“Don’t worry everything will be alright”, is an example of_____________.
Response: False reassurance
Correct answer: False reassurance
Score: 1 out of 1 Yes
Question 16
Obtaining valid nursing history and gathering information on the physiologic,
psychological, socio-cultural, and spiritual status. The nursing role focuses on
promoting health, screening for problems, and intervening to restore or improve
health or function as optimally as possible.
Response: Interview
Correct answer: Interview
Score: 1 out of 1 Yes
Question 17
These are ethical considerations in conducting health assessments except for:
Response: Supervision
Correct answer: Supervision
Score: 1 out of 1 Yes
Question 18
The goal is to elicit as much data about health status including biographical data,
reasons for seeking care, and history of present concern.
Response: Working phase
Correct answer: Working phase
Score: 1 out of 1 Yes
Question 19
Avoid being at different levels from the patient like standing in front of her/him. It
makes the patient feels inferior, he/she may not share critical information and may
feel you are disinterested.
Response: True
Correct answer: True
Score: 1 out of 1 Yes
Question 20
Is an agreement to a client to accept a course of treatment or procedure after being
provided complete information, including the benefits and risks of treatment,
alternatives to the treatment, and prognosis if not treated by a health care provider.
Response: Informed consent
Correct answer: Informed consent
Score: 1 out of 1 Yes
Question 21
The closing phase is where the nurse ends the interview by summarizing and stating
what the two to three most important patterns or problems might be and asking
patients if they would like to mention or need anything else.
Response: True
Correct answer: True
Score: 1 out of 1 Yes
Question 22
All is true about non- verbal therapeutic communication except for:
Response: d. Posture: Nurse is standing in open posture, while the client is sitting in a
chair.
Correct answer: d. Posture: Nurse is standing in open posture, while the client is
sitting in a chair.
Score: 1 out of 1 Yes
Question 23
It was mandated by Article III, Section 9 of R. A. 9173, promulgated by the Philippine
Regulatory Board of Nursing which serves as the ethical -and legal basis in the
practice of the nursing profession in the Philippines.
Response: Philippine Nursing Code of Ethics
Correct answer: Philippine Nursing Code of Ethics
Score: 1 out of 1 Yes
Question 24
It is the ability to focus on patients and their perspectives. Talking to patients with
eye contact.
Response: Active listening
Correct answer: Active listening
Score: 1 out of 1 Yes
Question 25
It helps to minimize uncomfortable feelings but may mislead a patient into
minimizing a health concern or neglecting to perform a needed health-promoting
activity.
Response: False reassurance
Correct answer: False reassurance
Score: 1 out of 1 Yes
Question 26
The following behaviors are expected of nursing students, except:
Response: Perform controlled acts without close supervision of a clinical instructor.
Correct answer: Perform controlled acts without close supervision of a clinical
instructor.
Score: 1 out of 1 Yes
Question 27
Choose the three guidelines to avoid mistakes for nursing students:
Response: Nursing students should always be under the supervision of their clinical
instructors.
Response: They should be given assignments that are at their level of training ,
experience, and competency.
Correct answer: Nursing students should always be under the supervision of their
clinical instructors. , They should be given assignments that are at their level of
training , experience, and competency.
Score: 2 out of 2 Yes
Question 28
Students are not permitted to:
Response: Act as a witness under any circumstances or for any purpose.
Response: Give phone advice for discharged families.
Response: Take verbal or telephone orders.
Response: Transport patients alone when the presence of an RN is required.
Correct answer: Act as a witness under any circumstances or for any purpose. , Give
phone advice for discharged families. , Take verbal or telephone orders. , Transport
patients alone when the presence of an RN is required.
Score: 4 out of 4 Yes
Question 29
When the community health nurse visits a patient at home, the patient states, “I
haven’t slept the last couple of nights.” Which response by the nurse illustrates a
therapeutic communication response to this patient?
Response: . "You're having difficulty sleeping?"
Correct answer: . "You're having difficulty sleeping?"
Score: 1 out of 1 Yes
Question 30
It is the ability to perceive, reason, and communicate an understanding of another
person’s feelings without criticism.
Response: Empathy
Correct answer: Empathy
Score: 1 out of 1 Yes
Question 31
A nurse states to a client, “Things will look better tomorrow after a good night’s
sleep.” This is an example of which communication technique?
Response: D. The nontherapeutic technique of "giving false reassurance"
Correct answer: D. The nontherapeutic technique of "giving false reassurance"
Score: 1 out of 1 Yes
Question 32
In verbal Communication, all is correct except for:
Response: Tell your patient that everything will be alright after the surgery.
Correct answer: Tell your patient that everything will be alright after the surgery.
Score: 1 out of 1 Yes
Question 33
It is a phase where the nurse establishes rapport by introducing herself/ himself and
explaining the purpose of the interview.
Response: Beginning phase
Correct answer: Beginning phase
Score: 1 out of 1 Yes
Question 34
It is the ability to connect with the patient and demonstrate compassion, sensitivity,
and patient-centered care.
Response: Caring
Correct answer: Caring
Score: 1 out of 1
Interviewing
-Need to obtain a valid nursing health history
• Biographical data
• Listening, observing cues, and using critical thinking skills to interpret and validate information
received from the client.
• Collaborating with the client to identify the client's problems and goals.
Summary and Closing Phase Should end gracefully, not abruptly
• Summarizing information obtained during the working phase
• Identifying and discussing possible plans to resolve the problem with the client.
• Asking about any other concerns or further questions ("Is there anything else you would like to
mention?"
Nonverbal Communication
- Appearance: professional, uniform/ID
- Dress code re: hair, nails, jewelry (minimal)
• Demeanor: Warm, professional
• Facial expression: Neutral, friendly
• Silence: Allows you and client to reflect
• Listening: ACTIVE listening
• Posture: At same level as client, open posture
• Attitude: Nonjudgmental, accepting
Nonverbal Communication to Avoid • Excessive or insufficient eye contact
• Distraction and distance
- Physical distance: for the interview avoid physical distance exceeding 2‐3 feet during the
interview. Greater distance conveys a non‐caring attitude or a desire to avoid close contact
Verbal Communication
• Open‐ended questions or statements
- "How?" or "What?" or "Tell me .....". Use these type questions first
• False reassurance
• Unwanted advice
• Using authority
- Family role
COLDSPA for symptom analysis
Character (description - what does it feel like)
During the working phase, the nurse collects data by asking specific questions. Two types of
questions are closed-ended and open-ended questions. Each type has a purpose; the nurse
chooses which type will help solicit the appropriate information. Pre-interaction, beginning, and
closing are all phases in the interview process. The pre-interaction phase is prior to meeting the
client, when the nurse collects data from the medical record. The information gathered from the
medical record is used to conduct the client interview. The beginning phase is when
introductions are exchanged, privacy is ensured, and actions are made by the nurse to relax the
client. The closing phase is when a review of the interview is conducting, summarizing areas of
concerns or importance, allowing the client to ask any closing questions.
A clinic nurse is caring for a newborn and the newborn's parents. Observing parental behavior is
an important nursing function during this child's well-baby visit. What would the nurse expect
during observation? A: Parents encouraging the baby's happy behaviors
The nurse observes the parents as they speak to their infant for encouragement of happy
behaviors and comfort for crying. Parental behavior should be appropriate for the situation; a
detached or irritable parent is cause for concern.
Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client
did not want to wait. The nurse has heard about this client many times from colleagues and is
aware that she is very talkative. Which of the following is a helpful technique to improve the
quality of the interview for both provider and client? A: Briefly summarize what the client
says in the first 5 minutes and then try to have her focus on one aspect of what she discussed.
The nurse can also say, "I want to make sure I take good care of this problem because it is very
important. We may need to talk about the others at the next appointment. Is that OK with you?"
This is a helpful technique that can help the nurse to change the subject, but at the same time,
validate the client's concerns; this can provide more structure to the interview.
Which of the following questions is most useful in the assessment of a client's diabetes
management? "What is your routine for checking your blood sugar these days?"
A nurse is interviewing a man complaining of a pain in his shoulder. The nurse asks him where
exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen
similar cases in other clients and recognizes that is likely from prolonged work at a computer,
particularly using a mouse. Which of the following is the most effective use of inferring that the
nurse might implement in this situation? Do you perform any sustained or continually
repetitive motions with that arm?"
Inferring information from what the client tells you and what you observe in the client's behavior
may elicit more data or verify existing data. Be careful not to lead the client to answers that are
not true. The question, "Do you perform any sustained or continually repetitive motions with that
arm?" is open enough to not lead the client to an expected answer but narrow enough for the
nurse to help elicit more information from the client about probable causes of his pain.
Recommending that the client change his posture while working at the computer is premature, as
the nurse has not confirmed that the computer work is the culprit. Likewise, "You work at a
computer a lot, don't you?" is a leading question, as it encourages the client to answer in the
affirmative. The question, "When did the pain start?" is a close-ended question; it will elicit more
information from the client but is not an example of inferring.
While interviewing a patient, the nurse asks, "What happens when you have low blood glucose?"
This type of response to the patient is used for what purpose? To clarify
Another way to clarify is to ask, "What happens when you get low blood sugar?" Such questions
prompt patients to identify other symptoms or give more information so that you can better
understand the situation.
The nurse is preparing to conduct an interview with a hospitalized patient. What nursing
intervention can best ensure a confidential and comfortable environment for the patient? Asking
permission to draw the client's privacy curtain.
In order to support effective communication, the client must feel that the environment is
comfortable and the conversation will be confidential. Drawing the privacy curtain is an effective
way to project privacy and thus improve the comfort on the environment where the interview
will take place.
Which type of question is asked first by the nurse in order to attain a full description of the
client's symptoms and to generate and test diagnostic hypotheses? open-ended questions to
encourage the client to tell his or her story.
Using the visualization of "the cone," the process begins with open-ended questions to hear "the
story of the symptom," ideally in the client's own words. Specific questions are then used to get
the features of every symptom. Yes-or-no questions, also referred to as pertinent positives and
negatives, are used to retrieve information from the review of systems assessment.
A client is asked to describe "something that brings the most hope." Which functional health
pattern is the nurse assessing?A: value-belief
The value-belief health pattern describes patterns of values, beliefs or goals that guide choices or
decisions. The self-perception-self-concept pattern describes body image, feeling state, self-
esteem, personal identity, and social identity. The role-relationship pattern describes patterns of
role interactions and relationships including family functioning and problems, and work and
neighborhood environment. The coping-stress-tolerance pattern describes general coping pattern
and its effectiveness in terms of stress tolerance. A client's spouse answers the interview
questions and will not leave the examination room. What should the nurse suspect be occurring
with the client? A: physical abuse
Physical abuse should be considered if the partner tries to dominate the interview and will not
leave the room. Nonverbal communication is a very important aspect in nurse-client
relationships. What can the nurse do to help gain trust in clients? Select all that apply. Do not use
facial expressions such as rolling the eyes or looking bored or disgusted. Use gestures
intentionally to illustrate points, especially for clients who cannot communicate verbally.
The physical appearance of the nurse sends a message to the client. Thus, it is important for
nurses to ensure that their dress and appearance are professional. Facial expressions should be
relaxed, caring, and interested. Facial expressions common in social situations (eg, rolling the
eyes, looking bored or disgusted) reduce trust. The nurse uses gestures intentionally to illustrate
points, especially for clients who cannot communicate verbally. The nurse may point with a
finger or gesture an action, such as pretending to drink or pointing to the bathroom. Gestures are
purposeful rather than distracting from the communication.
During the client interview, the nurse asks specific questions such as "What were you doing
when the pain started?" or "Was the pain relieved when you rested?" In what phase of the
interview is the nurse involved? working
A nurse is interviewing an adult client who had a miscarriage 3 weeks ago. The woman is crying
and is having difficulty talking. The nurse moves closer and places a hand on the woman's hand.
What type of communication is this? Active listening
Active listening is the ability to focus on the client and their perspectives. It requires the nurse to
constantly decode messages including thoughts, words, opinions, and emotions. For example, if
a client is sad, it is appropriate for a nurse to place a hand over the client's and to show a facial
expression of compassion.
What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory
problems caused by excessive smoking? Suggest methods and provide resources to assist
with smoking cessation
The client will know that the nurse understands that it is hard to quit smoking if the nurse
suggests methods available to help kick the smoking habit. The nurse should keep a neutral and
friendly expression, and avoid any display of surprise or shock at the situation. A neutral,
friendly expression will help the client to open up and explain to the nurse his efforts at breaking
free from the habit. The nurse need not tell the client that excessive smoking could cause cancer,
as the client will be well aware of the dangers of smoking.
Tell me about your pain" is an example of an open-ended question. True
If the patient has not mentioned his or her perspective on illness during the open-ended portion
of the interview, explore this perspective prior to the directive. Probe the personal context of the
illness by asking, "How has this affected you
A nurse assesses a client with regard to nutritional habits, use of substances, education, and work
and stress levels. The nurse recognizes this as what type of information? Lifestyle and health
practices profile
By assessing the client with regards to nutritional habits, use of substances, education, and work
and stress levels, the nurse expects to obtain a lifestyle and health practices profile. To determine
the history of present health concerns, the nurse should ask questions relating to the onset,
duration, and treatments, if any have been conducted on the client, for the present health concern.
The questions related to personal health history assist the nurse in identifying risk factors that
stem from previous health problems. Family health history helps the nurse to identify potential
risk factors for the client.
A nurse is discussing with a client the client's personal health history. Which of the following
would be an appropriate question to ask at this time? "What diseases did you have as a
child?"
Information covered in the personal health history section includes questions about birth, growth,
development, childhood diseases, immunizations, allergies, medication use, previous health
problems, hospitalizations, surgeries, pregnancies, births, previous accidents, injuries, pain
experiences, and emotional or psychiatric problems.
The nurse is beginning a health history interview with an adult client who expresses anger at the
nurse. The best approach for dealing with an angry client is for the nurse to allow the client to
verbalize his or her feelings.
When interacting with an angry client approach this client in a calm, reassuring, in-control
manner. Allow him to ventilate feelings.
The nurse is planning to interview a client who is being treated for depression. When the nurse
enters the examination room, the client is sitting on the table with shoulders slumped. The nurse
should plan to approach this client by A: expressing interest in a neutral manner.
When interacting with a depressed client, express interest in and understanding of the client and
respond in a neutral manner.
Working with an Interpreter Prepare ahead of time
• Nurse must be present
• Be patient; takes time
• Speak slowly/clearly
• Pause to allow interpreter
to translate
• Timing: about 20‐30
minutes at a time
• If you do not feel comfortable or competent discussing personal, sensitive topics, you may
make referrals as appropriate.
Interacting with a seductive client, Set firm limits on overt sexual client behavior and avoid
responding to subtle seductive behaviors.
• Encourage client to use more appropriate methods of coping in relating to others.
Review of Systems. Each body system is addressed to find out current health problems or
problems from the pat that may still affect them or recur.
Both maternal and paternal relatives are included in the family health history. Problems can arise
in families that are not genetically based but are manifest by virtue of exposure to lifestyle
practices. Parents, grandparents, aunts, uncles, and children are all included in this history. If the
relative is deceased, the cause and age of the relative is recorded. A client scheduled for surgery
tells the nurse that he is very anxious about the surgery. What is an appropriate action by the
nurse when interacting with this client? Provide simple and organized information.
The nurse should provide simple and organized information to reassure the client about the
procedure and its expected outcomes. The nurse approaches the aggressive, not anxious, client in
an in-control manner. The nurse refers the dying client or client with spiritual concerns to a
spiritual guide. The nurse should avoid expressing anxiety or becoming anxious like the client, as
it would make the client more anxious.
An elderly client with Parkinson's disease and his wife, who appears to be much younger than he,
are being interviewed by the nurse to update the client's health history. The nurse also has the
client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken
with the client's primary care physician, who had relayed some concerns to the nurse regarding
the progression of the client's disease. Which source of biographic information should the nurse
view as primary? The client
Biographic data usually include information that identifies the client, such as name, address,
phone number, gender, and who provided the information—the client or significant others. The
client is considered the primary source and all others (including the client's medical record) are
secondary sources. In some cases, the client's immediate family or caregiver may be a more
accurate source of information than the client. An example would be an older adult client's wife
who has kept the client's medical records for years or the legal guardian of a mentally
compromised client. In any event, validation of the information by a secondary source may be
helpful.
A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling
on her left side. Which of the following questions would be best for eliciting information related
to associated factors? "What other symptoms occurred during the spell?"
Examples of questions related to associated factors include the following: "What other symptoms
occur with it? How does it affect you? What do you think caused it to start? Do you have any
other problems that seem related to it? How does it affect your life and daily activities?" The
question, "How bad was the tingling and numbness?" relates to severity. The question, "How
long did the spell last?" relates to duration. The question, "Where did the numbness and tingling
occur?" relates to location.
The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular
accident. The nurse is unable to completely understand the client. What is the nurse's best action
Ask the client to repeat the statement or question.
The nurse should ask clients to repeat questions or statements if the nurse is unable to understand
what the client said. The nurse can also paraphrase client responses to verify understanding.
Learning about the effects of the illness does what for the nurse and the patient? Gives them
the opportunity to create a complete and congruent picture of the problem.
A student nurse is conducting her first patient interview. The student suddenly draws a blank on
what to ask the patient next. What is a useful interview technique for the student to use at this
point? Summarization
Summarization can be used at different points in the interview to structure the visit, especially at
times of transition. This technique also allows the nurse to organize his or her clinical reasoning
and to convey it to the patient, making the relationship more collaborative. It is also a useful
technique for learners when they draw a blank on what to ask the patient next.
For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal
illness or sexuality, the nurse should have knowledge of his or her own thoughts and feelings
about these issues.
Be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then
recognize that these factors may affect the client's health and may need to be discussed with
someone.
During the interview of an adult client, the nurse should provide the client with information
as questions arise.
Another important thing to do throughout the interview is to provide the client with information
as questions and concerns arise. Make sure that you answer every question as thoroughly as you
can. If you do not know the answer, explain that you will find out for the client. The more clients
know about their own health, the more likely they are to become equal participants in caring for
their health.
The nurse is beginning the review of systems with a client. Which approach would ensure that all
major body systems are included in this assessment? head to toe
Name: XXX
SOAP
SUBJECTIVE:
ID: K.B, DOB 9/08/1990, age 30. Male comes to clinic alone. Appears to be a reliable historian.
A 29-year-old male came for his well visit. He states he his last physical was a year ago and everything
was good. Feels well otherwise. No other complaints.
• High cholesterol. Diagnosed 4 years ago. Took Lipitor but stopped about 6 months ago due to
stomach issues and was not prescribed any other cholesterol medications.
• Gastritis. Diagnosed 4 years ago. Has flare ups. Last flare up a year ago. Takes a medication
(does not know the name) to treat it. States it comes when he is stressed.
• Denies any other medical conditions including any other heart disease, diabetes, or asthma.
MEDICATIONS-
ALLERGIES-
N/A
FAMILY HISTORY
• All grandparents are currently living except MGF who passed away at 78 years of age from
Covid-19. MGF also had pacemaker and diverticulitis. MGM has irregular heartbeat. FGM & FGF have no
medical history.
• Patients mother has no significant medical conditions. Father had 2 heart stents put in around 5
years ago and has seasonal allergies. No other complications. Siblings-has a brother with early-stage
diabetes and obesity, and a sister who had a kidney transplant 12 years ago. No other complications.
Children- has 3 girls all with no medical conditions.
• Patient also denies any other heart, kidney, diabetes, asthma problems. Patient denies any
cancer, obesity (other than brother), muscle problems, bleeding disorders, psych problems, genetic
disorders, or allergies in the family (other than father’s seasonal allergies).
SOCIAL HISTORY
-DRUG USE: Has one joint of pot on weekends. Denies any other drug use
-MARITAL HISTORY: Married with three kids. Lives in a home. Feels safe to go home. Reports no violence
or abuse at home.
-EXERCISE/DIET: Has cereal & milk for breakfast and has chicken/meat for lunch & dinner. Eats a lot of
candy. Denies drinking caffeine.
-STRESS/SLEEP: Stresses a lot from job, no coping strategy. Bikes for hobby. Wears helmet. Volunteers in
free time for EMS.
IMMUNIZATIONS:
SPIRITUAL AFFILIATION
Jewish
REVIEW OF SYSTEMS:
EARS, NOSE, MOUTH/THROAT: Denies any difficulty hearing, hearing loss, ringing, or buzzing in ear.
Denies any earaches. Denies any runny nose, congestion, sinuses, or difficulty smelling. Denies any
difficulty chewing, swallowing, sore throat, ulcer/blisters in mouth. Last dental exam 8 months ago.
CARDIOVASCULAR: States he gets sudden onset chest pain every week from stress. States chest pain
feels like tightening in middle of chest. Denies any abnormal heartbeat.
GASTROINTESTINAL: Has daily bowel movements. Gets occasionally-every month or so- constipation
related to stress, and it goes away itself. Denies any blood or black colored stool.
GENITOURINARY: Denies any hematuria, dysuria, or difficulty urinating. Denies any discharge.
MUSCULOSKELETAL: Complaints of sore back from bad bed occasionally, go away by sleeping flat.
ENDOCRINE: Denies heat or cold intolerance, hair lost, weight gain or loss.
PLAN OF CARE:
Educate patient on DASH diet and healthier food choices such as no more than 6 oz a day of lean meats.
RISK ASSESSMENT:
A. Patient is at risk for heart diseases due the fact that he does not take medications for his high
cholesterol, gets chest pain from stress, eats meats two times a day, does not exercise regularly, and has
a family history of heart disease (Centers for Disease Control and Prevention, 2019).
B. Patient is at risk for gastrointestinal problems due to chronic stress from work and due to
history of recurrent gastritis (Mayo Clinic, 2019).
C. Patient is at risk for obesity due to stress, family history, and eating fatty and high sugar foods
(World Health Organization, 2020).
REFERENCES:
Centers for Disease Control and Prevention. (2019). Know your risk for heart disease.
https://www.cdc.gov/heartdisease/risk_factors.htm
Mayo Clinic. (2019). Chronic stress puts your health at risk. https://www.mayoclinic.org/healthy-
lifestyle/stress-management/in-depth/stress/art-20046037
• THE HEALTH HISTORY FORMS THE FOUNDATION FOR CARE AS PATTERNS EMERGE
AND PROBLEMS ARE IDENTIFIED.
• IS A BASIC NURSING TOOL IN WHICH THE NURSE ENSURES THAT THE INTERACTION
FOCUSES ON THE PATIENT AND THE PATIENT’S CONCERNS.
•ACTIVE LISTENING
•ADAPTIVE QUESTIONING
•NONVERBAL COMMUNICATION
•EMPATHY, VALIDATION, AND REASSURANCE
•PARTNERING AND SUMMARIZATION
•TRANSITIONS AND EMPOWERMENT
VERBAL COMMUNICATION SKILLS
• ACTIVE LISTENING IS THE ABILITY TO FOCUS ON PATIENTS AND THEIR
PERSPECTIVES.
• RESTATEMENT RELATES TO THE CONTENT OF COMMUNICATION. THE
NURSE MAKES A SIMPLE STATEMENT, USUALLY USING THE SAME WORDS
OF PATIENTS.
• REFLECTION IS SIMILAR TO RESTATEMENT; HOWEVER, INSTEAD OF
SIMPLY ECHOING THE PATIENT’S COMMENTS, THE NURSE SUMMARIZES
THE MAIN THEMES.
• ENCOURAGING ELABORATION (FACILITATION) ASSISTS PATIENTS TO
MORE COMPLETELY DESCRIBE PROBLEMS.
• PURPOSEFUL SILENCE ALLOWS PATIENTS TIME TO GATHER THEIR
THOUGHTS AND PROVIDE ACCURATE ANSWERS. SILENCE CAN BE
THERAPEUTIC, COMMUNICATING NONVERBAL CONCERN•
• FOCUSING HELPS WHEN PATIENTS STRAY FROM TOPIC AND NEED
REDIRECTION. IT ALLOWS THE NURSE TO ADDRESS AREAS OF
CONCERN RELATED TO CURRENT PROBLEMS.
• CLARIFICATION IS IMPORTANT WHEN THE PATIENT’S WORD CHOICE
OR IDEAS ARE UNCLEAR.
• SUMMARIZING HAPPENS AT THE END OF THE INTERVIEW, WHEN THE
NURSE REVIEWS AND CONDENSES IMPORTANT INFORMATION INTO
TWO OR THREE OF THE MOST IMPORTANT FINDINGS.
NONTHERAPEUTIC RESPONSES
• • FALSE REASSURANCE HELPS TO MINIMIZE UNCOMFORTABLE FEELINGS BUT MAY MISLEAD A
PATIENT INTO MINIMIZING A HEALTH CONCERN OR NEGLECTING TO PERFORM A NEEDED HEALTH-
PROMOTING ACTIVITY.
• • SYMPATHY IS FEELING WHAT A PATIENT FEELS FROM THE VIEWPOINT OF THE NURSE, NOT OF THE
PATIENT.
• • UNWANTED ADVICE, ALTHOUGH COMMON IN SOCIAL SITUATIONS, IS NON- THERAPEUTIC,
BECAUSE IT USUALLY IS FROM THE NURSE’S PERSPECTIVE, NOT THE PATIENT.
• • BIASED (LEADING) QUESTIONS IMPOSE JUDGMENT AND LEAD PATIENTS TO RESPOND IN THE WAY
THEY THINK THE NURSE WANTS.
• • CHANGING THE SUBJECT MAY HAPPEN WHEN A SITUATION IS UNCOMFORTABLE FOR A NURSE
BECAUSE OF PERSONAL EXPERIENCES OR COPING MECHANISMS.
• • ENVIRONMENTAL DISTRACTIONS CONTRIBUTE TO NONTHERAPEUTIC COMMUNICATION.
• • TOO MANY TECHNICAL TERMS OR TOO MUCH INFORMATION CAN OVERWHELM PATIENTS. AS SHE
OR HE DEVELOPS MEDICAL VOCABULARY AND KNOWLEDGE, THE BEGINNING NURSE MUST
PRACTICE TRANSLATING FROM MEDICAL TERMINOLOGY TO LAY LANGUAGE.
• • TALKING TOO MUCH AND INTERRUPTING ARE NONTHERAPEUTIC. THE PROFESSIONAL NURSE
LISTENS MORE THAN TALKS.
PHASES OF THE INTERVIEW PROCESS
PRE-INTERACTION PHASE
BEFORE MEETING WITH THE PATIENT, THE NURSE COLLECTS DATA FROM THE MEDICAL
RECORD AND REVIEWS THE PATIENT’S HISTORY OF MEDICAL ILLNESSES OR SURGERIES,
CURRENT MEDICATION LIST, AND PROBLEM LIST.
BEGINNING PHASE
THE NURSE INITIALLY INTRODUCES HERSELF OR HIMSELF BY NAME, STATES THE PURPOSE
OF THE INTERVIEW, AND ASKS THE PATIENT HIS OR HER PREFERRED NAME
WORKING PHASE
THE NURSE ASKS SPECIFIC QUESTIONS, TWO TYPES OF WHICH ARE
CLOSED ENDED AND OPEN ENDED.
• stronger problem-solving
a b i l i t i e s w h e n
determining what may be
impacting a patient.
• helps to alleviate
anxiety or other negative
emotions in patients,
such as fear or
loneliness, more
effectively than standard
forms of communication.
ROLE PLAYING VIDEO ON
THERAPEUTIC AND NON
THERAPEUTIC COMMUNICATION
THANK YOU
Question 1
In disease conditions that causes narrowing of airways, what adventitious breath sound
you may expect to hear during auscultation?
Response: Wheezing
Correct answer: Wheezing
Score: 1 out of 1 Yes
Question 2
A part of health promotion and disease prevention activities in patient with skin
complaints, the following must be included in the self skin examination health teaching
except;
Response: Advise patient use emollient
Correct answer: Advise patient use emollient
Score: 1 out of 1 Yes
Question 3
A patient came in to the ER with central cyanosis, the following conditions you will
consider except:
Response: Beta Thalassemia
Correct answer: IDA
Score: 0 out of 1 No
Question 4
In assessing pallor and cyanosis, fingernails and lips are the areas you need to
examine because:
Response: They consist of thick layers of mucous membrane that changes in blood flow
can be easily seen
Correct answer: The layer is thin enough to cause less scatter of light
Score: 0 out of 1 No
Question 5
The following statements are true except:
Response: Pupillary constriction is a parasympathetic response
Correct answer: Visual cortex is part of the parietal lobe of the brain
Score: 0 out of 1 No
Question 6
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
Score: 1 out of 1 Yes
Question 7
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
Score: 1 out of 1 Yes
Question 8
The following are types of secondary skin lesions except
Response: Papule
Correct answer: Papule
Score: 1 out of 1 Yes
Question 9
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
Score: 1 out of 1 Yes
Question 10
Which statement is true about cyanosis
Response: Central cyanosis occurs when there is low venous oxygen level in the blood
Correct answer: Peripheral cyanosis occurs when cutaneous blood flow is decreased
Score: 0 out of 1 No
Question 11
The skin’s ability to return to its place when pinched or lifted up:
Response: Turgor
Correct answer: Turgor
Score: 1 out of 1 Yes
Question 12
The following are functions of the skin except:
Response: Excretion of waste
Correct answer: Wound regression
Score: 0 out of 1 No
Question 13
You are a dialysis nurse and you are taking of patient with pitting edema. Which of the
following is true of pitting edema:
Response: It’s a depression left when pressure is applied in the non-dependent area of
the body
Correct answer: A depression left for 16 seconds when pressed
Score: 0 out of 1 No
Question 14
Swollen and tender lymph nodes suggest:
Response: Infection
Correct answer: Infection
Score: 1 out of 1 Yes
Question 15
Asymmetric chest expansion can be in one of the following conditions:
Response: Flail chest
Correct answer: Flail chest
Score: 1 out of 1 Yes
Question 16
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
Score: 1 out of 1 Yes
Question 17
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
Score: 1 out of 1 Yes
Question 18
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.
Score: 1 out of 1 Yes
Question 19
A finding that may indicate CN XII damage:
Response: Deviation of the tongue
Correct answer: Deviation of the tongue
Score: 1 out of 1 Yes
Question 20
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 the superior oblique muscle is innervated by what
cranial nerve?
Response: Abducens nerve
Correct answer: Trochlear nerve
Score: 0 out of 1 No
Question 21
True of Rinne’s test, except:
Response: Conductive hearing loss sound is heard through bone as long as or longer
than is through the air
Correct answer: None of the above
Score: 0 out of 1 No
Question 22
The following is true about the examination of the head and neck except:
Borders of the anterior triangle of the neck, except
Response: SCM
Correct answer: Hyoid bone
Score: 0 out of 1 No
Question 23
Dryness of the skin can be associated in the following conditions except:
Response: None of the above
Correct answer: None of the above
Score: 1 out of 1 Yes
Question 24
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
Score: 1 out of 1 Yes
Question 25
The anterior-posterior chest diameter may increase with aging:
Response: True
Correct answer: True
Score: 1 out of 1 Yes
Question 26
Accurate description of the skin lesion is very important in making a dermatologic
Response: True
Correct answer: True
Score: 1 out of 1 Yes
Question 27
Inspiratory and expiratory sounds that are equal in length
Response: Bronchovesicular
Correct answer: Bronchovesicular
Score: 1 out of 1 Yes
Question 28
Dullness during percussion may indicate the following except:
Response: COPD
Correct answer: COPD
Score: 1 out of 1 Yes
Question 29
Functions of the nose, except
Response: Aesthetic functions
Correct answer: Aesthetic functions
Score: 1 out of 1 Yes
Question 30
Correct order of physical examination of the chest and thorax:
Response: Inspection, palpation, percussion, auscultation
Correct answer: Inspection, palpation, percussion, auscultation
Score: 1 out of 1 Yes
Question 31
A patient diagnosed with acne came in your primary care clinic and noted several
lesions on here back and face. The above-mentioned lesion is an example of:
Response: Papule
Correct answer: Pustule
Score: 0 out of 1 No
Question 32
Test for lateralization:
Response: Weber test
Correct answer: Weber test
Score: 1 out of 1 Yes
Question 33
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
Score: 1 out of 1 Yes
Question 34
Normal diaphragmatic excursion
Response: 3-7 cm
Correct answer: 3-7 cm
Score: 1 out of 1 Yes
Question 35
Gradual loss of ability of the eye to focus due to aging:
Response: Presbyopia
Correct answer: Presbyopia
Score: 1 out of 1 Yes
Question 36
Landmark of the thyroid ithmus:
Response: A and B
Correct answer: 2nd, 3rd and 4th tracheal rings
Score: 0 out of 1 No
Question 37
The chief muscle for breathing is innervated by:Supraclavicular nerve
Response: Phrenic nerve
Correct answer: Phrenic nerve
Score: 1 out of 1 Yes
Question 38
Contact lenses and eyeglasses must be removed when testing the distal visual acuity.
Response: False
Correct answer: False
Score: 1 out of 1 Yes
Question 39
A finding that may indicate CN XII damage:
Response: Deviation of the tongue
Correct answer: Deviation of the tongue
Score: 1 out of 1 Yes
Question 40
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
Score: 1 out of 1 Yes
Question 41
The following are symptoms of pulmonary tuberculosis, except:
Response: Bulimia
Correct answer: Bulimia
Score: 1 out of 1 Yes
Question 42
A simple test to check the acute inflammation of the external ear.
Response: Tug test
Correct answer: Tug test
Score: 1 out of 1 Yes
Question 43
The anterior-posterior chest diameter may increase with aging:
Response: True
Correct answer: True
Score: 1 out of 1 Yes
Question 44
You are assigned as nurse to care for a patient with dermatologic problem. Which of
the following is coonsidered the best practice in examining the skin:
Response: Thorough observation
Correct answer: Thorough observation
Score: 1 out of 1 Yes
Question 45
The nerve that innervates all the extrinsic tongue muscles
Response: Hypoglossal nerve
Correct answer: Hypoglossal nerve
Score: 1 out of 1 Yes
Question 46
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
Score: 1 out of 1 Yes
Question 47
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: Distinguish between conductive and sensorineural hearing loss using air and
bone conduction test
Correct answer: Distinguish between conductive and sensorineural hearing loss using
air and bone conduction test
Score: 1 out of 1 Yes
Question 48
The following are risk factors for melanoma except:
Response: Dark eyed individuals
Correct answer: Dark eyed individuals
Score: 1 out of 1 Yes
Question 49
General term for enlarged thyroid gland
Response: Goiter
Correct answer: Goiter
Score: 1 out of 1 Yes
Question 50
Adventitious breath sound that may indicate upper respiratory tract obstruction:
Response: Stridor
Correct answer: Stridor
Score: 1 out of 1
THE HEALTH CARE TEAM
IN HEALTH ASSESSMENT
SOCIAL WORKERS
TRAINED DAIS
HEALTH
ASSISTANTS
THE PHYSICIAN
Beginning Phase
The nurse initially introduces herself or himself by name, states the
purpose of the interview, and asks the patient his or her preferred
name
Working Phase
The nurse asks specific questions, two types of which are
closed ended and open ended.
• stronger problem-solving
abilities when determining
what may be impacting a
patient.
• helps to alleviate anxiety or
other negative emotions in
patients, such as fear or
loneliness, more effectively
than standard forms of
communication.
THANK YOU
Health Assessment NCM 101
Competencies
• Therapeutic Communication
• Health Plan
• Health Teaching
Plan
• Increase Health
Literacy
• Promote Healthy
Practices
• Address Health
problems
• Health Teaching Plan
• LEARNING OBJECTIVES/
OUTCOMES
• OUTLINE
• METHODS OF INSTRUCTION
• TIMEFRAME
• INSTRUCTIONAL MATERIAL
• EVALUATION
Understanding
varied groups
In the conduct of
the Health
Teaching
POINTS IN
PREPARING FOR
EFFECTIVE
TEACHING WITH
VARIED LEARNING
GROUPS
WHAT IS YOUR TOPIC?
WHERE IS YOUR
TEACHING TAKING
PLACE?
WHAT IS YOUR TOPIC?
• CLARITY OF TOPIC
• EFFECTIVITY IN THE DELIVERY
• EFFICIENT USE OF THERAPEUTIC
COMMUNICATION
• USE OF APPROPRIATE MATERIALS
Health Teaching Plan
Health
•PATIENT Teaching Plan
SCENARIOS
• LEARNING OBJECTIVES – 3
• OUTLINE (1 major topic, 1 minor)
• METHODS OF INSTRUCTION- case to case
• TIMEFRAME- 15 min presentation
• INSTRUCTIONAL MATERIAL- 1-2 appropriate
for audience
• EVALUATION-
RELEVANT ETHICO-LEGAL GUIDELINES IN
CONDUCTING HEALTH ASSESSMENT
V. HEALTH ASSESSMENT
Ethics – declarations of what is right and wrong.
• The purpose of ethics is to govern conduct to protect
an individual’s rights.
ARTICLE I Preamble
Sec.1 Health is a fundamental right of every individual. The Filipino registered nurse
believing in the worth and dignity of each human being, recognizes the primary
responsibility to preserve health at all cost. This responsibility encompasses the promotion
of health, prevention of illness, alleviation of suffering, and restoration of health. However,
when the foregoing are not possible, assistance towards a peaceful death shall be his/her
obligation.
Sec.2 To assume this responsibility, registered nurses
have to gain knowledge and understanding of man’s
cultural, social, spiritual, psychological, and ecological
aspects of illness, utilizing the therapeutic process.
Cultural diversity and political and socio-economic status
are inherent factors to effective nursing care.
ARTICLE 1 PREAMBLE
• Perform controlled acts authorized to nursing if they meet all three criteria:
• In 2012 the Philippines passed the Data Privacy Act 2012, comprehensive and strict privacy legislation
“to protect the fundamental human right of privacy, of communication while ensuring free flow of
information to promote innovation and growth.” (Republic Act. No. 10173, Ch. 1, Sec. 2).
SCOPE AND APPLICATION
• The Data Privacy Act is broadly applicable to individuals and legal entities that process
personal information, with some exceptions.
• Approach
• The Philippines law takes the approach that “The processing of personal data shall be
allowed subject to adherence to the principles of transparency, legitimate purpose, and
proportionality.”
COLLECTION, PROCESSING, AND CONSENT
• The act states that the collection of personal data “must be a declared, specified, and
legitimate purpose” and further provides that consent is required prior to the collection
of all personal data.
• It requires that when obtaining consent, the data subject be informed about the extent
and purpose of processing, and it specifically mentions the “automated processing of his
or her personal data for profiling, or processing for direct marketing, and data sharing.”
• Consent is further required for sharing information with affiliates or even mother
companies.
• Consent must be “freely given, specific, informed,” and the definition further requires that consent to
collection and processing be evidenced by recorded means. However, processing does not always require
consent.
• Consent is not required for processing where the data subject is party to a contractual agreement, for
purposes of fulfilling that contract. The exceptions of compliance with a legal obligation upon the data
controller, protection of the vital interests of the data subject, and response to a national emergency are
also available.
• An exception to consent is allowed where processing is necessary to pursue the legitimate interests of the
data controller, except where overridden by the fundamental rights and freedoms of the data subject.
• Required agreements
• The law requires that when sharing data, the sharing be covered by an agreement that provides adequate
safeguards for the rights of data subjects, and that these agreements are subject to review by the National
Privacy Commission.
SENSITIVE PERSONAL AND PRIVILEGED INFORMATION
• The law defines sensitive personal information as being:
About an individual’s race, ethnic origin, marital status, age, color, and religious, philosophical or political affiliations;
• About an individual’s health, education, genetic or sexual life of a person, or to any proceeding or any offense committed or
alleged to have committed;
• Issued by government agencies “peculiar” (unique) to an individual, such as social security number;
• Marked as classified by executive order or act of Congress.
• All processing of sensitive and personal information is prohibited except in certain circumstances. The exceptions are:
• Consent of the data subject;
• Pursuant to law that does not require consent;
• Necessity to protect life and health of a person;
• Necessity for medical treatment;
• Necessity to protect the lawful rights of data subjects in court proceedings, legal proceedings, or regulation.
INFORMED CONSENT
• Usually the client signs a form provided by the agency. It is the record of the
informed consent.
TWO TYPES OF CONSENT
• 1. Express- may take the form of either an oral or written agreement. ( needed for invasive
procedure)
• 2. Implied- exists when the individual’s nonverbal behavior indicates agreement ( ex. Patients
who position their bodies for an injection procedure or in a medical emergency where the
individual cannot provide or express consent)
• Primary care provider- is the one responsible to obtain an informed consent
• A nurse practitioner, nurse anesthetist, nurse midwife who will perform procedure in their
advance practice
GENERAL GUIDELINES FOR THE INFORMATION GIVEN
TO PATIENT
The diagnosis or condition that requires treatment
The purposes of treatment
What the client can expect to feel or experience
The intended benefits of treatment
Possible risks or negative outcomes of treatment
Advantages and disadvantages of possible alternatives to the treatment( including no treatment)
THREE MAJOR ELEMENTS OF INFORMED CONSENT
a. Compassion
equated to caring; the humane quality of understanding the suffering w/c others wanting to
do something about it; deep awareness of sympathy for another’s suffering.
b. Competence
adequate and well qualified to perform a specific role->encompasses a combination of knowledge,
skills and attitude utilize
c. Confidence
to improve performance, a feeling of self assurance; ability to perform or accomplish task and trust;
feeling of self awareness arising from appreciation of one's own abilities
d. Conscience
sense of right or wrong
e. Commitment to
_culture of excellence
performing to aim for perfection; update knowledge
_discipline
self control and obeying rules
_integrity
associated with honesty; moral soundness; steadfast adherence to a strict moral or ethical code
_professionalism
specialized knowledge of a subject to a field
3. Love of People
volunteerism; comply to the feeling of caring care to other
unconditionally
4.Love of Country
_patriotism- make sacrifices to your own country
_preservation and enrichment of rhe environment and culture heritage
Values of a Student Nurse
CDUCN (pneumonics)
C- compassion/courtesy( good manners)
D- dedication/ discipline(sense of responsibility and accountability)
U- uprightness ( being honorable with ur actions;righteousness; personal
and professional integrity)
C- competence and commitment (to god through man)
N- neatness(in person & in work)
CORE PROFESSIONAL VALUES
Professionalism
Professionalism involves the characteristics of a nurse that reflects his or her professional status. These
characteristics involve behaviors with regards to self, patients, others, and the public as they reflect the values of
the nursing profession.
Core Values of Nursing
BREAST AND LYMPHATIC SYSTEM
- Difficulty in breading
- Body mechanics will be very poor
6TH
AREOLA COMPLEX
MONTGOMERY TUBERCLES
- involve respiration
5TH AREA IS THE TAIL OF THE SPENCE OR THE AXILLARY BREAST TISSUE
AFTER MENOPAUSE THE GLANDULAR STRACTURE WILL ANTROPHY, THERE WILL BE NOTABLE DECREASE
NUMBER OF OBULES BECAUSE OF THE REGRESSION OR DECREASE DEPLETED ESTROGEN SUPPLY.
SLIDE 7
SLIDE 9
SUPERNUMERARY NIPPLE
SLIDE 11
GYNECOMASTIA
PSEUDOGYNECOMASTIA
MOST OF THE LYMPHATIC SYSTEM OF THE BREAST USUALLY DRAIN IN AXILLARY LYMPH NODES THEY
MAY EMERGED IN TAIL OF SPENCE.
Slides 12
CENTRAL NODES
SUBSCAPULAR NODES
LATERAL NODES
Slide 13
SBE
- Self-breast examination
- What you do personally on your own
CBE
GALACTORRHEA
PROLACTINE
Slide 37
- Fungating mass
Slide 43
- Erythematous
Slide 44
Slide 45
Slide 46
- Peau d’orange
LEFT VENRTICLE
APICAL IMPULSE
- The highest the loudest and the most recognizable heartbeat upon auscultation
PMI
- Locate in left boarder of the heart normally in the intercostal space. Just medial to mid clavicular
line. 4th to 5th
- Not usually palpable
Slide 4
CYSTUS INVERSUS
DESTROCARDIA
Slide 5
Slide 6
RIGHT ATRIUM
Slide 9
SYSTOLE PUMING
- Heart contract
- Aortic bulb is open
- Mitral bulb closes and pulmonic valve are open and tricuspid bulb closes
DIASTOLE FILLING
Slide 12
Aortic stenosis
S3
Slide 14
A2
- First sound
- Signify closure of aortic valve
P2
INSPIRATION
Slide 15
BELL
DIAPHRAGM
- Use for relatively high intensity of high pitch sound cause by S1, S2
SA NODES (SIANOATRIAL)
STROKE VOLUME
AFTERLOAD
PRESSUREOVERLOAD
VOLUME OVERLOAD
AUTOMATICTY
- Or the capacity to generate electrical impulses for a circumvented around the heart for the
heart to contract.
CHEST PAIN
LEVEL C TO D/CATEGORY 3 TO 4
ONSET
CHARACTERISTIC
DURATION
LOCATION
RADIATION
ASSOCIATION
- Masakit lng and doghan kong mag hakwat ko, kong ga kotoy tyan ko, kong mahigda
ALLEVIATING FACTORS
INTERMETENT CLUADICATION
ATRIAL FIBRIATION
DYSPNEA
ORTHOPEA
- Occurs when the patient is a supine/ tas gulpi lng nag tindog tas ng hapo kna
Paroxysmal – abot2
Nocturnal – sa gabeh lng
Dyspnea – hapo
SWELLING OR EDEMA
- Palng habok2
FAINTING
Slide 25
INSPECTION
Slide 55
Hypertension of the distal interphalangeal joint with flexion of the proximal interphalangeal joint is a
deformation as.
- Boutonniere deformity
The most predominant quadrant of the female breast where 33% of breast cancer cases according to
National Cancer Database is?
Which structure is used to demarcate the point of origin where the female breast is further divided into
4 quadrant?
- Sternum
- 6 months old
Which structure is used to demarcate the point of origin where female breast is further divided into 4
quadrants?
- Nipple
- A and B
Patient J, a female recently sought consult due to difficulty sleeping she claims to have episodes of
dyspnea awakening her from sleep usually 1-2 hours after going to bed urging her to sit up a nearby
window for some air. This symptom is medically known as?
Babinski reflex (extensor plantar response) in elderly patients is abnormal and indicates.
Women typically have a 13% risk of developing breast cancer over their lifetime. Angela Jolie on the
other hand had an estimated 87% risk of developing the disease and a 50% risk of ovarian cancer due to
heredofamilial tendencies discovered via gene testing. She underwent double mastectomy and later had
her ovaries and fallopian tubes removed significantly reducing risk of developing cancer. What specific
gene mutation conferred Angelina Jolie her risk for breast and ovarian cancer?
- BRCA1
Among edentulous patients, the tongue may enlarge due to the following.
- A. amyloidosis
The most predominant quadrant of the male breast where 17% of the breast cancer cases are detected
according to the national cancer database is?
The following heart sounds can be best heard using the diaphragm of the stethoscope
Patrick, a 14 years old adolescent, has been hooked to alcoholic beverages and habitual smoking of
cigarettes which caught his parent’s attention. He was brought to the clinic for behavioral modification
and counseling which of the following approaches will best benefit Patrick?
- Interview Patrick separately from parents to provide safe space for discussion of personal or
sensitive concerns that need to be voiced out
Patient HY, a 33YO female patient, sought consult at the OPD due to singular breast mass described as
soft, elastic, well delineated, mobile. Which of the following lesions most probable based on the
patient’s profile and description?
- Firboadenoma
The statement jane, 34yo, mother of baby boy KY- 90% reliability as informant, tita, 45YO female
caremaker at home of baby boy KY – 50% reliability as informant should be included in the pediatric
history under which category of information?
Breast cancer among men occurs in approximately 1% of the population. A nurse knowledgeable of this
incidence will put emphasis on palpation of which territory to detect the lesion?
- Developmental history
The most widely used tool for the assessment of the risk of developing pressure ulcer is?
- Barden scale
Black splinter hemorrhages in the middle or distal third of the fingernail are more likely to be due.
- Trauma
Patient KL, a 13yo female, was accompanied by the mother to purchase her first pair of brassieres. Her
breasts still has no distinct contour separation of the nipple-areola complex. Grossly her breast has now
assumed a rounded contour with tissues configuring a small cone. This can be documented by nurses as
Tanner stage
- Stage 4
- A and B
Patient JK, a 60yo female sought consult due to difficulty sleeping. She claims to have episodes of
dyspnea awakening her from sleep usually 1-2 hours after going to bed urging her to sit up or to rush to
a nearly window for some air. This symptoms medically known as?
The most widely used method of screening for valvular heart disease according to American college of
cardiology and the American heart association is/
- 2-dimensional echocardiography
The following are areas which differentiate the pediatric fromadult history taking and assessment except.
- Spontaneous unilateral bloody discharge from one or two ducts may indicate carcinoma
- A and b
- A and B
The following views/maneuvers are employed in the inspection of the breast except.