CHAPTER 4

HA

ASSESSMENT OF

PATIENT/CLIENT

LEARNING OBJECTIVES

Learning

Objectives

• Assessment of patient/client

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• Importance, principles, methods of assessment

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• Height, Weight, posture

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• Head to toe examination

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• Physiological Assessment

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• Vital signs, normal, abnormal

• Characteristics, factors

influencing the variations

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• Observation and collection of

checklist specimens-urine,

stool, vomitus and sputum

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• Psychological Assessment –

Mood, Intelligence, Emotions

Normal and Abnormal behavior

SECTION A : ASSESSMENT OF

PATIENT/CLIENT

Health Assessment

INTRODUCTION

• Client health status assessment is one of the most important aspect of nursing care. Health assessment of client has two main parts:
1. History collection
2. Physical examination

Health assessment is important to recognize the unmet needs, health problems and also to know the response of the patient to the interventions provided through treatment.

NURSING PHYSICAL ASSESSMENT

• Nursing physical assessment is the process in which nurse collects the information from the patient regarding their health.
• Based on the information gathered from the patient, the nursing interventions are planned and implemented to provide quality care to the patient

Types of Health Assessment

• Comprehensive health assessment: It involves complete health assessment of the patient and usually performed when the patient is admitted to the hospital. Comprehensive health assessment acts as baseline data which is further used for comparison.
• Focused health assessment: This type of health assessment is done to identify the specific problems.

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• Emergency health assessment: This type of health assessment is performed in emergency situations to identify the serious conditions. For example, assessment of the airway, breathing and circulation before cardiopulmonary resuscitation (CPR).
• Ongoing health assessment: This type of health assessment is done while providing regular care to the patient. Ongoing health assessment should be done at regular interval to determine the changes in health status.

Purposes of Health Assessment

Principles of Health Assessment

• Accuracy
• Timely
• Confidentiality
• Documentation

Methods of Performing Physical Examination

• Inspection

In this technique, the examiner will do observation. Here the nurse will use the sense of vision, to collect the data and to identify any abnormality. It involves examining specific body parts normal and abnormal characteristics.

This method is used to identify the color, texture of the body, shape, position and symmetry of the body.

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• Palpation:

Palpation includes use of sense of touch. The finger pad is used to feel the organs and to identify the size and shape of the organs.

There are two types of palpation:

• Light palpation: Fingertips are used to perform light palpation. In this the skin is slightly depressed approximately ½ or ¾ inch (1–2 cm).

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• Deep palpation: This is performed using one or both the hands. Skin is depressed approximately 1½ to 2 inches (about 4–5 cm) either with one or both the hands
• With both hands: While performing palpation with both the hands, the nurse will use the finger pad of her dominant hand for light palpation and then middle three fingers of her dominant hand over the interphalangeal joint.

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• Using one hand: Use the finger pad of the dominant hand to press over the area need to be palpated. Sometimes the other hand is used to support a mass or organ from below.

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• Percussion: In this the examiner will tap on the body surface. The tapping will be light and quick. Due to tapping over the body tissues the sound waves or vibration will be produced, which is known as percussion sounds.

Two types of percussion are as follow:

• Direct percussion
• Indirect percussion

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• Auscultation: Here the examiner will hear the body sounds using stethoscope The most commonly used to hear the heart sound, lung sounds, bowel sounds and fetal heart sounds. This provide clue to identify the abnormalities.
• Olfaction: In this method the sense of the smell is used to collect the data. For example, bad breath may indicate that patient may have gum disease and alcohol in breath suggests the reason for agitation or irritability.

PROCESS OF PHYSICAL ASSESSMENT

• History Collection: History collection is the first parameter of health assessment. In this the nurses collect the information which is provided by the patient or primary care giver.

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Components of History Collection

• Demographic profile/Identification data
• Chief complaints
• Present medical history
• Past medical history
• Past surgical history
• Family history
• Personal history
• Physical assessment

PRE-PROCEDURE PREPARATION

• Explain procedure to the patient and take consent.
• Make patient comfortable
• Provide privacy to the patient.
• Make sure there should be fresh bed sheet on the examination table and extra sheets available to drape the patient.
• Avoid unnecessary exposure
• Ensure examination table is working.
• Room temperature should be appropriate, it should not be too low or high.
• In case patient had meal, start procedure after two hours.
• Nurse should have thorough knowledge and skills to perform the physical examination.
• Nurse should be aware regarding the history
• Nurse should be empathetic

Equipment for Physical Examination

• Thermometer
• BP apparatus
• Watch with second’s hand
• Height scale
• Weight scale
• Measuring tape
• Spatula/tongue depressor
• Snellen chart
• Percussion hammer

Equipment for Physical Examination

• Tuning fork
• Nasal speculum
• Otoscope
• Ophthalmoscope
• Disposable glove
• Drape sheets
• Record sheet
• Pen light
• Goniometer
• Cotton balls, hot/cold object, spirit swab for smelling

GENERAL PHYSICAL EXAMINATION

• The general physical examination is the first part of physical examination. In this the examiner or nurse will observe the patient’s overall appearance and behavior.
• Nurse will also measure the vital signs, weight and height.

Steps of General Physical Examination

• Perform hand hygiene.
• Provide self-introduction to the patient.

The following things need to be assessed when the patient enter first in the examination room:

• Patient grooming ƒ
• Consciousness level
• Size of the body Posture
• Gait
• Using ambulatory aids
• Mood of the patient
• Emotional tone
• Modulation of voice
• Look for the signs of stress like—frown and grimace
• Identify the patient and collect the identification details.

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• Assessment of Mental Status
• Ask who is accompanying to him, this question will help the nurse to identify whether patient is oriented to time place and person or not.
• Assess the patient ability to think, remember and communicate.
• Assess the speech style and content of speech to identify dysphagia
• Assess the level of consciousness

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• Posture and motor behaviour
• Assess whether patient is anxious, restless or quiet.
• Dress, grooming and personal hygiene: Dressing with excess clothing or cold intolerance indicates hypothyroidism.
• Measure the height and weight of the patient and calculate BMI.
• BMI formula= weight in kg/height in (meter square).

HEAD TO TOE

EXAMINATION

SKIN OR INTEGUMENTARY ASSESSMENT

Inspect the Skin

Color Skin color can be varying from person to person and among different races. Exposed skin areas such as feet, hands and face may have different color as compared to areas that are usually covered with clothing.

Inspection of Skin Vascularity and Bleeding or Bruising

The older person has thin skin. Skin turgor will be reduced. There will be visible blood vessels and capillaries.

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• Assessment of Skin Lesion
• Record the size and shape of the lesion.
• Note down the location, colour, depth, drainage and texture of the lesion, if present the swab for further investigation.
• Wear gloves for the assessment of lesion for self protection and to prevent the contamination

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Assessment of Skin Temperature, Texture and Turgor

• Assess the skin temperature with back of the hand.
• Check the texture and moisture by palpation
• Assess the skin turgor by pinching and releasing the skin

Assessment of Edema

Assessment is performed by pressing the skin. The purpose is to assess the fluid accumulation under the skin. Normal findings will reveal no depression after pressing the skin.

ASSESSMENT OF NAILS

• While doing inspection of the nails; assess the nail plate, nail beds, texture of the nails, colour of the nail bed, angles between the nails bed and fingernails.
• Check the shape of the nail plate.
• Check the angle between the root of nail bed and finger.
• The normal angle will be 160°.
• Check for presence of Schamroth window.
• Nails texture will be assessed by palpating the nails

ASSESSMENT OF HEAD, HAIR AND FACE

Head Assessment

• Observe the shape of the head and circumference using measuring tape.
• The normal shape of the head is known as normocephalic and it should be symmetric.
• Head and body ratio is important to determine the hormonal imbalance.
• Skull should be mobile and tenderness should not be there.

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Hair Assessment

• Look the distribution of the hair.
• In normal person there will be normal hair distribution and hairs will be resilient.
• Check the texture of the hair and scalp.
• No scarce growth will be there.
• Dandruff free scalp, no lice or lesion indicates healthy hair and scalp.

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Face Assessment

• While assessing the face, check the expression and symmetry of the face, eye, eyebrows and facial hair.
• In normal condition the facial expression will be appropriate and face will be symmetric.

Eye Assessment

• Eye assessment includes assessment of the eye symmetry, assessment of the conjunctiva, lacrimal apparatus, cornea and lenses, coordination of the eye and assessment of the visual field.
• Check the symmetry of eyeballs, eyelids and eyebrows.
• Assess the conjunctiva and sclera and also assess the vascular pattern. Normally it is pinkish.
• Observe the eyelids for edema, lesions and eyelashes for adequate hair

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• Assess the lacrimal area and palpate the lacrimal gland for swelling or excessive tear. In normal situation lacrimal apparatus is not palpable.
• Cornea and Lens Assessment
• Assess the cornea of each eye for opacity with help of ophthalmoscope.
• Instruct the patient to look straight while examining.
• In normal condition cornea and lens will appear transparent with no abrasion or white spots

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Pupil Assessment

• Assess the size of the pupils and reaction to light.

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• Inspect the pupil colour and shape

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• Partially darken the room for assessment of pupil.

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• While doing pupil assessment instruct the patient to look straight and then use

the penlight and shine it on the pupil and observe the changes in pupil size

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Assessment of the Eye Coordination Movements

• To assess the coordination of eye movements, hold an object at a distance and instruct the client to keep the head still and follow the object with eyes. Nurse moves the object left to right eye then roof to floor.
• Assessment of coordination of eye movements is helpful to identify any brain dysfunction and muscular attachment problem of the eye.

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• Oculomotor Test
• This test is done to assess the functions of the cranial nerve III, IV, and VI (oculomotor, trochlear, and abducens nerves).
• To assess the oculomotor functions, nurse will instruct the patient to follow the finger of nurse. Six cardinal field gazes is assessed.

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Assessment of Visual Field

• To assess the visual field nurse and client both closes one eye of same side. Nurse will instruct the patient to tell when object is visible. Then nurse brings object or finger in the visual field from corner of eye.
• Assessment of Visual Acuity

Visual acuity of the patient is assessed with the help of Snellen chart. Nurse will instruct the patient to read the smallest possible line of letters on chart.

Ear Assessment

Assessment of External Ear

• Look and palpate the pinnae of the external ear.
• Observe the color of the auricle, its symmetry and position.
• Assess the texture of the auricle by palpating the auricle.
• Inspect the elastic of the auricle and also look for tenderness

Auditory Canal Assessment

• Examine the external auditory canal by pulling the ear downward and backward. Use otoscope for

examination.

• The normal finding will be that there will be no pain while pulling the ear downward and backward.

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Assessment of the Hearing Ability

• Nurse shall whisper in the patient ear to test the hearing ability by

standing at least 1–2 feet away from the patient.

• Patient is instructed to close the ear which is not being tested.
• The patient will repeat the word whispered by the nurse.
• Nurse will murmur slowly about two syllable words like Monday, fifteen and basketball.

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• Weber test: Activate the tunning fork by striking it at the edge of the palm and then place it on the forehead or vertex and ask patient which ear vibration/tone is heard better.
• Rinne test: It compares air conduction to bone.

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Assessment of Vestibulocochlear Function

• To assess the vestibulocochlear function, the nurse will instruct the patient

to walk with closed eyes.

• Ensure the safety of the patient. In normal situation the patient will move

straight.

• Imbalance in the posture and gait indicates cranial nerve dysfunction.

Nose Assessment

• Assess the size, symmetry, flaring and for any deformity.
• Assess the inner area of the nose.
• Assess the inferior and anterior part of the nose.
• Look for the presence of any polyp or mass
• Check the patency of the nose by blocking one side nostril at a time and

instruct the patient to inhale and exhale through nose.

• Assess the inner area of the nose with pen light.
• The normal findings will be hair with smooth surface.

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Assessment of the ethmoid sinus:

• To assess the ethmoid sinus, the nurse will keep her index finger in medial angle of eye or at roof of eye socket and then will press.
• In normal condition patient will have no pain.
• In case patient complains of pain after pressing, then it indicates sinusitis

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Assessment of the frontal sinus:

• To check the frontal sinuses, just above medial angle of the eye should be tapped by using index or middle finger. In normal there will be no pain.
• In case of sinusitis patients may complain of pain.

Assessment of the maxillary sinus:

• To assess the maxillary sinus, the area just below the cheek bone need to be tapped using thumb.
• In normal condition the patient will feel no pain.

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• Assessment of smell: For assessment of smell, instruct the patient to close the eye and ask to identify the smell.

Assessment of the Oral Cavity

• Assessment of the oral cavity includes examination of the oral mucosa lip, gums, tongue, teeth, hard palate and soft palate
• Wear gloves for oral examination.

The purpose is to identify the abnormalities

• Observe the oral mucosa, lips, gums, teeth, tongue, hard and soft palates for any discoloration like paleness or bluish color.
• Lips are assessed for hydration- lips should be plump and free from cracks. Color change like pale/bluish suggests pathological condition. On palpation lips should be free from nodes/mass.
• Teeth and gums are assessed for dental caries or cavities

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• Look for gingivitis if patient has halitosis(bad odor from mouth).
• It also reflects the hygiene for oral cavity.
• Check for coated tongue and plaque on teeth or tanning of teeth (brown discoloration observed in smokers or tobacco chewers)
• Angle of mouth is assessed for cuts which indicates scurvy - deficiency of vitamin C.
• Observe the teeth and identify if missing. Look for artificial dentures

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Tongue Assessment

• Assess the tongue. Instruct the patient to move to take out the tongue.
• Assess the function of the uvula by instructing the patient to say ‘ahh’

while sticking out the tongue.

• Instruct the patient to move the tongue in all direction and look for hydration and coating.
• Perform palpation of the tongue to identify presence of any mass.

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Gag Reflex Assessment

• Before assessment of the gag reflex, explain the procedure to the patient.

Explain to the patient, that it may have some discomfort.

• The gag reflex is assessed by touching the tongue depressor at the posterior pharynx. Patient will have vomit sensation (gag reflex) when posterior pharynx is touched with tongue depressor
• The normal gag reflex will indicate the normal functioning of the glossopharyngeal

and vagus nerve

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Neck Assessment

• Examine the neck to rule out any dysfunction and also check the stiffness.
• Instruct the client to shrug the shoulder by opposing pressure on each

side.

• Normally there will be smooth movements, patient will be able to oppose the pressure.
• This reflect normal spinal accessory nerve function.
• Neck rigidity suggest meningitis (inflammation of meninges)

Assessment of the Lymph Nodes

• Lymph node or lymph gland assessment is done by palpating the lymph nodes. Use the finger pads to feel the lymph node
• During palpation feel the underlying tissues of each area. Palpate each lymph node simultaneously in both side

Order of Lymph Node Palpation • Preauricular • Posterior-auricular

• Tonsillar • Submandibular
• Submental • Superficial cervical
• Posterior cervical • Deep cervical
• Supraclavicular

Tracheal Assessment

• Check the trachea. This is done by standing at the back of the patient using

finger pads.

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• Assess and feel for the cartilage rings in the neck and feel for any deviation.

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In normal condition trachea is in the midline and symmetric.

Thyroid Gland Assessment

• Thyroid gland assessment is performed after the assessment of trachea.
• Nurse will instruct the patient to flex the neck little forward. Then nurse will

place the finger just below the cricoid cartilage.

• While palpating the thyroid gland ask the patient to swallow and then feel

the movement of thyroid gland

Jugular Venous Pressure Assessment

• There are two methods of assessment of jugular venous pressure (JVP).
• One is to provide semi fowler’s position to the patient asking the patient

to turn the neck on the side and observe for visible pulsation.

• The rise in pulse is observed between trachea and the sternocleidomastoid muscle.
• Apply pressure on the liver at right upper quadrant the raise in the

pulsation of the neck veins.

CHEST AND LUNGS ASSESSMENT

Assessment of Chest

• Observe the chest for presence of any scar due to
• previous surgery like thoracotomy and also look for any chest deformity.
• Assess the shape of the chest, movement of chest during inspiration and

look for labored breathing

Normal Findings

There should be no deviation in chest shape, chest expansion and retraction should be bilateral

with inspiration and expiration, and respiratory rate should be 12–20 breaths/min.

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• Abnormalities in Chest Shape
• Pectus excavatum
• Pectus carinatum
• Barrel chest
• Scoliosis and kyphosis

Palpation of the Chest

• Chest palpation is done to determine the difference between normal and abnormal tissues.
• Palpate the chest for tenderness, masses, and any painful areas.
• Palpate the apex beat at midclavicular line or at 5th intercostal space.
• Place the palm of your hand on the chest of the patient to identify the thrills and hives.
• Normally the skin should be warm and dry. The muscle movements should be

symmetric.

Chest Expansion

• The nurse shall keep the hands on the patient posterolateral chest wall at T9 and T10 covering the chest circumference and thumbs should meeting each other.
• Ask the patient to inhale, during inspiration the thumbs will move away.
• Thumbs should move approximately 2 cm during inspiration. This indicates bilateral expansion.

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Assessment of Tactile Fremitus

• Tactile fremitus is assessed by placing the hand on the posterior chest and

instruct the patient to say some words like 99 and blue moon.

• The vibration should be felt on both side, i.e., anterior and posterior side of

the chest

Percussion

• Start with percussion from the anterior part of the chest from

supraclavicular area to the base of lung

• Repeat the same process in the posterior part of the chest also.
• Vesicular sounds: Heard over most of the lungs.
• Bronchial sounds: Heard over upper half of the sternum.
• Bronchovesicular: Normal sound heard over the trachea

Cardiovascular and Peripheral�Vascular Assessment

• The assessment includes examination of the heart and extremities. The purpose is to determine the signs and symptoms of heart diseases and peripheral vascular diseases.
• Instruct the patient to lie down or get sitting position. The light should be adequate.
• The nurse has to perform the examination by standing the right side of the patient. This will gives the good view of the heart.
• For peripheral vascular assessment, assess the blood pressures, skin perfusion of the extremities and peripheral pulses

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Inspection of Precordium

• Assess the part of the body over heart, which is known as precordium area and the

lower parts of the thorax.

• Normally there will be no visible pulsation excluding for the apical pulse.
• Apical pulse will be present at left midclavicular line at 4th or 5th intercostal space.
• Assess the abdominal aorta for pulsation at the epigastric area and at the tip of the

sternum.

• Determine any distension in the neck veins.

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• Palpation of the Precordium Area
• Palpation is performed by using the palm of the hand with four fingers.
• Make sure that the hands are warm before palpation.
• While doing palpation look for any visible pulsation.
• Palpate in a organized manner, pay specific attention to the cardiac

landmarks like Erb’s point and all the valves of the heart.

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Auscultation of Heart Sounds

• The purpose of auscultation of heart sound is to identify the sounds that occur

because of closure of heart valves.

• Auscultation helps to differentiate the normal heart sounds with abnormal one
• Diaphragm of the stethoscope is used to identify the high-pitched sounds while bell of the stethoscope is used to identify the low-pitched sound.
• Concentrate the rate, rhythm and regularity of the heart sounds.
• Auscultate the carotid artery for bruits

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Palpation of the Peripheral Pulses

• Peripheral pulses are assessed.
• Palpate pulse bilaterally for comparison.
• Assess the amplitude and symmetry of the pulse.
• Assess the rate, regularity and rhythm of the pulse.
• Check the arterial blood flow.

Assessment of Breast

• Assess the size, shape, symmetry, colour, texture, and skin lesions on the breast.
• Assess the size of the areola and size of the nipples.
• Assess the nipples for any discharge, crusting, and inversion
• Instruct the patient to lift the arm above the head, and put a towel under area which need to be palpated

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• Perform palpation gently in a circular motion using finger pad.
• The palpation of the nipple starts from center to periphery like the bars of the

wheel.

Inspection of the Nipple

• Assess the symmetry and shape of the nipple.
• Assess for the bleeding and for ulceration.

Normal Findings • No dimpling • No discharge • No bleeding Assessment of the Axilla • Instruct the patient to lift the arm and support it with nondominant hand and palpate the axilla. • Normally lymph nodes will not be palpable

Abdominal assessment

• Abdomen is divided into nine regions and four quadrants, it helps to locate the anatomical position of underlying organs and perform examination in systematic manner.
• The purpose of auscultation to be done after inspection is to prevent the false results. Palpation and percussion can stimulate the bowel which can increase the bowel motility.
• Instruct the patient to lie down in the supine position.
• Expose the abdomen, avoid unnecessary exposure.
• Sheet can be used to cover the exposed area

Auscultation of the Abdomen

• The hands as well as stethoscope should be warm, and make sure that light should be adequate.
• The fingernails should be short to prevent the risk of injury. Before auscultation ask the patient to

empty the bladder.

• Make sure that the patient is calm and comfortable to prevent the contraction of the abdominal

muscle, which makes auscultation difficult.

• Instruct the patient to lie down in supine position, keep the pillow under the head and knees to

provide comfort to the patient.

• Assess the vascular sounds of the abdomen using the bell of the stethoscope.
• Auscultate the sounds in all four quadrants of the abdomen.

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• Record the timing of the bowel sounds. Absent bowel sound is called when the examiner is unable hear the bowel sounds for 5 minutes.
• In a minute 5 bowel sounds can be heard. This is also affected by the

ingestion of the food, like after ingestion of food, the bowel sounds are increased.

Percussion of the Abdomen

• Percussion should be done in all the quadrants of the abdomen.
• The purpose is to identify the presence of gas or tympany or dullness.
• It has to be done in a logical sequence.
• Start from the lower right quadrants, then move towards the upper right quadrants, further upper left quadrants and lastly lower left quadrant.

Palpation of the Abdomen

• Make sure the hands should be warm.
• Patient should be comfortable.
• Do light palpation first to identify the areas of tenderness.
• Palpate the abdominal wall lightly by pressing about 1 cm.

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• During palpation fingers should be move in a circular motion.
• In orderly sequence palpate all the four quadrants of the abdomen.
• Identify the areas of tenderness, mass or guarding and ask the patient to

let you know when the patient feels pain.

• Normally the abdomen should be soft to touch, relax and no tenderness.
• Assess for rebound tenderness. This is also called as Blumberg’s sign

Palpation of the Spleen

• Move the hand behind the left side at 11th and 12th ribs. The nurse will place her right hand on left upper quadrants obliquely.
• The fingers should be pointing towards the axilla and it should below the rib margin. In normal patient the spleen will not palpable. In case of splenomegaly, the spleen will be palpable.

Palpation of the Kidneys

• Kidneys are palpated on each side of the abdomen by supporting the kidney with nondominant hand. Normally the kidney is not be palpable.

Palpation of the Urinary Bladder

Bladder is not palpable until it is distended. While examining the bladder, check for tenderness.

Assessment of Musculoskeletal System

• Assessment of musculoskeletal system includes assessment of the muscle tone, size of the muscle, symmetry of the muscle and the most important muscle tone.
• Nurse will also asses the patient for tremors (involuntary movement of the limb). It also includes assessment of the bones and joint. Joints should be assessed for any swelling, pain, thickening, and crackling sound.

Assessment

• Observe the extremities for their skin color
• Assess for presence of lesions, rashes and muscle mass.
• Palpate the muscles for any tenderness.
• Assess the muscle tone and strength.

Assessment of Muscle Strength

• The nurse shall ask the patient to extend the arms, and nurse applies

pressure and the patient will counteract the force or resist it.

• Afterwards ask the patient to push against the nurse’s hand and

repeat the assessment on lower limbs.

• Instruct the client to squeeze the nurse finger

Assessment of Joints

• Instruct the patient to move all the joints like neck shoulder, wrist, fingers, hip knees, ankles and toes one by one.
• Do the movement in all possible directions.
• Palpate all the joints for pain, tenderness and for stiffness.
• Restriction of movement is assessed with Goniometer (instrument used for angle of range of motion).

Assessment of the Female Genital Organs

• Assess the pubic area for hair distribution, amount of hair and characteristics of pubic hair.
• Normally the hair distribution is in the shape of inverse triangle.
• Assess the clitoris, urethral opening and vaginal orifice when separating the labia minora. The normal findings are absence of lesion, inflammation and swelling. No discharge.
• The next step is the inguinal lymph node assessment. This is done by palpating the

inguinal lymph nodes by finger pads and do it in rotatory motion.

Assessment of the Female Genital Organs

• Assess the pubic area for hair distribution, amount of hair and characteristics of pubic hair.
• Normally the hair distribution is in the shape of inverse triangle. In menopausal women, the pubic hair will be straight and thin. Kinky hair in the menstruating women.
• Hormonal problem can be there if women have scant pubic hair.
• Assess the skin for any inflammation, swelling and for lesion. This is done by

separating the labia

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• Assess the pubic area for hair distribution, amount of hair and characteristics of pubic hair.
• Hormonal problem can be there if women have scant pubic hair.
• Assess the skin for any inflammation, swelling and for lesion.
• Assess the clitoris, urethral opening and vaginal orifice when separating the labia minora.
• The normal findings are absence of lesion, inflammation and swelling. No discharge.
• The next step is the inguinal lymph node assessment. This is done by palpating the

inguinal lymph nodes by finger pads and do it in rotatory motion

Assessment of Male Genital Organs

• Assess the pubic area for hair distribution, characteristics of hair and amount of hair.
• Normally the hair is distributed in a triangle shape and mostly spread up to the abdomen.
• Assess the glans and shaft of the penis for presence of lesion, inflammation
• Observe the urethral meatus for presence of swelling, inflammation and for any discharge & swellings.

Assessment of Anus

• Provide side lying position to the patient.
• Assess the anus and the surrounding tissues for skin, color and for any skin lesion.
• Lightly touch the anus.
• Normally anal skin is pigmented and moister than the perineal skin and usually without hair.

Neurological Assessment

• Detailed neurological assessment required 1–3 hours, so routine screening test should be performed first.
• In neurological assessment, the nurse has to check the consciousness of the patient, metal status, functions of the cranial nerve, reflexes, motor as well as sensory functions

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• Level of Consciousness Assessment

Glasgow Coma Scale (GCS): This is the standardized scale used to assess the consciousness level of the patient.

• It has three parameters eye opening, verbal response and motor response of the patient.
• Minimum score is 3 and maximum score is 15.

Assessment of Memory

• Immediate, recent and remote memory of the patient is checked by asking the question that will recall the present and past events.
• The following sub groupings are to be recorded
• Assessment of Abstract Reasoning
• Language Assessment
• Insight
• Judgment

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Assessment of Abstract Reasoning

• In this the nurse will ask the patient to explain a proverb like "Where there is a will, there is a way". Patient will repeat the phrases and gives unnecessary explanation if intellectual ability is impaired.

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Language Assessment

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Language assessment of the patient can be done by asking simple question from the patient like.

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"Name the items lying in the room"

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"Count the number of chair"

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"Patient can be asked to follow commands like extend your arms etc."

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"Patient can be asked to read some short sentences from the newspaper or magazines"

CRANIAL NERVES ASSESSMENT

Cranial Nerve I (Smell)

• Evaluate the patency of both the nasal passages by asking the patient to

breathe in through one nostril at a time.

• Place a soap near the patent nostril and ask to smell the object and

report what it is (check for both the nostrils separately).

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Cranial Nerve II (Visual Acuity, Visual Fields)

• Test visual acuity with Snellen’s chart and ask patient to cover one of their

eyes completely with their hand and read the lowest line on the chart possible.

• Next evaluate the visual fields by asking the patient to see the moving finger of examiner without turning the head with one eye closed (Discussed in eye examination.

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• Cranial Nerves II and III (Pupillary Reactions)
• Ask the patient to focus on an object in the distance.
• Check the size and symmetry of the pupils. Observe the pupil reaction

with light.

Cranial Nerves III, IV and VI (Extraocular Movements, Including Opening of the Eyes)

• Ask the patient to follow the penlight or ophthalmoscope with their eyes without moving the head.
• Check for horizontal or vertical nystagmus (rapid eyeball shift).

Cranial Nerve V (Facial Sensation, Movements of The Jaw, and Corneal Reflexes)

• Ask the patient to open mouth against resistance applied by the nurse at the

patient’s chin.

• Next, test gross sensation of the trigeminal nerve.
• Ask the patient to close eyes and identify the object as ‘sharp’ or ‘dull’ when

an object touch their face.

• Touch the each temple, nose and each side of the chin with an object ask patient to respond.
• Check corneal reflex: Approach the cornea laterally and touch with cotton wisp or Q-tip (not the sclera) and look for the eye to blink.
• Repeat for other eye.

Cranial Nerve VII (Facial Movements)

• Inspect face for any facial asymmetry including drooping, sagging or smoothing of normal facial creases.
• Ask the patient to raise eyebrows, frown, puff cheeks, smile and showing

teeth.

• Instruct patient to close eyes tightly and not let the instructor pull them

open.

Cranial Nerve VIII (Hearing and balance)

• Ask the patient to close his/her eyes and to say ‘left’ or ‘right’ when a

sound is heard.

• Instructor to rub his/her fingers vigorously near to, yet not touching, ear

of the patient and ask him to respond.

• Perform the Rinne and Weber tests.

Cranial Nerves IX and X (Swallowing, Elevation of the Palate, Gag Reflex)

• Instruct the patient to swallow and ask if he/she felt any difficulty doing so.
• Instruct the patient to open his mouth wide, protrude tongue, and say ‘AHH’. Also observe the soft palate, uvula and pharynx.
• Check gag reflex

Cranial Nerve XI (Shrugging the Shoulders and Turning the Head)

• Tell the patient to move shoulders while the examiner resists this

motion by pressing down on the patient’s shoulders.

• Tell the patient to turn head to the side as strongly while the examiner resists with hand.

Cranial Nerve XII (Movement and Protrusion of Tongue)

Assessment of Sensory and Motor Function Steps of Sensory Assessment

• Nurse instructs the patient to close the eyes.
• Skin can be touched by sharp or soft object or with a wisp of cotton swab.
• Perform the procedure from distal to the proximal part like from hands, arms,

feet and then move to the trunk.

• Ask the client to feel sensation.

Assessment of Motor Functions and Coordination

Assessment of Gait and Balance

Romberg’s test: This is a test done to assess the balance of the patient.

• To perform the test instruct the patient to close the eyes and stand straight.
• Arms should be on the side and feet together.
• Then wait for 20 seconds.
• Make sure the patient should not fall

Continue…

• Normally the patient should be able to balance.
• Romberg’s test helps to evaluate the cerebellar function and vestibulocochlear

function.

• Coordination: Test patient’s ability to perform rapidly alternating and point-to-point movements correctly.
• Point-to-point movement evaluation: Instruct the patient to extend their index finger and touch their nose, and then touch the examiner’s finger. Do with or without closed eyes

Continue…

• Gait: Ask the patient to walk normally, then heel toe walk (patient walks by keeping toe behind.
• Observe any gross gait abnormalities.

Assessment of Motor Function Assessment and Coordination

• Ask the patient to touch all fingers with the thumb immediately,

as well as tap the foot on the floor.

​

• Repeat the same procedure on the other limb.

​

• Normally the movements will be coordinated.

​

• Uncoordinated movements suggest upper motor neuron and

cerebellum dysfunction.

Assessment of Deep Tendon Reflexes

• Deep tendon reflexes are assessed to monitor the functions of the particular segment of the spine.
• Percussion hammer or reflex hammer is used to see the muscular contraction and reflexes.

SECTION B : PHYSIOLOGICAL

ASSESSMENT

INTRODUCTION

Vital signs are the important part of assessment of the patient as these provide the baseline data about the condition and functioning of the

patient’s body.

​

Vital signs include monitoring of the body temperature, pulse, respiration and blood pressure

Guideline for taking vital signs

DEFINITION

BODY TEMPERATURE

Purposes of Measuring Body Temperature

• To have baseline data about patient.
• To assess the patient’s condition.
• To determine the effectiveness of treatment.

FACTORS AFFECTING BODY TEMP.

Age

Physical

exercises

Circadian

rhythm

Weather conditions

Hormonal

level

Mood

Health

condition

Drugs

AGE

Neonates and aged persons are not able to maintain their body temperature and are more prone for hypothermia as compared to the

adults.

PHYSICAL EXERCISES

Increased physical exercises lead to increased heat

production, thus increase body temperature.

CIRCADIAN RHYTHM

Body temperature gets affected by time of the

day, thus increase in body

temperature during day

because of increase in environmental temperature

and physical activity as

compared to night and

early morning hours.

WEATHER CONDITIONS

When the person gets exposure to extremes of

weather conditions, his/her body temperature

fluctuates accordingly. For example, when a

person is exposed to hot

weather his body

temperature raises.

HORMONAL LEVEL

Secretion of progesterone in women raise their

body temperature during ovulation approximately

0.5–1.0oF.

MOOD

Changes in the mood affect the body temperature.

For example, a person who is excited with joy will

have raised body temperature.

HEALTH CONDITION

Few health conditions and infections may result in

altered body temperature. For

example, in most of

the infections temperature raises but sometimes

there is any change in the

body temperature high

or low that may occur due to sepsis.

DRUGS

Drugs can alter the body temperature.

For

example, Beta blockers used to treat hypertension

may lower the body temperature on the other

hand drugs containing thyroid hormone used

to treat hypothyroidism may elevate the body

temperature.

ASSESSMENT OF BODY TEMPERATURE

Equipment

Body temperature can be assessed with a variety of

devices—glass thermometer, electronic or digital

thermometer, tympanic membrane thermometer,

disposable single-use thermometer and automated

monitoring devices.

• Mercury Glass Thermometers .

These are of two types:

• Oral thermometer
• Rectal thermometer

• Digital Thermometer

Tympanic Membrane Thermometer

Sensor Touch (Skin) Thermometer

Disposable Single-use Thermometer

state of consciousness

Factors Affecting Site Selection

​

patient’s age

​

amount of pain

type of treatment being provided

Sites and Methods of Assessing Body Temperature

Oral Temperature

Sites and Methods of Assessing Body Tempe

Tympanic Membrane Temperature

Sites and Methods of Assessing Body Tempe

Axillary Temperature

Sites and Methods of Assessing Body Tempee

Rectal Temperature

Celsius/Fahrenheit reference table

Primary alterations in body temperature

FEVER

• Body temperature above normal range is known as fever.

• CAUSES
• Substances like bacteria and viruses.
• May also be caused by chemicals produced in the body in

response to tissue injury, e.g., myocardial infarction.

CLINICAL MANIFESTATIONS OF FEVER

TYPES OF FEVER

Management of rigor stage

Hyperthermia

It is defined as raised body temperature than normal range. It is mainly caused because of failure in thermoregulation and this leads to uncontrolled increase in body temperature.

Complications due to hyperthermia

Hypothermia

• Hypothermia is a body temperature below the lower limit of normal.
• Hypothermia occurs when the compensatory physiologic responses meant to produce and retain heat are overwhelmed by unprotected exposure to cold environments.

Acute conditions

Chronic conditions

Postoperative patients

​

Age

Endocrinal disorders

Neurological disorders

Risk Factors

Types of hypothermia

Treatment

Internal rewarming

External rewarming

Passive external rewarming

Nursing Management

Assessment

• Assess the body temperature
• Assess the pattern, extent and course of fever

Nursing diagnosis: Hypothermia related to illness as evidenced by decrease in body temperature .

Interventions

Assess patient’s

body temperature

• Assess the pattern, extent and course of fever

Rewarming—by covering the patient with adequate layering of clothes and blankets

Warm fluids

Hot Application

• It is to apply the warmer agent either in the moist or dry state to the body to relieve pain or to provide warmth.

Menstrual cramps

Indications

Pain

Muscle stiffness

Hypothermia

Congestion

Constipation

Cancer

ContraIndications

Impaired liver, heart and renal functions

Very young and very old age group

Open wounds

Paralysis

TYPES OF HOT APPLICATIONS

HOT WATER BOTTLE

It is the most common method of applying dry heat to the body as a therapeutic and comfort purposes.

Indications

• To relieve pain in back ache, dysentery, dysmenorrhea.
• To relieve local muscular spasm.
• To reduce inflammation and congestion.
• To relieve retention of urine.

ARTICLES

STEPS OF

PROCEDURE

Heating Lamp

• Flexible necked lamps are used to supply dry heat to the body part and are placed 18–30 inches from the area to be treated. The duration of the treatment is 20–30 minutes.

​

The recommended distances are:

• 25 Watt bulb : 35 cm away from the body part
• 40 Watt bulb : 45 cm away from the body part
• 60 watt bulb : 60–75 cm away from the body part

Heating Lamp

• Indications
• To provide dry heat to increase circulation to a small area such as in decubitus ulcer.
• To reduce the inflammation.
• To dry casts, moist wounds.
• To promote healing.

STEPS OF

PROCEDURE

Local Moist Heat Applications

• Application of moist heat means the use of an agent warmer than the skin which is applied in moist form to produce local effect.

Fomentation

• A fomentation is the local application of moist heat to the skin by means of double thickness of flannel or other soft material. It is of two types—medical and surgical fomentation.

Medical Fomentation

• Fomentation is done by using only hot water with or without medicine.

To stimulate the circulation and relax the muscle tissue.

To relieve pain and congestion in inflamed area.

To relieve the retention of urine.

To stimulate the absorption of serous exudate and effusion from the body cavities.

Purposes:

Preliminary assessment of the patient

• Identify the patient.
• Check the diagnosis and physician’s order.
• Inspect the body part.
• Determine the duration and frequency of the treatment.
• Check the general condition of the patient and his ability to follow instructions.
• Check the articles available in the patient’s unit.

STEPS OF

PROCEDURE

Preparation of the patient and the unit:

• Identify the patient with name and explain the procedure.
• Screen the patient.
• Drape the part according to the need and expose only the needed part of the patient.
• Switch off the fan.
• Place a Mackintosh and a towel under the patient to protect the bed.
• Keep the abdominal binder in place ready for application.
• Prepare the part and apply oil or Vaseline.

After care of the patient and the�articles:

• Change the compress every 3 minutes for 15 minutes, if a hot water bottle is not used. If single application is made and kept warm with a hot water bottle, remove the last fomentation after 20 minutes.
• Dry the skin, observe for redness, and blisters, etc. If any it should be reported immediately to the physician. If redness is there, apply Vaseline.
• Cover the patient, make him comfortable and remove the screen.
• Report and chart the effect of treatment with date, time, kind, duration, and body part

treated, patient’s reaction before, during and after the procedure.

• Wash all the articles. Disinfect the pads and replace them in their proper place.

​

Special points to remember:

• Avoid chilling the patient in between fomentation.
• In case of redness, report and take immediate steps.
• Always apply the fomentation on the area after ascertaining the patient’s sensibility to

heat. This is done by applying the fomentation gradually.

Surgical Fomentation

• This is the local application of moist heat requiring surgical asepsis when the skin is broken.

To stimulate the circulation and relax the muscle tissue.

To reduce swelling around a wound

To hasten separation of slough.

To help in the drainage of exudates

Purposes:

• A kettle of boiling water.
• A tray containing: Two sterile basins
• Two sterile fomentation pads
• Two sterile forceps
• Two sterile small towels
• A piece of plastic binder
• A kidney tray and a paper bag

​

• Dressing trolley
• Screen

ARTICLES

STEPS OF

PROCEDURE

STEPS OF

PROCEDURE

Sitz Bath

It is local application of moist heat to the pelvic organs. The patient is usually immersed from the mid-thigh to the iliac crests. The temperature of water should be 110°F-115°F (43°C- 46°C). Duration of the bath is 15–30 minutes.

Purposes

• To relieve congestion of the pelvic organs.
• To relieve pain following cystoscopy.
• To relieve inflammation and pain. (hemorrhoids, cystitis).
• To relieve pain in retention and painful urination.
• To promote wound healing by cleaning it off discharge and debris.

• Potassium permanganate: 1:5000
• Boric acid: 1 Dram to 1 Pint
• Dettol (1:40)

Solutions Used

• Screen, if the procedure is to be done at bedside.
• Suitable bath tub or basin.
• A jug with warm water.
• A bedside stool.

ARTICLES

• Explain the procedure.
• Fill the tub with water about half full at a temperature of 100°F.
• Screen the patient.
• Assist the patient to undress, avoid unnecessary exposure.
• Stand directly at patient’s back; help the patient to sit down in the tub with the feet flat on the floor. There should be no pressure on the sacrum or thighs.
• Be sure that the thighs, buttocks and the lower abdomen are immersed in the solution.
• Drape the patient’s legs and thighs. Wrap a bath blanket around the

patient’s shoulders to protect him from chills.

• Observe the patient closely for any signs of weakness, fatigue.

Discontinue if any signs of faintness, pallor, rapid pulse or nausea, etc. occur.

• Allow the patient to remain in the basin for 15-30 minutes.
• Do not leave the patient alone
• Help the patient to come out of the basin when the bath is completed.
• Dry the patient with a bath towel and cover him adequately.
• Rinse the basin, scrub well with soap, rinse, dry and replace.
• After care of patient and articles, and document the procedure findings.

STEPS OF

PROCEDURE

General Application of Dry Heat

Hot Dry Packs

Purposes

To prevent chilling.

To relieve retention of urine.

To provide a warm bed with blankets and hot water bottles and thus to prevent and treat surgical shocks.

• The dry hot pack frequently follows a hot bath.
• Wrap the patient in hot dry blankets.
• Keep 2-3 hot water bottles surrounding the blankets.
• Give hot drinks, e.g., hot soups, etc.
• Cold compress may be applied at the head if the patient has headache, to prevent extreme.

STEPS OF

PROCEDURE

General Application of Moist Heat

Hot Moist Packs

It is the application of hot moist blankets or flannel pieces to a larger area. The hot packs may be used to relieve muscle spasm in poliomyelitis.

Whirlpool Bath or Full Immersion Bath

These baths are helpful in promoting sedation, relieving pain and encouraging debridement of widespread surface burns.

When immersed in water, the body becomes buoyant and exercises are, therefore, performed with less effort.

Cold Application

It is to apply the cooler agent either in the moist or dry state to the body to relieve pain or to reduce the body temperature.

• Indications
• Pain
• Hemorrhage
• Hyperthermia
• Edema

• Contraindications
• Shock
• Muscle spasm
• Impaired sensation
• Peripheral vascular disease

TYPES

Local Cold Applications

• The application of cold to small areas may be given in different ways, e.g., chips by

mouth, ice soaks to an injured extremity, ice compress and packs.

​

​

Objectives

• To relieve pain, burning or irritation.
• To control bleeding
• To prevent gangrene by decreasing the tissue metabolism.
• To prevent inflammation or edema.
• To inhibit the bacterial growth and prevent suppuration.
• To reduce the body temperature.
• To anaesthetize an area for a short period.

Indications

• Sprains and fractures.
• Localized hemorrhage, i.e., nose bleeding and hematoma.
• Localized wounds, insects bites, minor burns and after injections.
• Headache, muscle spasm, pain due to malignancy.
• Low and moderate pyrexia.
• Dental extractions and surgical repairs.
• General cold moist applications—cold sponging, hypothermia.

Types

Ice Bag and Ice Collar (Local Dry Cold)

• The ice bag or ice cap and ice collar are commonly used for applying dry cold to the body.
• An ice collar is a long narrow rubber or plastic bag, which fits around the neck. The bags are usually made with an opening through which small pieces of ice are inserted.

ARTICLES

Preliminary assessment of the patient:

• Explain the purpose and procedure to the patient.
• Maintain a comfortable position.
• Prevent draughts by covering the patient with a blanket or a bed cover.

STEPS OF

PROCEDURE

STEPS OF

PROCEDURE

Cold Compress (Local Moist Cold)

• This is a local moist application made out of folded layers of gauze, lint piece or old soft linen. The gauze is cooled over ice chips, wrung out and then applied.

Purposes

• To treat epistaxis.
• To supply moist cold to the eyes.
• To apply on forehead to reduce fever and headache.

​

Articles

• A tray containing:
• A bowl of water containing ice.
• Several pieces of lint or gauze.
• A kidney tray.
• A small mackintosh and a towel to protect the bed.

Procedure

• Explain the procedure to the patient.
• Carry equipment to the bedside and screen the patient if necessary.
• Place the mackintosh and a towel under the area to be treated.
• Wring out the compress and apply on the area.
• Replace the compress as necessary to maintain coolness.
• On completion of treatment remove and clean the equipment and return to proper places.
• Leave the patient comfortable and chart the treatment.

​

Points to Remember

• Do not cover a cold compress, as it would soon reach body temperature.
• Apply cold compress for 15-20 minutes at a time.
• Observe for numbness and mottled bluish

STEPS OF

PROCEDURE

Cold Pack (Local Moist Cold)

• The procedure of applying cold packs is similar to the application of moist hot packs. The pack could be a wash cloth, towel, flannel or a sheet depending on the size of the body part to receive the application. A basin of cold water is prepared with a small amount of ice chips and packs are immersed into it. When cooled, excess water will wring out and the pack is applied to the body area. The temperature of water is maintained at 75°F. Replacing the pack is necessary to maintain coolness.

​

Ice Packs (Local Moist Cold)

• Ice packs are used occasionally to lower the temperature of patient’s limb before surgery or to decrease swelling. It is also a method to lower the body temperature artificially. Plastic bags of ice, which are covered with the towel, are placed on the specific area. Lower body temperature is used for checking inflammation and suppuration by decreasing the blood supply.

General Moist Cold Application

Cold Sponging

• It is used to reduce temperature in a patient with hyperpyrexia.

​

Objectives

• To soothe the nerves and promote sleep.
• To relieve discomfort.
• To reduce temperature.

ARTICLES

STEPS OF

PROCEDURE

PULSE

• The pulse is defined as a wave of blood being pumped into the arterial circulation by the contraction of the left ventricle.

Characteristics of Pulse

Factors Affecting the Pulse

Rate

Characteristics of Pulse

Rhythm

Quality

Assessment of Pulse

• Parts of stethoscope

Common peripheral sites of pulse assessment

RESPIRATION

• It is the physical and chemical processes (such as breathing and diffusion) by which an organism supplies its cells and tissues with the oxygen needed for metabolism and relieves them of the carbon dioxide formed in energy-producing reactions

Factors affecting respiration

Age related variation in respiratory rate

Depth

Characteristics of Respiration

Rate

Rhythm

Assessment of Respirations

• The nurse assesses respiratory rate, depth, and rhythm by inspection (observing and listening) or by listening with the stethoscope. Other methods of assessing respiratory effectiveness include using a pulse oximeter to determine oxygenation of blood and monitoring arterial blood gas results.

PROCEDURE OF TPR MONITORING

• To determine body temperature, pulse and respiration.

​

• To assist in diagnosis and evaluating status of patient's

blood volume, cardiac output and vascular system.

​

• To compare with subsequent changes that may occur

care of patient.

​

• To determine if immediate measures should be implemented

to reduce elevated body temperature or converse body heat

when body temperature is extremely low.

​

​

• To evaluate patient's response once heat conserving or heat

reducing measures have been implemented

PRE-PROCEDURAL PREPARATION

ARTICLES REQUIRED TO ASSESS TPR MONITORING

• A digital thermometer

​

• Spirit swabs

​

• A container with lid

​

• Stethoscope

​

• Kidney dish

​

• Recording and graph sheet

​

• Black, blue and red pen

​

• Watch with second hand

​

FOR PROCEDURE

REFER PAGE NO. - 242

BLOOD PRESSURE

• “It is the force of the moving blood against arterial walls. Maximum blood pressure (BP) is exerted on the walls of arteries when the left ventricle of the heart contracts and pushes blood through the aortic valve into the aorta at the beginning of systole.

Factors Affecting Blood Pressure

Exercise.

Stress

Medications

Age

Diurnal variations

Disease Conditions

Blood volume

Temperature

EQUIPMENT USED TO MEASURE BLOOD PRESSURE

Assessment of BP

FOR PROCEDURE

REFER PAGE NO. 244-245

Postprocedural responsibilities after monitoring the blood pressure

DOCUMENTATION AND RECORDING OF VITAL SIGNS

STOOL ROUTINE EXAMINATION (TYPES AND COLLECTION OF SPECIMEN

OF FAECES: OBSERVATION)

Definition:

It is a method of obtaining stool specimen from the patient.

Purpose:

To check the stool for the presence of specific material (blood,

bacteria

ova, parasite or

like and

Salmonella Shigella, etc.)

STOOL ROUTINE EXAMINATION (TYPES AND COLLECTION OF SPECIMEN

OF FAECES: OBSERVATION)

CULTURING THE STOOL

• The stool can be cultured for disease-causing bacteria.
• A stool sample is placed in an incubator for at least 48–72 hours and any disease-causing bacteria are identified and isolated.
• Not all bacteria in the stool cause problems; in fact, about half of stool is bacteria, most of which live there normally and are necessary for digestion.

TESTING THE STOOL FOR OVA AND PARASITES

• Stool may be tested for the presence of parasites and ova (the egg stage of a parasite) if a child has prolonged diarrhea or other intestinal symptoms.
• The doctor will collect two or more samples of stool to successfully identify parasites.
• If parasites or their eggs are seen when a smear of stool is examined under the microscope, the child will be treated for a parasitic infestation.
• The hospital will provide a special collection container that contains chemical preservatives for parasites.

URINE TESTING- TYPES AND COLLECTION

OF URINE SPECIMEN

Urine Testing - Albumin, Acetone, pH, Specific Gravity

​

​

Urine test provides useful information in diagnosis and treatment of variety

of disease conditions. Analysis of urine helps in examining the appearance,

odor, pH, specific gravity and presence of albumin, sugar and acetone.

​

​

Urinalysis is a diagnostic, physical and chemical, microscopic detection of any

abnormality of urine.

Purpose

​

​

• Monitoring the urine abnormality.

​

• General evaluation of health.

​

• Monitoring the conditions like diabetes

mellitus, kidney disease.

Articles

​

A clean tray containing the following articles:

​

• Test tube holder

​

• Test tube 4-6 on the test tube stand

​

• Spirit lamp with match box

​

• Rag pieces

​

• Kidney tray, paper bag

​

• Dropper (2) one for urine and one for reagents

​

• Litmus paper to check the reaction of urine

​

• Calibrated urinometer to check the specific gravity

​

• Wide mouth specimen jar
• Jar for urine

Bowl

​

• Clean gloves (1 pair)

REAGENTS

​

• For albumin hot test-acetic acid solution 2%

​

• For sugar testing- Benedict's solution

​

• For albumin cold test- Nitric acid solution

​

• For acetone test- sodium nitroprusside crystal

​

• For acetone test-ammonium sulfate crystals

TEST FOR ALBUMIN IN URINE: HOT TEST

Description

• This test (hot test) is used to find out the presence of albumin in the urine.

Procedure

• Refer book (page no. 248)

TEST FOR ALBUMIN IN URINE: COLD METHOD

This test (cold method) is done to find out the presence of albumin in the urine.

PROCEDURE

Refer book (page no. 248)

TEST FOR ACETONE IN URINE

Testing of the urine specimen for identifying the presence of acetone.

Description Procedure

Refer book (page no. 248)

BILE TESTS

SUGAR OR GLUCOSE TEST

• PROCEDURE

Refer book (page no. 248)

RESULT FOR GLUCOSE TEST

Description

Reagent strips are available for urine

testing which

yields the results

quickly. These are

available for

ketone and glucose

assessment in

urine (also called

ketostix or diastix).

Procedure

How to use:

Refer book (page no. 650)

Refer book (page no. 249)

​

PROCEDURE FOR CHECKING URINE SPECIFIC GRAVITY

COLLECTION OF URINE SPECIMEN AND URINE TESTING

COLLECTING URINE SPECIMEN FOR CULTURE

Description

• For detecting the presence

and growth

microorganisms

urine sample,

of

in the a small

amount (30–60 mL) of

urine is collected.

Purposes

• To identify the antibiotic sensitivity of the pathogen in the urine sample.

• Culture pathogenic

microorganisms are

present in the urine.

COLLECTING URINE SPECIMEN FOR CULTURE

Articles

• Sterile container
• Sterile needle if required in case of catheterized client
• Soap and water
• Bedpan
• Laboratory form

Procedure

• Refer book (page no. 249)

COLLECTION OF URINE SPECIMEN FOR ROUTINE EXAMINATION (MIDSTREAM URINE)

Procedure

Refer book (page no. 250)

COLLECTION OF 24 HOURS URINE

• It is a collection of the urine specimen for a period of 24 hours without any spillage or wastage.

Description

and electrolyte,

• To detect kidney, liver and cardiac conditions.
• To measure the total proteins, creatinine hormones.

Purposes

• Clean container with lid
• Measuring jar
• Urinal and kidney tray to collect urine at each voiding
• A complete laboratory form

Articles

• Refer book (page no.250)

Procedure

SPUTUM

A sputum culture is a test that checks for bacteria or another type of organism that may be causing an infection in the lungs or the airways leading to the lungs.

CULTURE

DIFFERENT COLORS OF SPUTUM

COLLECTION OF SPUTUM FOR CULTURE

Collection of coughed out sputum for culture to identify respiratory

pathogens (acid-fast bacillus, streptococci,

pneumococci,

diphtheria bacilli).

PURPOSES OF COLLECTION OF SPUTUM FOR CULTURE

Purposes

Identify respiratory pathogens.

Look for the color of sputum like hemoptysis, greenish color in bronchitis, rusty color in pneumonia.

COLLECTION OF SPUTUM FOR CULTURE

ARTICLES

• Sterile specimen container
• Tissue paper
• Sputum mug with disinfectant
• Sterile gloves
• Disposable mask
• Requisition form

PROCEDURE

Refer book (page no. 251)

COLLECTION OF VOMITUS SPECIMEN

Vomitus is the forceful expulsion of the gastrointestinal products,

in acute phase of illness.

​

Vomitus can be collected only when patient vomits. And it should

be sent to lab immediately to laboratory for investigation.

​

In case it has to be stored then it should be stored at 40C. And

handling is specimen is same as stool specimen.

When patient vomits, the kidney tray is offered so that the vomiting

is collected in it . Nurse shall collect small amount of vomitus in the

specimen container and send to laboratory with appropriate labels.

​

PROCEDURE

who is at risk of hyperglycemia or

MONITORING CAPILLARY BLOOD GLUCOSE (GLUCOMETER RANDOM BLOOD SUGAR)

Measurement of the blood glucose level of the patient,

using

portable glucometer

hypoglycemia, a by

putting the drop of blood on the glucometer strip using the needle or lancet.

PURPOSES OF MONITORING CAPILLARY BLOOD GLUCOSE

• To monitor the blood glucose level of the patient.
• To educate the patient regarding diet management and medication.
• To encourage the patient about compliance with the treatment regimen.

MONITORING CAPILLARY BLOOD GLUCOSE

ARTICLES

A clean tray containing:

• Glucometer
• Testing strips
• Sterile lancet or 26FG sterile needle
• Dry cotton swab and alcohol swab
• Clean gloves
• Hand rub

PROCEDURE

​

Refer book (page no.252)

FASTING BLOOD SUGAR

• This is a test that helps in determining the amount of glucose (sugar) in a blood sample after an overnight fast. The fasting blood glucose test is commonly used to detect diabetes mellitus.
• The normal range for blood glucose is 70–100 mg/dL.
• A blood sample can be taken in a lab, physician’s office, or the hospital. The test is done in the morning, before the person has taken breakfast.

RANDOM BLOOD SUGAR

• A random blood sugar (RBS) test is the testing of the blood sugar level at any time or random time of the day.
• According to American Diabetes Association:
• The RBS test is done within 1 or 2 hours of eating then the RBS normal value should be 180 mg/dL.
• The RBS normal range should be anywhere between 80 and 130 mg/dL prior to eating for healthy blood sugar levels in the body.

​

​

​

NORMAL RANGE OF BLOOD GLUCOSE

POSTPRANDIAL BLOOD SUGAR

• The word postprandial means after a meal; therefore, PPG concentrations refer to postprandial plasma glucose concentrations after eating. Postprandial plasma glucose tests show how tolerant the body is to glucose.

LEVELS OF

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POSTPARANDIAL BLOOD SUGAR

SECTION C : PSYCHOLOGICAL ASSESSMENT-

MOOD, INTELLIGENT, EMOTIONS,

NORMAL AND ABNORMAL BEHAVIOR

Assessment of mood and emotions can be assessed by correlating

the expressions of patient while talking, eg, patient may look anxious

and replies that he is happy. Such uncorrelated emotions and mood

shall be identified by the nurse

Mood assessment helps to identify the general cerebral functions.

In this the nurse will assess the intellectual and emotional function

of the patient.

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• Check the overall appearance of the patient.

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• Assess the appearance of the patient, behaviour, ability to speak
• as well as the ability to respond to question

Assessment of Mood

Patient awareness is assessed by checking the awareness of

patient to time place and person. It can be assessed by asking

the following question from the patient:

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"What is time right now"

"What is date today"

"What is the day".

" Which season of the year going on".

Level of Awareness Assessment

• Then assess whether patient is oriented to place by asking questions like

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"Where are you now"

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"What is the name of the hospital or clinics or place".

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"What is the name of the place where you live",

• Further awareness of the person to the himself/ herself

can be assessed by asking the following questions

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"Who you are?"

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"What is your age?"

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"With whom you came to the hospital ?

ASSESSMENT OF MEMOERY

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• Recent and remote memory of the patient is checked by asking

the question that will recall the present and past events. E.g. For

assessment of present or recent memory .

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"What did you eat last night for dinner"

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"What you have in the breakfast"

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For remote memory

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"In which year you got married"

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"When is your birthday"

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In this the nurse will ask the patient to explain a proverb

Like "Where there is a will, there is a way". Patient will

repeat the phrases and gives unnecessary explanation

if intellectual ability is impaired. Make sure the phrase

should not be specific to any culture.

Assessment of Abstract Reasoning

Intelligence is not limited to IQ alone. The IQ tests measure only a part of

overall competence of human beings. Success in life depends on several

other aspects, such as creativity, social competence, practical problem solving

abilities etc. Further, the traditional IQ tests may not recognize the other kind

of intelligences.

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Assessment of Intelligence

Language Assessment

Language assessment of the patient can be done by

asking simple question from the patient like:

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• "Name the items lying in the room"
• "Count the number of chair“
• Patient can be asked to follow commands like extend your

arms etc."

• "Patient can be asked to read some short sentences from
• the newspaper or magazines"

Abnormal Findings

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Aphasia due to injury to the cortex. Aphasia can be expressive means

the person will understand the written or spoken words but will not be

able to communicate or receptive means the person will not understand

the written or spoken words

“Textbook of Foundation of

Nursing" by Jyoti Kathwal