HEALTH ASSESSMENT
Skills Performance Checklist:
HEALTH ASSESSMENT
A. KNOWLEDGE · States the objective / Purpose of the activity · Uses appropriate terms · States the steps of procedure in order. Explains rationale of every step. | |
B. SKILLS | |
1. Read the patient’s chart To have a background knowledge about the case of the patient. - Baseline - To know the patient’s background and status - reading a patient's chart is essential for providing comprehensive, safe, and effective healthcare. It ensures a thorough understanding of the patient's health status, facilitates collaboration among healthcare providers, and supports informed decision-making in the patient's best interest. Check if the patient have respiratory caution (to be safe and avoid being contaminated) | - Obtaining essential background information: - Understanding the patient's current health status: The chart includes recent vital signs, laboratory results, diagnostic test results, and notes from other healthcare providers. -Ensuring continuity of care - Preventing medication errors and adverse drug reactions - Assessing the effectiveness of treatment plans - Identifying potential health risks and red flags - Informing patient education and communication: In summary, reading a patient's chart is essential for providing comprehensive, safe, and effective healthcare. It ensures a thorough understanding of the patient's health status, facilitates collaboration among healthcare providers, and supports informed decision-making in the patient's best interest. |
2. Wash hands and observe appropriate infection control procedures - Washing hands is crucial before entering the room so both the nurse and the patient would be safe. - TO AVOID CROSS CONTAMINATION - TO KEEP EVERYTHING STERILE - To avoid infection between the nurse and the patient. To keep everything sterile. | - Preventing the spread of infection: Many infections are transmitted. - Protecting patients - Protecting healthcare workers: Healthcare workers are at increased risk of exposure to infections because of their frequent contact with patients. - Legal and ethical obligations Ultimately, hand hygiene and infection control are essential for promoting patient safety, protecting healthcare workers, and maintaining a safe and healthy environment in healthcare settings. |
3. Greet and identify the client To make sure that he/she is truly the patient.
| - Ask permission first & knock before entering the room. - Check the bed, there is a piece of paper on the side of the bed where the name of the patient is there The patient should only say their own name (what if they just came from anesthesia) |
4. Introduce yourself To eliminate the anxiety of the patient from the unknown.
| - Introduce yourself in the first meeting - Talk politely Overall, introducing yourself is a simple but crucial step in the health assessment process that helps create a positive and professional experience for both you and the client. |
5. Explain plan and procedure In order for patients to make informed treatment decisions. - Explain the patient on what is happening - What will be the plan - Be Careful of cultural differences, there are certain religious practices not allowed for certain people.
| - Simply explain the procedure on what you will do to them. - Take Vitals (no 2nd measure)- Bp, pulse rate, respiratory rate, temp. - If the patient refused to be treated or intake, a specific medicine the hospital and patient will write a libel. - Examples, you will be taking vital signs and explaining the procedure and what materials you will use. |
6. Provide privacy for the client | - Close the doors, curtains and windows - Cover their body parts while washing - Providing blankets (mostly for bedridden patients) - To protect and preserve the dignity of the patient |
7. Assess the environment, resources and the client’s medical condition on how to systematically complete the procedure | Patient's chart is a legal document and not all hospitals give the nurse a patient chart, that is why it is important. - Look at the patient’s chart Overall, assessing the environment, resources, and the client's medical condition before beginning a health assessment procedure is a critical step in providing safe, efficient, and effective care. |
8. IDENTIFYING DATA: Demographic Information
| - To know the background and the status of the patient. Gathering this demographic information can help healthcare providers tailor their care to the unique needs and circumstances of each client, leading to more personalized and effective care. |
A. Name B. Age C. Gender D. Marital Status E. Address F. Date of birth G. Religion H. Occupation I. Type of Health Plan | Name: Identifying the client's name is essential for accurately documenting their care and ensuring that their medical records are correctly linked to them. |
Age: A client's age can provide important context for understanding their health risks and needs. Knowing a patient's age is crucial for assessing age-specific health risks, determining appropriate preventive care measures, and adjusting treatment plans accordingly. For example, certain health conditions are more common in specific age groups, and treatment recommendations may vary based on age. For example, certain screening tests are recommended at specific age intervals. | |
Gender: A client's gender can affect their risk for certain health conditions, as well as their comfort with certain types of examinations or procedures Gender is essential for evaluating gender-specific health risks and tailoring health assessments and treatment plans accordingly. Some medical conditions are more prevalent or present differently in males and females. | |
Marital status: Knowing a client's marital status can provide insight into their social support system and may be relevant to discussions about family planning or end-of-life care. | |
Address: A client's address can provide information about their living situation and potential environmental risk factors, such as exposure to pollutants or lack of access to healthcare services. | |
Date of birth: This information can be used to verify the client's identity and determine their age. | |
Religion: Knowing a client's religious beliefs can help providers be sensitive to their values and beliefs and tailor their care accordingly. | |
Occupation: A client's occupation can provide insight into potential occupational hazards or exposures that may affect their health. | |
Type of health plan: Understanding a client's health insurance coverage can inform discussions about treatment options and financial considerations. Ex, Eligibility for Philhealth | |
9. SOURCE AND RELIABILITY OF HISTORY Examples of SOURCES
Examples of why need RELIABILITY
| - To know where the source came from.
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10. CHIEF COMPLAINT | - The complaint of the client - To know the reasons why the patient goes to the hospital. Overall, the chief complaint is a vital piece of information that guides the health assessment process and informs subsequent clinical decision-making Ex, SOP- Shortness Of Breath |
11. Client’s perception of their health status | Assessing a client's perception of their health status is an essential aspect of a comprehensive health assessment, as it provides valuable insights into the client's beliefs, attitudes, and experiences related to their health. Understanding the client's perspective can influence their adherence to treatment plans, health-related decision-making, and overall well-being. Ask if the patient feels healthy. |
12. HISTORY OF PRESENT ILLNESS A. Onset of the problem B. Setting in which it has developed C. Manifestations D. Treatments | The History of Present Illness (HPI) is a crucial component of a health assessment, as it provides detailed information about the client's current health concerns or symptoms. The HPI helps healthcare providers understand the nature, onset, and progression of a client's health issues, which is essential for making an accurate diagnosis and developing an effective treatment plan. - The latest illness or what kind of the latest pain the patient feels. |
The latest illness Determining when the problem started helps healthcare providers understand the temporal relationship between the onset of symptoms and potential triggers, exposures, or precipitating events. This information can provide important clues about the underlying cause of the health issue and inform the diagnosis. When did it occur” | |
Understanding the context in which the problem developed can help identify environmental factors or exposures that may contribute to the health issue. For example, a client who develops respiratory symptoms after starting a new job in a factory may have been exposed to harmful airborne substances in the workplace. | |
The signs/symptoms of the patient - - Symptom- Subjective, perception is a manifestation of a disease that physician perceives - Signs- Objective, observable and measurable, and evidence based, a manifestation of disease apparent to the patient himself Ask the signs and symptoms Ex. “Where is the pain located and what position”,” | |
Drugs that the patient's intake to control the illness -Identify the purpose of the treatments and drugs they intake. - Name, dose, route, action and frequency of the drug they intake. Additionally, knowing about any prior treatments can alert healthcare providers to potential interactions or adverse effects that may impact the client's current health status | |
13. Principal Symptom A. Location- Identifying where the symptom occurs in the body can help narrow down potential causes and inform the diagnostic process B. Quality C. Quantity or Severity D. Timing (Onset, Duration and Frequency) E. Setting in which it occur F. Aggravating factor and Relieving factors G. Associated Manifestations | These are factors to help the nurse/physician identify the cause of the severity of the pain |
Pointing out on what part Ask where is the pain located Ex, the pain is in the pectoralis major Pointing out on what part For example, chest pain may indicate a cardiovascular issue, while abdominal pain could point to a gastrointestinal problem | |
Describing the quality of the symptom, such as whether it is sharp, dull, burning, or aching, can provide additional insights into the underlying cause and help differentiate between various potential diagnoses Ex. Burning sensation | |
Assessing the severity of a symptom can help determine its impact on the client's daily life and function. This information can also guide treatment decisions and prioritize interventions based on the symptom's severity. - Use the pain scale (1-10) on what scale how the patient feel the pain - PAIN SCALE: (1-3) Mild (4-7) Moderate (7-10) Severe pain | |
When and how did it start; how long; how frequent Understanding when the symptom started, how long it lasts, and how often it occurs can provide important clues about the cause and progression of the health issue. For example, symptoms that worsen over time or occur more frequently may indicate a deteriorating condition that requires urgent attention | |
Where did it occurred Identifying the environment or circumstances in which the symptom occurs can help identify potential triggers or contributing factors. For instance, symptoms that appear or worsen in specific settings, such as at work or during physical activity, may point to environmental or occupational exposures as the cause | |
Aggravating factors- these are the things/factors/actions that make the pain worse. Relieving factor- these are the things/factors/actions that can relieve the pain. can guide treatment recommendations and help clients manage their symptoms more effectively. This information also aids healthcare providers in identifying potential interventions that may be more or less effective for the client. Ex, the patient tells where it hurts. The patient tells what action they do to make the pain less painful | |
14. Medications (Prescription, over the counter, herbal preparations) A. Name- B. Dose- C. Route- D. Action- E. Frequency- | - Identify the prescriptions, over the counter, herbal preparation)
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- Identify the name of the drug with the prescription. Ex. Aspirin Name: Knowing the names of the medications a client is taking helps healthcare providers avoid prescribing medications that may cause adverse interactions with existing medications | |
The dose of a medication is crucial for ensuring its effectiveness while avoiding harmful effects. Inaccurate dosing can result in under- or over-treatment, leading to treatment failure or adverse effects. Ex. 80 mg | |
The route of administration (oral, topical, intravenous, etc.) affects how a medication is absorbed, distributed, and metabolized in the body. Identifying the correct route of administration is essential for maximizing the medication's benefits and minimizing its risks. ➤ Ex. Oral | |
Understanding a medication's mechanism of action (how it works) is crucial for anticipating its effects and adjusting treatment plans accordingly. Ex. Blood thinner (anti-hypertensive) (Pampalabnaw ng dugo) | |
Knowing the recommended frequency of medication administration helps prevent medication errors, ensure consistent treatment, and support proper medication adherence. Ex. 2-3 times a day | |
15. Allergies (Drug, Food, Insects and Environmental factors)
A. Name of allergen B. Type of reaction C. Remedy taken | Allergies- Are immune response triggered by allergens (an ordinarily harmful substance) - It is different for every people Because reaction to allergen is a triggering factor in asthma Allergen- triggering factor that ushered the histamine in the body.Allergens are substances that can trigger an allergic reaction Histamine- a natural reactions towards allergens |
Identifying the allergen helps in avoiding exposure Name of Allergen: Identifying the specific allergen is crucial for preventing future exposure and minimizing the risk of allergic reactions. Common allergens include medications, food, insect stings, and environmental factors such as dust, pollen, or pet dander. Knowing the precise name of the allergen allows healthcare providers to document it in the client's medical record Types of allergens: 1. Pollen- allergic rhinitis, asthma Signs/symptoms: Pruritus- itchiness of the body. 2. lodine- contains high concentration of iodine. (seafood) and bicevic appropriate patient 3. Drugs- E.g. Antibiotics (Amoxicillin) (Clindamycin) are no. 1 drugs that mostly causes allergic reaction 4. Food- seashell, eggs, peanuts 5. Insects- stain of the bees: releases substances (venom) that can trigger a (allergic reaction) more-serious immune system reaction. | |
The signs and symptoms if one has an allergy. To determine the appropriate treatment if it is suited to the patient (effectiveness) Type of Reaction: Assessing the type of allergic reaction helps healthcare providers gauge the severity of the client's allergies and anticipate the potential consequences of future exposures. Allergic reactions can range from mild symptoms, such as itching or a rash, to severe, life-threatening reactions like anaphylaxis. Types of Reaction: (signs/symptoms) 1. Pruritus- itchiness of the body 2. Difficulty of Breathing- this occurs because when allergy occurs the internal organs become swollen (Trachea and esophagus) where air flows; If allergic people drink water, they will feel that the water is just gradually dropping in their throat slowly. 3. Teary eyes- because of difficulty breathing. 4. Nausea and Vomiting (Both nausea and vomiting can be symptoms of a variety of underlying conditions, including infection, food poisoning, gastroenteritis, or pregnancy.) - Nausea is feeling an urge to vomit. It is often called being sick to your stomach. Feeling discomfort in the stomach. - Vomiting or throwing up forces the contents of the stomach up through the food pipe (esophagus) and out of the mouth. Nausea is a subjective symptom reported by the patient, while vomiting is an objective sign that can be observed by a healthcare provider. 5. Edema- The accumulation of excess fluid in the body’s tissues, which results in swelling of any part of the body (mostly the face and hands) - Allergic Rhinitis (Only occurs at the evening) | |
Knowing the remedy indicates the effectiveness of previous treatments and helps in planning future management. Remedy Taken: Knowing the remedies a client has taken in response to an allergic reaction can help healthcare providers determine the effectiveness of previous treatments and guide future management strategies. - What herbal/drugs do they intake to prevent the allergic reaction. Claritin- antihistamine (side effect: drowsiness) Munti Lucas- form of histamine to prevent vomiting. | |
16. Cigarette or Tobacco use Assessing a client's cigarette or tobacco use is crucial in a health assessment for several reasons:
A. Type B. Quantity C. If some has quit, How long? | - To know how many years did it affected the lungs - Lungs recuperate/recovery: To know if the lungs still have a chance to recover. 3,000 different types of chemicals a) Tar- used for plastering a surface (road asphalt) b) Formalin- contains formaldehyde, and is used for embalming. c) Chloroform- used for cleaning in the comfort room. |
Different types of tobacco products have varying health risks What type? (Brand) Type: Knowing the type of tobacco product a client uses (cigarettes, cigars, pipes, chewing tobacco, etc.) provides insight into the potential health risks and the level of exposure to harmful substances. Different types of tobacco products may have varying levels of risk and require different interventions. | |
Correlates with the degree (how severe or not) of health risk. How many sticks/packs per day Quantity: Understanding the quantity of tobacco use helps healthcare providers gauge the level of exposure to harmful substances and assess the associated health risks. Higher levels of tobacco use generally correspond to higher health risks, so knowing the quantity can guide healthcare providers in developing appropriate interventions. | |
Provides insight into individuals current health status and risk reduction How many years/what span of years since they stopped using or intake cigarettes? (LUNGS WILL. AFTER 5 YEARS) Quitting History: Asking about quitting history, including the length of time since quitting, can provide valuable information about a client's current risk level and their level of success in past quitting attempts. This information can help healthcare providers offer targeted support, counseling, or medications to help clients maintain abstinence or attempt to quit again.. | |
17. Alcohol and Drug Use A. Type B. Quantity C. Frequency | To know if the liver is affected too much or not - To identify potential risks for respiratory and cardiovascular diseases, cravings, or relapse concerns. By asking about the type, quantity, and quitting history related to alcohol and drug use, healthcare providers can develop personalized treatment plans that address the unique needs of each client, improve health outcomes, and promote overall well-being. It affects the liver. |
- To identify how hard/strong or low level of content of alcohol Type: Identifying the type of substance a client uses (e.g., alcohol, marijuana, cocaine, opioids) is essential for understanding the potential health risks, side effects, and the level of addiction risk. Different substances carry varying levels of risk and may require different treatments or interventions. Beer/hard 2 types of drugs: a) Upper (Shabu)- you will be high; b) downer (marijuana)- you will be asleep. | |
Quantity: The quantity of substance use can provide valuable insight into the severity of a client's substance use and the level of associated health risks. Higher quantities of substance use often correspond to higher levels of health risks and addiction potential. How many bottles? How much alcohol? | |
Quitting History: Information about a client's quitting history, including the length of time since quitting, can inform healthcare providers about the client's past experiences with addiction, recovery, and relapse. This knowledge can help providers offer targeted support, counseling, or medications to assist clients in maintaining abstinence or attempting to quit again. How frequent? Is it sometimes, often, always | |
18. PAST HISTORY A. Childhood illness B. Adult illness (Medical, Surgical, Obstetric/Gynecologic and Psychiatric) C. Health Maintenance (Immunizations- Screening Tests) | What are the patient's illness in the past Assessing a client's past health history is important for understanding their overall health status, potential risks, and future healthcare needs. By asking about childhood illnesses, adult illnesses, and health maintenance practices, healthcare providers can develop a more comprehensive understanding of a client's health background and provide more effective care. |
- It may have a direct link/causes the patient’s present illness - It can have a long-term implications and may influence current health Childhood Illnesses: Understanding a client's childhood health history can provide insight into potential long-term effects on their current health status, as well as identify any potential risk factors for adult diseases. For example, certain childhood illnesses may increase the risk of developing specific conditions later in life, such as asthma, allergies, or autoimmune disorders. Primary complex- Childhood Onset Tuberculosis- if not treated, it will be the illness in present) (It can be at the blood, brain, stomach, lymph nodes, and bones not just the lungs) Idiopathic- relating to disease which arise for which the cause is unknown (the cause is unknown) (Ex, Appendicitis) Example, Diarrhea- every year you can have diarrhea if you do not intake your medicine | |
Identifying the past illnesses informs and provides about potential chronic conditions, surgeries, treatments that may impact current health - If the person is having a problem in the organ Adult Illnesses: Gathering information about a client's medical, surgical, obstetric/gynecologic, and psychiatric history helps healthcare providers understand the client's health experiences and potential ongoing health concerns. 18 and above- major problems; medical/surgical a) Appendectomy- It is a surgery to remove the appendix when it is infected. (mostly near the groin) EXPLORATORY LAPAROTOMY- this surgery uses one large cut (incision)/ to find the cause of problems that testing could not diagnose. b) Obstetric/Gynecologic- problem in private organ c) Psychiatric- problem that bothers you.(There should be no problem in stigma)
“Do you have major problems with health?” | |
- The immunization and screening history helps ensure that they are up-to-date on preventive measures and identifies potential gaps in care. Health Maintenance: Assessing a client's health maintenance practices, including immunizations and screening tests, helps healthcare providers determine whether the client is up to date on preventive care measures. This information can identify potential gaps in care and help providers recommend appropriate screenings or vaccinations to promote health and prevent disease. ➤ Acute Illness develops quickly and lasts only a short amount of time) Chronic Illness is a health condition that is long-lasting in its effects and needs maintenance drugs. - What are the immunizations or screening that patients did | |
19. FAMILY HISTORY A. Acute and Chronic Illness (Medical, Surgical, Obstetric/ Gynecological & Psychiatric) B. Age, Cause, Health and Relation | Assessing a client's family health history is a crucial component of a comprehensive health assessment, as it can provide valuable insight into a client's genetic predispositions and potential health risks. By asking about acute and chronic illnesses in the family, as well as the age, cause, health, and relationship of affected family members, healthcare providers can better understand a client's risk factors and develop personalized care plans. |
Acute- only lasts within a short span Chronic- lasts within a long span (need maintenance drug) Ex, Cancer is inheritable while other disease such as Heart pain disease (because of lifestyle and habits) and tuberculosis (Is contagious) - Understanding the family member medical history helps in assessing genetic predisposition and potential risks for certain conditions Acute and Chronic Illnesses: Gathering information about a family's history of acute and chronic illnesses in the medical, surgical, obstetric/gynecological, and psychiatric domains can help identify potential genetic or familial risks for the client. Certain conditions, such as heart disease, cancer, diabetes, or mental health disorders, may have a strong genetic component, making it important to know if these illnesses are present in the family history. | |
They provide a context for assessing familial risk factors and genetic inheritance patterns Age, Cause, Health, and Relation: Understanding the details of a family member's illness, such as their age at diagnosis, the cause of the illness (if known), their overall health status, and their relationship to the client, can help healthcare providers identify patterns or potential risk factors. | |
20. PERSONAL AND SOCIAL (A.D.L)- ADL- Activities of daily living A. Personal history (Personality, Interests, Sources of support, coping style, Strengths, Fears, Job history, Religion and Spiritual Beliefs) B. Exercise (Type and Frequency) C. Diet (Usual Food intake, supplements & Frequency) | Assessing personal history, exercise, and diet as part of a health assessment provides valuable insights into various aspects of a client's life that can impact their overall health and well-being. |
> Personal history (Type A- competitive/ Type B- laid-back) > Interest (what do you always want to talk about?) (hobbies) > Source of Support (significant other) > Coping style (coping mechanism) > Strengths (desirable trait) > Fear ➤ Job history > Religion Spiritual Beliefs Aids in understanding the individuals background which can influence health behaviors and outcomes Personal History:
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Knowing the type and frequency of exercise provides insight into the individual’s physical activity level and overall fitness which are important factors in health promotion and disease prevention. Exercise: Identifying the type and frequency of exercise a client engages in helps healthcare providers assess the client's physical activity levels and provide recommendations to improve or maintain their physical health. Regular exercise has numerous health benefits, including reducing the risk of chronic diseases, promoting mental well-being, and improving overall quality of life. | |
- Understanding dietary habits helps in assessing nutritional status and identifies potential deficiencies - Also Promotes healthy eating behaviors for disease prevention and management - What do they eat - Do they eat breakfast, lunch and dinner Diet: Evaluating a client's usual food intake and supplement use can provide valuable insights into their nutritional status and potential deficiencies or excesses. Understanding dietary habits allows healthcare providers to offer tailored nutrition advice, recommend appropriate dietary modifications, and address potential issues related to malnutrition, obesity, or nutrient deficiencies. | |
21. REVIEW OF SYSTEMS A. General B. Skin C. Head, Eyes, Ears, Nose, Throat (HEENT) These senses are interconnected D. Neck E. Breasts F. Respiratory G. Cardiovascular This system plays a vital role in our health and well-being by:
Pulmonary circulation (Lesser circulation): This loop carries blood between the heart and the lungs. Deoxygenated blood from the body is pumped to the lungs, where it picks up oxygen and releases carbon dioxide. The oxygenated blood then returns to the heart. Systemic circulation (Greater circulation): This loop carries oxygenated blood from the heart to all tissues and organs in the body. The deoxygenated blood then returns to the heart through the veins, completing the cycle. H. Gastrointestinal The GI system relies on the contribution of several accessory organs:
I. Urinary The urinary system is a network of organs and structures responsible for filtering waste products from the blood, producing urine, and eliminating it from the body. This system plays a crucial role in maintaining overall health by: - Removing waste products: The urinary system filters out excess water, salts, and toxins from the blood, preventing them from accumulating to harmful levels. - Regulating body fluids and electrolytes: The urinary system helps maintain proper balance of water, electrolytes (minerals), and other essential components in the body. - Contributing to blood pressure regulation: The kidneys, the main organs of the urinary system, play a role in regulating blood pressure by controlling blood volume and electrolyte balance. - Supporting red blood cell production: The kidneys produce a hormone called erythropoietin (EPO), which stimulates the bone marrow to produce red blood cells. Function of the Urinary System: The urinary system operates in a continuous cycle:
Maintaining Urinary Health: Maintaining a healthy lifestyle is crucial for optimal urinary system function. Here are some tips:
J. Genital (Male) (Female) Genital (Male and Female): Assessing the genital system helps identify symptoms or concerns related to reproductive health, sexual function, and potential sexually transmitted infections. For males, this may include questions about penile discharge, testicular pain, or erectile dysfunction. For females, this may involve inquiries about vaginal discharge, pelvic pain, or menstrual irregularities. Identifying these issues can guide further testing, treatment, and education to promote sexual and reproductive health K. Peripheral Vascular Peripheral Vascular: Assessing the peripheral vascular system helps identify symptoms such as leg pain, swelling, varicose veins, or cold extremities, which may indicate conditions like peripheral artery disease, venous insufficiency, or blood clots. Early detection and management of these issues can prevent complications and improve overall health. Peripheral vascular refers to the blood vessels (arteries and veins) that are located outside of the heart and brain. Peripheral vascular disorders can affect the blood vessels in the arms, legs, abdomen, and other parts of the body. Here are some key components of peripheral vascular disorders: - Peripheral artery disease (PAD): PAD occurs when the arteries that supply blood to the arms and legs become narrowed or blocked, reducing blood flow to these areas. - Deep vein thrombosis (DVT): DVT occurs when a blood clot forms in a deep vein, usually in the leg, which can lead to pain, swelling, and potentially life-threatening complications. - Varicose veins: Varicose veins are swollen, twisted veins that are most commonly found in the legs. They can cause discomfort and may increase the risk of blood clots. - Lymphedema: Lymphedema is swelling that occurs when lymphatic fluid builds up in the body's tissues, usually in the arms or legs. - Ankle-brachial index (ABI): This test compares the blood pressure in the ankle to the blood pressure in the arm to assess PAD. - Doppler ultrasound: This test uses sound waves to visualize blood flow in the veins and arteries and can help diagnose DVT or other vascular problems. - Visual inspection: Healthcare providers may examine the arms and legs for signs of swelling, redness, or skin changes that may indicate a vascular disorder. - Palpation: Healthcare providers may feel for pulses in the legs and feet to assess for decreased blood flow. - Venous filling time: This test measures the time it takes for veins to refill after being compressed, which can help diagnose venous insufficiency. L. Musculoskeletal Musculoskeletal: Evaluating the musculoskeletal system involves asking about joint pain, stiffness, swelling, muscle pain, or limitations in mobility. These symptoms may suggest conditions like arthritis, osteoporosis, or other musculoskeletal disorders. Identifying these issues can guide treatment and interventions to maintain or improve mobility and overall function M. Neurologic Neurologic: Inquiring about the neurologic system can reveal symptoms like headaches, dizziness, weakness, numbness, tingling, or changes in memory or cognition. These symptoms may indicate neurological disorders such as stroke, multiple sclerosis, or dementia. Early detection and management of these issues can help prevent further complications and improve cognitive and functional outcomes. N. Hematologic Hematologic: Assessing the hematologic system involves asking about symptoms like fatigue, weakness, easy bruising, or bleeding, which may suggest blood disorders like anemia, leukemia, or clotting issues. Identifying these issues can guide appropriate testing and treatment to maintain healthy blood function. O. Endocrine Endocrine: Evaluating the endocrine system helps identify symptoms related to hormone imbalances, such as unexplained weight changes, fatigue, temperature intolerance, or changes in skin, hair, or nails. These symptoms may indicate endocrine disorders like diabetes, thyroid disease, or adrenal issues. Early detection and management of these conditions can improve overall health and quality of life. P. Psychiatric | The Review of Systems (ROS) is an essential component of a comprehensive health assessment, as it provides a systematic evaluation of a client's overall health status by inquiring about symptoms related to various body systems. By conducting a thorough ROS, healthcare providers can identify potential health issues, guide further investigations, and develop targeted treatment plans. |
General: The general section of the ROS assesses overall health indicators, such as weight changes, fatigue, fever, and general well-being. Inquiring about these symptoms can help healthcare providers identify systemic issues or potential underlying illnesses. | |
Skin: Assessing the skin helps providers identify any skin conditions, rashes, lesions, or changes in moles that could indicate underlying health problems or skin diseases. The skin can provide valuable clues to various systemic disorders, such as autoimmune diseases, infections, or allergic reactions. Skin is the largest Organ of the body - Protection (from microorganisms, ultraviolet radiation (UVR) - Thermoregulation - Also secretion of sweat 5 senses Layers of the skin Epidermis Dermis Hypodermis - Maintenance of fluid and electrolyte balance. - Absorption, excretion, sensation, immunity, and vitamin D synthesis.
Accessory part: (Made of Keratin) - Nails - Hair - Oil Glands (Sebaceous Glands) - Maintenance of fluid and electrolyte balance. - Absorption, excretion, sensation, immunity, and vitamin D synthesis. | |
Head, Eyes, Ears, Nose, Throat (HEENT): This part of the ROS focuses on symptoms affecting the head, eyes, ears, nose, and throat. Inquiring about these areas can help identify potential issues related to vision, hearing, sinus problems, allergies, headaches, or dental health, among others Head- was separated In testing mostly eyes, ears, nose and throat are interconnected EYES: - HEALTHY EYES- Clear iris & sclera (not much eye fluids and secretions - CONJUNCTIVITIS- Sore Eyes Transmission: touching the infected eye and the contaminated hound will touch the eyes of the others. EARS - Eyes and ears: Impacted cerumen (Tutuli) - OTITIS MEDIA: or in Tagalog known as Luga - NOSE: Check if there is SINUSITIS(due to mucus) SINUSITIS: runny nose, allergic rhinitis, cold IF BACTERIAL: Malapot at hindi lumalabas (Greeny) (ALlergy) IF VIRAL: Runny nose (watery and clear) (Rhinitis) - THROAT: Check if there is: - Sore throat - Tonsillitis Note: Lesser than 7yo (<7) have ear infection (after 2 months of no treatment will result in sore throat and if worsens they will have chance of rheumatic heart disease E.g Kung may Sakit- (Sinipon-nagluluha-walang panlasa at mahina ang pandinig)
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Neck: Assessing the neck can reveal information about thyroid issues (e.g., enlargement or tenderness), lymph node swelling, or any pain or discomfort that might indicate musculoskeletal or neurological problems. - WHEN checking patient’s neck look at the: - Symmetry (Pantay ba ang neck ng patient - Presence of Bulges (Bukol) Use the following; (IPPA) I- Inspection (Visual Examination) appearance observed P- Palpation- kakapain pag may bukol (If there are bulges) use the three pad of fingers when feeling it P- Percussion- Listen to the sound of the breathing A- Auscultation- Use of Stethoscope Check: Lymph Nodes- Purifies intracellular fluid (fluids in our body will go to the lymph nodes and the dirt/wastes will be purified or filtered.
CHECK: What to look at the patient - Goiter (Can be hereditary) - Cyst (Bukol) - Tuberculosis | |
Breasts: For individuals with breast tissue, a breast assessment can help identify lumps, discharge, pain, or other abnormalities that may indicate breast-related issues, such as mastitis or breast cancer. Early detection of breast abnormalities can significantly improve treatment outcomes WHAT DO WE LOOK FOR?CHECK: - Color (CHeck if there are any discoloration(redness) of both breasts/ if the color is same) - Lumps CHeck up is two weeks before and after of menstruation - Pattern to feel a breast - TYPES OF CANCER: - BENIGN- Non-harmful - MALIGNANT- Harmful, spreads fast (cancer mostly spread fast at lung) ( They spread fast due to the transportation of the lymph nodes) | |
Respiratory: Assessing the respiratory system helps identify symptoms like cough, shortness of breath, wheezing, or chest pain, which may indicate conditions such as asthma, COPD, pneumonia, or other respiratory infections. Early detection and management of respiratory issues are essential for maintaining overall health and preventing complications. WHAT DO WE LOOK FOR?CHECK: - Tonsils- Protect our body when we eat dirty food (filtering & produce antibodies) - Trachea- Windpipe - Larynx- Airway and voice box - Pharynx- Foodway Epiglottis- Close one of the larynx and pharynx | |
Cardiovascular: Inquiring about the cardiovascular system can reveal symptoms like chest pain, palpitations, swelling, or dizziness, which may suggest cardiovascular conditions such as hypertension, heart disease, or vascular problems. Identifying these symptoms can guide further investigations and help healthcare providers develop appropriate treatment plans. WHAT DO WE LOOK FOR? CHECK: - The aneurysm HEART: - Sinoatrial Node- Pacemaker of the heart, responsible for initiating the electrical impulses that trigger each heartbeat. (Induce 60-90 per minute) Once it release stimulus it will travel to atrial ventricular (transportations; internodal trunk from internodal node it will travel to bundle leutis) It will be divided to the left and right bundle branch After that it will go to the lowest part of Electrical Conduction System: The electrical impulse generated by the SA node travels through the atria, the atrioventricular (AV) node, the bundle of His (bundle branches), and finally reaches the ventricular myocardium, causing the heart to contract and pump blood. - NEGATIVE FEEDBACK- maintains balance (Homeostasis) - Hypotension- BP goes down (Low Blood Pressure) - Baroreceptors- Heart and kidney. These are specialized receptors located in the heart, aorta, and carotid arteries that detect changes in blood pressure and send signals to the brain to adjust heart rate, blood vessel constriction/dilation, and other mechanisms to maintain normal blood pressure.
- Release of Hematopoietic - To bone marrow (creates new blood) - TO MPSTC (Multi-potential stem cell) - to 5 UPSC (To different cells) - To creation of blood (3 types0
a. Erythrocytes (Red Blood Cells): These are responsible for carrying oxygen and carbon dioxide. b. Granulocytes: This group includes neutrophils, eosinophils, and basophils, which are involved in immune defense and inflammatory responses. c. Lymphocytes: These include T cells, B cells, and natural killer cells, which are important components of the immune system. Additionally, you listed: d. Monocytes: These are large white blood cells that can differentiate into macrophages and play a role in the immune response. e. Lymphocytes (again): This repetition suggests a potential mistake, as lymphocytes were already mentioned in the third category. Pericardium- 2 types
Myocardium- The middle and the thickest layer of the heart Endocardium- Provides smooth surface of the internal environment The heart wall is composed of three layers:
The different layers of the heart wall have distinct functions:
Components of the Cardiovascular System: The cardiovascular system is made up of the following key elements:
Heart in Cardiovascular System
Arteries: Carry oxygen-rich blood away from the heart to tissues and organs. Veins: Carry oxygen-depleted blood and waste products back to the heart. Capillaries:Microscopic vessels that connect arteries and veins, allowing for the exchange of gases, nutrients, and waste products between the blood and tissues. Blood: A fluid tissue that circulates within the blood vessels and carries oxygen, nutrients, waste products, and immune cells. Function of the Cardiovascular System: The cardiovascular system operates in a continuous cycle, known as the circulation. There are two main circulatory loops: | |
Gastrointestinal: The gastrointestinal assessment focuses on symptoms related to the digestive system, including abdominal pain, nausea, vomiting, diarrhea, constipation, or changes in bowel habits. These symptoms may indicate gastrointestinal disorders like gastroesophageal reflux disease (GERD), peptic ulcer disease, inflammatory bowel disease, or colon cancer. Timely detection and management of these issues can improve overall health and quality of life. WHAT DO WE LOOK FOR? CHECK: Major Organs
Notes:
This list outlines the major organs of the digestive system in the correct order:
This sequence of organs allows for the ingestion, digestion, absorption, and elimination of food and waste products in the human body. Functions:
Note: If in extreme diet (the person doesn’t eat that much) the acid will digests the organ inside the stomach that results in ulcer. 3 Factors that produces acid
Note: Borborygmi Rhythm- The sound of the stomach/intestine The GI system is made up of several key organs: Mouth: The first point of entry for food, where mechanical and chemical digestion begins with teeth, tongue, and saliva. Pharynx: A muscular passageway that connects the mouth to the esophagus and trachea. Esophagus: A muscular tube that carries food from the pharynx to the stomach. Stomach: A muscular sac that stores and breaks down food further using gastric juices. Small intestine: The longest part of the GI system, where most nutrient absorption occurs. It consists of three parts: duodenum, jejunum, and ileum. Large intestine: The primary function of this part is to absorb water and electrolytes from the remaining waste material and form stool. It consists of the cecum, colon (ascending, transverse, descending, and sigmoid), and rectum. Anus: The final opening of the GI system, responsible for eliminating waste products from the body. Function: The GI system works in a series of steps to process food and extract nutrients: - Ingestion: Food enters the mouth, where it's chewed and broken down mechanically by teeth. Saliva, containing enzymes, begins the chemical breakdown of carbohydrates. - Deglutition (swallowing): The chewed food, now called a bolus, travels down the esophagus through muscular contractions. - Gastric storage and digestion: Food enters the stomach, where it's stored and further broken down by strong gastric juices containing enzymes and acid. - Small intestine absorption: Partially digested food moves into the small intestine, where nutrients are absorbed into the bloodstream through the villi (microscopic finger-like projections) lining the walls. The remaining waste material moves further down the intestine. - Large intestine water and electrolyte absorption: The large intestine absorbs water and electrolytes from the remaining waste material, forming stool. - Egestion (elimination of waste): Stool is eliminated from the body through the anus. Accessory Organs: | |
Urinary: Evaluating the urinary system involves asking about symptoms like changes in urination patterns, pain or burning during urination, blood in the urine, or incontinence. These symptoms can suggest conditions such as urinary tract infections, kidney stones, or bladder problems, which requires appropriate treatment and management to prevent complications. Parts:
Note: If the person is dead both the urinary and anal sphincter will open together with cardiac sphincter Components of the Urinary System: The urinary system consists of four main organs: - Kidneys: A pair of bean-shaped organs located in the lower back, on either side of the spine. The kidneys are the workhorses of the system, responsible for filtering waste products and water from the blood to produce urine. The urinary system is a network of organs and structures responsible for filtering waste products from the blood, producing urine, and eliminating it from the body. This system plays a crucial role in maintaining overall health by: - Removing waste products: The urinary system filters out excess water, salts, and toxins from the blood, preventing them from accumulating to harmful levels. - Regulating body fluids and electrolytes: The urinary system helps maintain proper balance of water, electrolytes (minerals), and other essential components in the body. - Contributing to blood pressure regulation: The kidneys, the main organs of the urinary system, play a role in regulating blood pressure by controlling blood volume and electrolyte balance. - Supporting red blood cell production: The kidneys produce a hormone called erythropoietin (EPO), which stimulates the bone marrow to produce red blood cells.
The urinary system consists of four main organs:
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WHAT DO WE LOOK FOR? CHECK: Mons pubic- where the pubic hair grows The term "genitals" refers to the external organs of the human reproductive system, both male and female. These organs are involved in sexual function, urination, and in females, childbirth. Male Genitals The male genitals include:
Male Genitals
Female Genitals The female genitals, collectively called the vulva, include:
For male clients:
For female clients:
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WHAT DO WE LOOK FOR? CHECK: The peripheral vascular system is a network of blood vessels that carries blood throughout the body, excluding the heart and lungs. It plays a crucial role in delivering oxygen, nutrients, and hormones to tissues and organs, and removing waste products from them. Components of the Peripheral Vascular System: The peripheral vascular system consists of three main types of blood vessels: Arteries: These are thick-walled, muscular vessels that carry oxygen-rich blood away from the heart to various organs and tissues. They have a narrow lumen (inner space) and high blood pressure. Arteries in Peripheral Vascular System Capillaries: These are microscopic, thin-walled vessels that connect arteries and veins. They allow for the exchange of gasses, nutrients, and waste products between the blood and the surrounding tissues. Capillaries in Peripheral Vascular System Veins: These are thin-walled, less muscular vessels that carry oxygen-depleted blood and waste products back to the heart. They have a larger lumen than arteries and lower blood pressure. Veins in Peripheral Vascular System Function of the Peripheral Vascular System: The primary function of the peripheral vascular system is to:
Importance of the Peripheral Vascular System: The peripheral vascular system is essential for maintaining overall health and well-being. Proper blood flow is crucial for the proper functioning of organs and tissues. Disruptions in the peripheral vascular system can lead to various health conditions, such as peripheral artery disease (PAD), deep vein thrombosis (DVT), and chronic wounds | |
WHAT DO WE LOOK FOR? CHECK: Muscle: For movement Bone: Form and protection The musculoskeletal system is a complex network of organs and tissues that work together to provide our body with the following crucial functions:
Components of the Musculoskeletal System: The system comprises two main components: 1. Skeletal System:
Types of bones: There are different types of bones, including long bones (arms, legs), short bones (wrist, ankle), flat bones (skull, ribs), and irregular bones (vertebrae).
2. Muscular System:
- Skeletal muscles: Voluntary muscles attached to bones that allow for conscious movement. - Smooth muscles: Involuntary muscles found in organs like the stomach and intestines, responsible for involuntary movements like digestion. - Cardiac muscle: The muscular tissue of the heart, responsible for pumping blood throughout the body.
Function of the Musculoskeletal System: The musculoskeletal system works in a coordinated manner to achieve various functions:
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WHAT DO WE LOOK FOR? CHECK: Brain:
Average person use 10-20% of the brain 80% involuntary movement Medalla: Thermoregulatory function Amygdala: Center of the love & lust The nervous system is a complex network of specialized cells called neurons that coordinate all of the body's activities. It acts as the body's communication and control center, receiving and transmitting messages throughout the body to:
Components of the Nervous System: The nervous system can be broadly divided into two main parts:
Central nervous system (CNS)
- Somatic nervous system: Controls voluntary movements of the skeletal muscles. - Autonomic nervous system: Regulates involuntary functions like heart rate, digestion, and blood pressure. It further divides into the sympathetic and parasympathetic nervous system, which have opposing effects on these functions. Peripheral nervous system (PNS) Function of the Nervous System: The nervous system operates through a complex network of communication:
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WHAT DO WE LOOK FOR? CHECK:
Here are some specific things that may be checked during the assessment:
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WHAT DO WE LOOK FOR? CHECK: Composed of glands - Secretes hormones - Located down the pancreas - Islet of Langerhans Have two types of endocrine function:
Produce 3 enzymes (tumutunaw) - Enzymes- starch - Protease- protein - Lipase- Fat
- Located under the liver - Have alpha cells- glucagon- initiates the process of glycolysis (dissolve the food eaten) and gluconeogenesis (produce sugar) - Beta Cells- Insulin- the sugar will go inside the cell to the mitochondria Through the process will become Adenosine Triphosphate (ATP) - Pituitary Glands- Have two types Anterior (Growth hormone) and posterior ( - Adrenal Gland- Located up on the kidney and produces aldosterone Example - Insulin is a hormone to manage the balance of diabetes | |
Psychiatric: Assessing the psychiatric system involves inquiring about symptoms like mood changes, anxiety, depression, or changes in thought patterns or behaviors. Identifying these symptoms can guide mental health support, treatment, and interventions to promote emotional well-being and overall mental health. | |
22. ENDORSEMENT OF DATA A. Comprehensively B. Precisely C. Concisely D. Conveys the data fluently and clearly | By endorsing data comprehensively, precisely, and concisely, healthcare providers can ensure that they have a thorough understanding of the client's health, leading to accurate diagnoses, targeted treatment plans, and optimal health outcomes. This process also supports effective communication and collaboration among healthcare team members, fostering a well-coordinated approach to client care. |
Comprehensively: Ensure that all relevant information about the client's health status, history, and concerns has been collected and documented. This allows for a thorough understanding of the client's overall health and needs, facilitating accurate diagnoses and the development of appropriate treatment plans. | |
Precisely: Guarantee that the information documented is accurate and detailed, minimizing the potential for misinterpretation or misunderstanding. Precise data allows healthcare providers to make informed decisions based on the client's unique health profile, leading to more effective treatments and interventions. | |
Concisely: Present the collected information in a clear and succinct manner, focusing on the most pertinent details. This enables healthcare providers to quickly grasp the client's health status, identify any significant issues, and prioritize care needs. | |
C. ATTITUDE · Answers questions · Shows effort to improve performance. · Work harmoniously with the clinical instructor and group mates. · Reports in clean uniform, well- groomed and neat. |
Components of the Urinary System:
Skills Performance Checklist: GORDONS 11 FUNCTIONAL HEALTH PATTERN
Encompasses all parts and function
A. KNOWLEDGE · States the objective / Purpose of the activity · Uses appropriate terms · States the steps of procedure in order. · Explains rationale of every step. | |
B. SKILLS | Ø Baseline of the data/ information of the patient Ø Aviod cross contamination/ infection Ø Be polite and introduce yourself “Hi! I am GWL, and Ill be performing your kineme” Ø Explain the plan and procedure of your patient “I would like to inform you that we are going to do the kineme” Ø For clients comfortability, make sure to tell them that we are closing some doors, curtains etc. Ø Mag Q&A na kayo |
1. Read the patient's chart |
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2. Wash hands and observe appropriate infection control procedures. | |
3. Greet and identify the client. | |
4. Introduce yourself, explain plan and procedure. | |
5. Provide privacy for the client. | |
6. Assess the environment, resources and the client's medical condition on how to systematically complete the procedure. | |
7. HEALTH PERCEPTION/HEALTH MANAGEMNET | |
a. How would you describe your usual health status? | Ø
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b. Are you satisfied with your usual health status? | --Tanggap Gives you an idea if there is something lacking/regret to the patient - Okay ba saiyo yung kalusugan na meron ka ngayun? Or may feeling of regret ka or lack on situation |
c. Tobacco use? Number of packs per day? | - If they intake of cigarette - How much packs or per stick do they intake per day/ month/ a year |
d. Alcohol use? How much and what kind? | - How much do they intake Rationale: alcohol and cigarette contains drug e.g carcinogen that cause disease/cancer - can cause problem in the liver and stomach |
e. Street drug? What and how much? | -shabu /manjuana -How much do they intake |
f. Any history of chronic disease? Describe. | ØChronic- ipangmatagalan - long-term - E.g Asthma, pneumonia, rhinitis, chronic tension |
g. Immunization History? | Ø Expect their immunization since they were kids (MMR vaccine, Hepatitis covid-19) Booster Nakatanggap ka ba ng mga immunize Ø Expectation: Childhood - hepatitis,Pulyo etc. Ø Adult - covid 19 etc. |
h. Have you sought any health care assistance in the past year? Why? | Ø - If they have / conducted a checkup in the past and present - To have an idea if the patient is concerned with their health. Coordinate the situation because maybe the patient feels about something in the past. Ano ang nararamdaman mo noon at bat ka nag pa check u |
i. Current work & how would you rate your working conditions. | Ø -ask them according to their perception if they are inducive. - Is there work hazardous - To know their working environment Perception on work or applicability Ø Poor work condition: like hazzard or prone to incedent |
j. How would you rate living condition at home | Ø - In the perception of the patient (opinion) - How can they rate their living condition ex, They are okay or they are crowded. ex, the place / position Sa palagay mo, kumusta nmn yung pamumuhay mo sa loob ng bahay niyo?? Nakaka luwag ka ba? |
k. Do you have any difficulty securing any of the following services? | Ø Rationale - To know their conditions - Some of the center in the local government is not available - the health fees are expensive - Can they afford it or not? Medical services bcs some local government like center is not always available or some private hospital is expensive Ø Subordinate - professional fee Ex. General Med |
l. Medications (over the counter & prescription) Have you followed the routine prescribed for you? | ask the client whether he/she intake medication / prescription drugs (maintenance drug's- daily intake of drug e.g hypertension & diabetes) 3 types 1. Prescription - nirereseta ng doctor over the 2. counter-nabibili sa generics 3. Herbal - prepared Ø Any maintenance of medicine Ø Prescription Drugs - highblood Ø Over the counter - vitamins Ø Health Preparation - |
m. Have you had any accidents/injuries/falls in the past? describe. | -If the patient experienced any accident -to have an Idea whether the past injury is the reason of present injury Ø Simula nung pagkabata, nagkarron ka ba ng incedente? It may contribute to the present |
n. Have you had any problems with cuts healing? | Ø Matagal gumaling ang mga sugat like: Ø Diabetic - condition where the blood is and not into circle in capillaries Maybe the patient have diabetes (the blood become thick & dense) That is why blood is having a hard time circulating throughout the body
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o. Do you exercise on a regular basis? Type & Frequency? | TO know the health status of the patient Ø Exercise or what at gaano kadalas at kahirap |
p. Do you have any suggestions or requests for improving your health? Describe. | Rationale: Patient should have active participation to their healings -Some patients have knowledge about their healing (alternative medications, what kind of action do they do to relief the pain) Ø Sa tingin mo ba may suggestion ka ab para mapabuti ang iyong kalusugan? |
q. Do you do (breast/testicular) self-examination? How often? | Ø Gaano kadalas ka nag eexam sa sarili mo. You should do it while in shower. In female: 2 weeks before/after menstruation. |
8. NUTRITIONAL - METABOLIC | Ø Diet of the patient Ø Problem in some parts like hyperthyroidism |
a. Any weight gain& gain in the last 6 months? How many? | A. Any weight gain & gain loss To check the diet of the patient (e.g intake of more calorie -They have a problem in metabolism that can cause hyperthyroidism (thyroid) Ø Nababawasa o nadgdagan ang timbang at gaano |
b. How would you describe your appetite? | Ø Your food preferences and likeness |
c. Do you have any food intolerance/restrictions? Describe. | Do they have any specific Food that is not allowed to them Intolerance - hindi na kaya kainin ·Restriction - Bawal Ø Intolerance - maarte ka lang talaga Mga bawal na pagkain or restrictions |
d. Describe an average day's food intake for you (meals/snacks)? | - from the breakfast to dinner what does the patient usually eat Ø Normal intake: Morning, Lunch, Snack, Dinner at ano ang kinakain mo sa mga yun |
e. Describe an average day's fluid intake for you. | - How many glass of water (one cup) do they intake - Average cup (240 ml) that is the standard. - To know if the patient is hydrated or dehydrated Ø Fluid intake: nakaka ilan na tubig Ø 240 mL of a cup in every water Ø Most healthy people can stay hydrated by drinking water and other fluids whenever they feel thirsty. For some people, fewer than eight glasses a day might be enough. But other people might need more. |
f. Describe food likes and dislikes. | Ø Mga araw at favorite mo. from favorite to least favorite food |
g. Would you like to gain or lose weight? | - Ask the patient - This will give you an idea about, their body perception Ø Your body perception like gusto mo ba na may mabago sa timbang na meron ka |
h. Any problems with: Nausea, vomiting, swallowing, chewing, indigestion | -signs and symptoms that have a direct impact to their metabolism factor: Ø Tuwing kumakain ka ba, may nararamdaman ka ab sa mga susunod na ito: Nausia - duwal Ø Vomit - suka Ø Swallow - lunok Ø Chewing - nguya |
i. Would you describe your usual lifestyle? | the majority of adult affects their disease through their particular lifestyle Ø Unusual lifestyle of the patient like it may be connected in majority of disease |
j. For breastfeeding mothers only: Do you have concerns about breastfeeding? Describe | For mothers only |
9. ELIMINATION PATTERN | Ø regulation, control, and removal of by-products and wastes in the body. The term usually refers to the movement of feces or urine from the body. |
a. What is your usual frequency of bowel movements? | - (1-2 average per day of bowel movements) - If 4-5-7 there is LBM. Ø Normal bowel movement is 1-2 only while 4-5 is LBM (isang kondisyon sa tiyan o sistemang panunaw kung saan ang taong apektado nito ay may sobrang lambot o kaya ay mala-likidong dumi sa tuwing magbabawas.) |
b. Character of Stool: character, color and bleeding | Character of stool: character, color and bleeding 1. consistency : hard, buoy watery, soft (related with the fart) stool exam 2. Color: Normal color is “Brown” 1. Green : Too much intake of leafy foods (vegetable) or problems in the bile (liver) 2. Black: Hemorrhage - stomach to small intestine. - some intake persulfate and its in black, it is normal 3. Bright red: problems of bleeding. in large intestine to anus 4. Gray: Blockage of Bile that is why there is no color. Bile: the one mat gives color to poop & urine Orange: The patient is taking anti- tuberculosis medication (nakakahawa) - some foods are not ingested, there is still come residue -like sinigang, mais Ø Character - consistency or watery of stool Ø Orange - most probably the stool ownwer has tubercolosis Ø How do the colon and rectum work? Ø - The colon absorbs water and salt from the remaining food matter after it goes through the small intestine (small bowel). The waste matter that’s left after going through the colon goes into the rectum, the final 6 inches (15cm) of the digestive system. It’s stored there until it passes through the anus. Ring-shaped muscles (also called sphincters) around the anus keep stool from coming out until they relax during a bowel movement |
C. History of constipation (usage of bowel movements aids)
Bile is a sticky, yellow-green digestive fluid made by the liver. Its main job is to break down fats into fatty acids so that they can be absorbed by your body through the digestive tract. Bile is stored in the gallbladder and is sometimes also called gall. | -Kayo po ba ay nahihirapan dumumi constipation - cannot poop Diarrhea: Keeps pooping - to ask if the patient have colorectal cancer or blockageØ Ask if there are difficulty in term of bowel movement like Constipation - hard na ate Ø Colorectal Cancer - known as bowel cancer, colon cancer, or rectal cancer, is the development of cancer from the colon or rectum (parts of the large intestine). Signs and symptoms may include blood in the stool, a change in bowel movements, weight loss, and fatigue. Most colorectal cancers are due to old age and lifestyle factors, with only a small number of cases due to underlying genetic disorders Ø Types of cancer in the colon and rectum - Most colorectal cancers are adenocarcinomas. a. Carcinoid tumors - start from special hormone-making cells in the intestine. b. Gastrointestinal stromal tumors (GISTs) - from nerve cells in the wall of the gastrointestinal tract. Some are benign (not cancer). These tumors are most commonly found in the stomach and small intestine. They are not commonly found in the colon or rectum. c. Lymphomas - cancers of immune system cells. They mostly start in lymph nodes, but they can also start in the colon, rectum, or other organs. Information on lymphomas of the digestive system can be found in Non-Hodgkin Lymphoma. d. Sarcomas - start in blood vessels, muscle layers, or other connective tissues in the wall of the colon and rectum. Sarcomas of the colon or rectum are rare. |
d. History of diarrhea | pee & poop 3-5 times. woly Explosive diarrhea: When pooping the Poop explodes. Ø Past like are you prone into diarrhea Ø 3x5 is considered as Diarrhea Ø Happens because of a virus that gets into your gut. Some people call it "intestinal flu" or "stomach flu." Ø To understand colorectal cancer, it helps to know about the normal structure and function of the colon and rectum: a. first section is called the ascending colon. It starts with a pouch called the cecum, where undigested food comes in from the small intestine. It continues upward on the right side of the abdomen (belly). b. second section is called the transverse colon. It goes across the body from the right to the left side. c. third section is called the descending colon because it descends (travels down) on the left side. d. fourth section is called the sigmoid colon because of its “S” shape. The sigmoid colon joins the rectum, which then connects to the anus. |
h. History of incontinence | - can never control their pee ex, sleeping and having a wet dream. -Anytime the pee goes out Level of incontinence 1. The female laughs hard they cannot maintain their pee Ø Incontinence - hindi mapigilan ang ihi like sobrang pagtawa. Most of the time, anytime sya na lumalabas Ø Incontinence is a common condition and happens because of problems with the muscles and nerves that help the bladder hold or release urine. You may leak urine when you cough or sneeze. Or you may have a sudden urge to go but can’t get to the bathroom in time. |
i. Usual voiding pattern: frequency, awareness / urge to void, amount, color, incontinence | 1. Frequency: gaano kadalas umihi
2. Color of pee of the patient
much water intake
- If a person is diabetic, the ants (hovering) will start to drink their pee, which means their pancreas is dead. Ø Gaano ka kadalas umiihi sa isang araw Ø Pinipigilan mo ba ang paglabas ng ihi mo at gaano kadami Ø |
10. ACTIVITY-EXERCISE PATTERN | Ø Examines an individual’s level of physical activity, exercise routine, and ability to engage in activities of daily living. By assessing this pattern, healthcare professionals can identify barriers to physical activity and provide recommendations to improve an individual’s overall fitness and mobility. |
a. How does the client perceive her/his own self-care activities? | - to the client's perception of what they always do to have self-care. activities (eg sleep water intake, exercise) Ø Self care act is like thinking about yourself physically such as skin care or working out like a pilate. |
b. How many pillows do you use to sleep on? | - Normally 1-2 pillows - 2-3 pillows- have a problem in the chest or lungs (water inside the lungs) they feel like drowning) - 45° of position allows maximum lung expansion Ø Normal use of a pillow is 2 only, but if more than that t you must ask this because it might be the patient has problem with the heart and lungs. |
c. Do you experience fatigue/ weakness? Describe. | fatigue: Tiredness Weakness: Panghihina/feeling weak. - The patient may have problems in the heart and lungs - They cannot do normal activities Ø Fatigue - no energy Ø Weakness - panghihina |
d. Occupation | Ø Ano trabaho mo - In relation to activities and exercises |
e. Describe your usual leisure time activities / hobbies | рurposе: To know their level of activities Ø Hours you spend to know the lvl of action and doing |
f. Any problems with concentration? Describe | - Pertaining to the ability of the mind to focus - If one is having a problem focusing there is a problem in the brain or lack of sleep.Ø If we are capable to focus on one particular aspect or attention; Hyperactivity - a state of being unusually or abnormally active |
11. SLEEP REST PATTERN | Ø Evaluates an individual’s sleep quality, sleep duration, and any disruptions to their sleep routine. It helps identify sleep disorders, insomnia, or other conditions that may affect sleep patterns. By addressing this pattern, healthcare professionals can provide strategies to improve sleep hygiene and promote better restorative sleep. |
a. Usual sleep habits? Describe. | Ø Ano mga oras o nasusunod mo sa sarili mo |
b. Problems: difficulty going to sleep? Awakening at night, early awakening? Insomnia? | Ø Problema sa quality ng tulog mo Ø 2 types of Insomnia a. Acute insomnia - short term insomnia that can last from a few days to a few weeks. b. Maintenance insomnia - difficulty staying asleep or waking up too early and having trouble getting back to sleep. ~Awakening at night: Many patients die at 3am due to sleep apnea - The body is processing a hormone (growth hormone) comes but at lights off - That is why other parts of the body are not in focus. - If a person is diabetic, they pee 3x during night - Or if a normal person wake up at night because they want to pee, it is due to the coldness or bad dreams |
c. Methods used to promote sleep: medication, warm fluids, techniques | Melatonic: natural hormone in the body the body Ø May mga bagay ka ba na ginagawa paa makatulog ka kaagad: Ø Oral - melatonin Antihistamine - pakalma or drinking warm milk Ø Tech: babasa or nagbibilang |
12. COGNITIVE-PERCEPTUAL PATTERN | Ø assesses an individual’s cognitive function, sensory perception, and ability to process information. It helps identify cognitive impairments, sensory deficits, or cognitive-behavioral issues. Ø By understanding this pattern, healthcare professionals can provide appropriate interventions or referrals to support cognitive well-being. |
a. Pain: PQRST | Ø Palliation: Helps figure out what factors cause or alleviate the pain they are experiencing. Ø Quality: Refers to the nature and intensity of the pain. Ø Region: Involves identifying where the pain is and if it spreads to other areas. Ø Severity: Asks patients to rate the intensity or severity of pain on a scale of 0 to 10. Ø Timing: Involves understanding when the pain started and if it is constant or intermittent. |
b. Perception of decision making? | Ø Will of ability to decision right away; ano sa palagay mo |
c. Knowledge level: current problems, restate current therapeutic regimen | - Is the patient knowledgeable about the disease/illness/injury they have? Ø Ano ano yung mga bagay na kaalaman sa sakit mo ganun |
13. SELF-PERCEPTION AND SELF-CONCEPT PATTERN | Ø focuses on an individual’s self-esteem, body image, and overall self- perception. It helps identify issues related to self-esteem, body dissatisfaction, or distorted self-perception. Ø By addressing this pattern, healthcare professionals can provide support and interventions to enhance an individual’s self-perception and promote positive self-esteem. |
a. What is your major concern at the current time? | - State of the mind of the patient Ø Mga iniisip mo, tulad ng mga bayarin o utang or kundisyon |
b. Do you think this admission will cause any lifestyle and result in any body changes for you? | - E.g major concern is tuberculosis Ø S palagay mo, may pagbabago ba na mangyayari dahil sa mga iniiisip mo |
c. What is your visual of yourself? | ØSelf-image |
d. Do you believe you will have any problems dealing with your current health situation? Describe. | Ø |
e. On a scale of 0-5 rank your perception of your level of control in this situation | Ø |
f. On a scale of 0-5 rank your usual assertiveness level. | Ø Assertiveness means kagustuhan Ø Ex: “I want to live” |
14. ROLE-RELATIONSHIP PATTERN | Ø examines an individual’s roles, responsibilities, and relationships with others. It helps identify issues related to role strain, role conflict, or dysfunctional relationships. By assessing this pattern, healthcare professionals can provide guidance and interventions to improve an individual’s role performance and enhance their relationships. |
a. Status of your patient. If married, rate your parenting skills. | Civil status either single married, widow or separated. Ø Civil status ganun Ø Paano mo masasabi na mabuti kang magulang gaurn |
b. Any loses: physical, psychologic, social in past year? | Ø |
c. How is the patient handling this loss at this time? | - How the patient handles his/her situation Ø How you handle grief |
d. Do you believe this admission will result in any type of loss? | Ø Major changes E.g If one family member or friend died, will they change |
e. Do you think this admission will cause changes in family role? | Ø |
f. How would you rate your usual social activities? | ØFriendship/coworkers/social life |
g. How would you rate your comfort in social situations? | Ø |
h. What activities or jobs do you like and dislike to do? Describe. | Ø Mga ayaw mo gawin ganun |
15. SEXUALITY-REPRODUCTIVE PATTERN | Ø focuses on an individual’s sexual health, reproductive function, and sexual relationships. It helps identify sexual dysfunction, reproductive issues, or concerns related to sexual health. By addressing this pattern, healthcare professionals can provide education, counseling, or referrals to support an individual’s sexual and reproductive well- being. |
a. Female: LMP, Pregnancy, Menopause? Birth Control Measures, history of vaginal discharge, bleeding, lesions, pap smear, sexually transmitted disease. | LMP: Last menstrual Period - ano ang unang araw ng regla - Nakailang pregnancy - Symptoms of menopause - Are they using birth control Ø Last menstrual period (LMP) refers to the start date of the most recent menstrual period. A typical menstrual cycle is around 21-35 days in length, with the first day of bright red menstrual bleeding signifying day 1 or the start of the cycle. Ø IE - Internal Examination - checks the health of the reproductive organs. help find the cause of symptoms such as pelvic pain, unusual vaginal bleeding or discharge, skin changes, painful sex, or urinary problems. Ø 2 Types of Contraceptive: a. Natural - calendar method, withdrawal, mucos or basal temperature of female (ovoluation) b. Artificial - condom, pills, iodine
Birth control: - Calendar control - 1 day after do not engage into sexual activities - 7 days before they can engage into sexual activities Artificial: - withdrawal (pull out) - Body temp is high when ovulating - (38 °C F) - (36°C F)- Normal Ø Sexually transmitted diseases (STDs) are caused by sexually transmitted infections (STIs). They are spread mainly by sexual contact. STIs are caused by bacteria, viruses or parasites. A sexually transmitted infection may pass from person to person in blood, semen, or vaginal and other bodily fluids. |
b. Male: prostate problems, penile discharge, bleeding, lesions, sexually transmitted disease. | Ø Men must have masturabet atleast 2 a week to prevent from prostate cancer (pamumuo ng puti sa loob) Ø Penile Discharge - dugo sa ari o nana |
c. Both: problems in sexual functioning, sexual relationship, Describe. | Male: Ø Such as Erectile Dysfunction - inability to get and keep an erection firm enough for sex.
Female: - No lubrication due to no interests on sex/lust - Ask the patient how much sex do they intake - Tuwing kailan or gaano kadalas nagtally |
d. Do you believe this admission will have any impact on sexual functioning? Describe. |
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16. COPING-STRESS TOLERANCE PATTERN | examines how individuals cope with stressors and their ability to adapt to challenging situations. It helps identify maladaptive coping mechanisms, high levels of stress, or ineffective stress management strategies. By assessing this pattern, healthcare professionals can provide support, resources, and interventions to improve an individual’s coping abilities and enhance their stress tolerance. |
a. Have you experienced any stressful or traumatic events? | Mga nakaraan |
b. How would you rate your usual handling of stress? | Paano mo nakakalma o handle |
c. What is the primary way you deal with stress or problems? | This level usually requires help from a healthcare professional that includes teaching, identifying strengths, and coping. |
d. Have you used any counseling groups in the past year? | Psychiatrist and Psychology It develops when the body’s response mechanism fails to adapt to a stressful situation with assistance. This stage requires an advanced approach by seeking the help of professionals and making unique coping strategies. |
e. What do you believe is the primary reason behind this admission? | Sa palagay mo, ito ba ang dahilan ng sakit mo ngayun? May parte mo say sa sarili mo ngayun |
f. Do you seek health assistance at the first symptom? | Sa unag simtomas, nagtaka kana ba at nanghingi na agad ng tulong like basic help |
g. Are you satisfied with the care you have been receiving? |
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17. VALUE-BELIEF PATTERN | explores an individual’s personal values, beliefs, and spiritual practices. It helps identify values conflicts, spiritual distress, or issues related to belief systems. By understanding this pattern, healthcare professionals can provide support and interventions to promote spiritual well-being and address any conflicts or distress related to personal values and beliefs. |
a. Are you satisfied with the way your life has been developing? | Tanggap mo ba ang meron ka ngayun at nag ddevelop |
b. Will this admission interfere with your plans for the future? | Mya plano ka ba para sa next step |
c. Religion? Any religious restrictions to care? | Ø Men must have masturabet atleast 2 a week to prevent from prostate cancer (pamumuo ng puti sa loob) Ø Penile Discharge - dugo sa ari o nana Ø |
d. Will this admission interfere with your spiritual or religious practices? | Ø Such as Erectral Dsyfunction - inability to get and keep an erection firm enough for sex.
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e. Have your religious beliefs helped you to deal with problems in the past? | |
C.ATTITUDE · Answers questions · Shows effort to improve performance · Work harmoniously with the clinical instructor and group mates. · Reports in clean uniform, well-groomed and neat. |
Skills Performance Checklist: ASSESSMENT OF SKIN, HAIR & NAIL
A. KNOWLEDGE · States the objective / Purpose of the activity · Uses appropriate terms · States the steps of procedure in order. · Explains rationale of every step. | |
B. SKILLS | Ø Baseline of the data/ information of the patient Ø Aviod cross contamination/ infection Ø Be polite and introduce yourself “Hi! I am GWL, and Ill be performing your kineme” Ø Explain the plan and procedure of your patient “I would like to inform you that we are going to do the kineme” Ø For clients comfortability, make sure to tell them that we are closing some doors, curtains etc.
NOTE: The IPPA Assesment a. Inspection - visual examine of part of body b. Palpation - kakapain o hahawakan c. Percussion - tunog o may nakakapa d. Ausuculation - use of instrument like BP & Stethoscope |
1. Read the patient’s chart. | |
2. Wash hands and observe appropriate infection control | |
3. Greet and identify the client and introduce yourself. | |
4. Explain the procedure and provide patient privacy. | |
5. Assess the environment, resources and the client's medical condition on how to systematically complete the procedure. | |
6. ASSESS: Inquire if client has any history of the following: a. Pain or itching | Ø “Is there any pain and itchiness around your body?” |
b. Presence and spread of any lesions, bruises, abrasions, or pigmented spots | Ø “Are there any lesion bruises, abrasions?” Ø Lession - sugat o hiwa Ø Bruises - pasa like black to violet Ø Abbravation - gasgas Ø Pigmented spots - may nangingibang kulay |
c. Skin problems | Ø “Do yo have skin problem? Such as: Atopic Dermatitis Ø Eczema |
d. Associated clinical signs and Problems in other family members | Ø “Are there any associated clinical signs and problems regarding on your prsent sitaution? |
e. Related systemic conditions |
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f. Use of medications, lotions, or home remedies | Ø “Have you use any kind of lotion or whatsoever? |
g. Excessively dry or moist feel to the skin | Ø “Do you feel that sometimes you are dry or moist of the feeling?” |
h. Tendency to bruise easily | Ø “Do you tend to actually bruise easily?” |
i. Any association of the problem to a season of the year | Ø “Are the any associated problem that connect?” |
SKIN 7. Note any distinctive color | Ø composed of two main layers: the uppermost thin layer called the epidermis made of closely packed epithelial cells, and the inner thick layer called the dermis that houses blood vessels, hair follicles, sweat glands, and nerve fibers. created by pigments, including melanin, carotene, and hemoglobin. |
8. Inspect for generalized color variations (brownness, yellow, redness, pallor, cyanosis, jaundice, erythema, vitiligo) | Ø Brownness - Normal Ø Yellow - means a jaundice (inflammatory condition of the liver is caused by infection, autoimmune disease, extreme blood loss, medications, drugs, toxins, or alcohol.) Ø Pallor - lighter than your typical complexion. It can occur due to emotions, reduced blood flow, or a low number of red blood cells. Ø Cyanosis - blue, grayish, or purple skin, lips, or nail beds. It occurs when there isn't enough oxygen in your blood. Blue tinge of cyanosis means your muscles, organs, and other tissues may not be getting the oxygen they need to operate properly Ø Erythema - apillary congestion causes the condition, and red splotches on the hands or feet are classic examples of it. (look like psoriasis) Vitiligo - occurs when cells that produce melanin die or stop functioning. |
9. Inspect uniformity of skin color. | Ø To easily know which part of the skin will be treated and to see if the skin is healthy |
10. Inspect the color and describe the all the possible findings: a. Skin b. Sclera c. Lips d. Palm & Soles | A. See any skin color abomalities B. Sclera - white of the eye (means healthy), is strong tissue that wraps around your eyeball. It helps maintain your eye’s shape and protects it from injury. A. Lips - due to other causes, such as dehydration and vitamin deficiencies. Palm & Soles - mga abnormal sa palad at talampakan mo like iba klay or rough ganurn
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11. Inspect for lesions. a. Anatomical location and distribution b. Arrangement and type of skin lesion c. Size and shape d. Color | Ø To gather essential information about potentially fatal diseases, especially among the elderly who are susceptible to skin breakdown. Moles - use the ABCDE mnemonic to watch for signs of early-stage melanoma developing in moles. Asymmetrical: The sides of the moles are not symmetrical Borders: The edges of the mole are irregular in shape Color: The color of the mole has various shades of brown or black Diameter: The mole is larger than 6 mm. (0.24 in.) Evolving: The shape of the mole has changed |
12. Palpate a. Lesions b. Texture (roughness, smoothness) of skin, using palmar surface of fingers. c. Temperature (cool, warm and hot) d. Mobility and turgor by pinching up skin. e. Edema by pressing thumbs over affected area. | a. May sugat ba mga kamay nya b. Any dryness or what normal skin feels smooth and firm, with an even surface. c. Skin should be warm and the temperature should be equal bilaterally, warmth suggests normal circulatory status. Hands and feet might be slightly cooler in a cool environment. Use dorsal part of hand to assess temperature bilaterally. d. Pinch up a large fold of skin on the interior chest (over sternum or under the clavicle) or forearm and release, inspect for ease of skin rising and time to return to place. Turgor is an excellent indicator of adequate hydration and nutrition. a. Edema - use the 3 point finger to press the ares, usually sa mga namamaga to n 1+ Mild pitting: slight indentation: no perceptible swelling of the leg n 2+ Moderate pitting: indentation subsides rapidly 3+ Deep pitting; indentation remains for a short time; legs look swollen. |
SCALP & HAIR 13. Inquire if client has any history of recent use of hair dye, curling, straightening preparations, chemotherapy or presence of disease. | Ø Made of dead, keratinized cells that originate in the hair follicle in the dermis. Hair serves a variety of functions, including protection, sensory input, thermoregulation, and communication. Ask: “For the past months, have you been using any kind of coloring, curling, kineme kineme ganurn. |
14. Inspect color and amount of distribution | Ø Color: Variable/shiny Ø Distribution : Fine villous hair coats the body, wheras, coarser terminal hairs grows at the eyebrows, eyelashes and scalp.bDuring puberty, distributionvconforms to normal male and female patterns |
15. Inspect and palpate for: a. Thickness b. Texture c. Oiliness d. Lesions e. Parasites | a. Makapal sya, sana all b. Scalp hair may be fine or thick and may look straight, curly or kinky. c. May oil unti or dry d. Presence of Scalp Lesions: No scalp lesions e. Walang kuto or lisa |
NAILS 16. Inspect for grooming and cleanliness. | Formed on the nail bed and protects the tips of our fingers and toes as they experience mechanical stress while being used. Nail edges are smooth, rounded, and clean suggesting adequate self-care. |
17. Inspect for color and markings and shape. | Ø The surface is smooth and regular, not brittle or splitting. Ø Nail thickness is uniform. The nail firmly adheres to the nail bed and the nail base is fROm to palpation. |
18. Palpate texture and consistency. | Ø Nails Shape, contour, consistency, color. Nail beds should be pink. Nails should be convex in shape, smooth and flexible, not brittle or thickening. |
19. Test for capillary refill. | a. The translucent nail plate is a window to an even, pink nail bed underneath. b. Dark skinned people may have brownblac pigmented areas to linear bands or streaks along the nail edge. c. Normally color return is an instant or at least within a few seconds ( 1-2 seconds) |
ANALYSIS OF DATA 20. Inform client findings as necessary | |
21. Wash hands | |
22. Document findings and report significant deviation from normal. | |
23. Formulate nursing diagnosis (wellness, risk, actual) | |
24. Formulate nursing interventions. | |
C.ATTITUDE · Answers questions · Shows effort to improve performance · Work harmoniously with the clinical instructor and group mates. · Reports in clean uniform, well-groomed and neat. |
Skills Performance Checklist: ASSESSMENT OF THE NECK
A. KNOWLEDGE · States the objective / Purpose of the activity · Uses appropriate terms · States the steps of procedure in order. · Explains rationale of every step. | |
B. SKILLS | |
1. Read the patient’s chart. | |
2. Wash hands and observe appropriate infection control | |
3. Greet and identify the client and introduce yourself. | |
4. Explain the procedure and provide patient privacy. | |
5. Assess the environment, resources and the client's medical condition on how to systematically complete the procedure. | |
6. Assemble equipment such as Gloves and Stethoscope. | Ø You will be doing the Palpation (kapa) Ø When using the Stet, use the Bell part of the stet ü Bell - lower frequncy sounds Diaphragm - higher frequency sounds |
7. ASSESS: inquire if the client has any history of the following: a. Neck lumps and neck pain b. Stiffness c. Any previous diagnosis of thyroid problems d. Other treatment provided. | Ø Ask the patient A. Nakakapang bukol o sakit B. Paninigas, possible sa mga sleep position nya C. Thyroid gland problem - (genetic) - Hypothyoidism - intolorerance of cold, mabagal ang tibok (Bradcardia - slow heart rate) - Hyperthyroidism - intorelance of heat, bulding of eyes (Tachycardia - increase heart rate for any reason) |
8. Inspection: Describe ALL the possible findings a. Neck muscles (sternocleidomastoid & trapezius) | Ø Kindly check any muscle
A. Two-headed neck muscle, which true to its name bears attachments to the manubrium of sternum (sterno-), the clavicle (-cleido-), and the mastoid process of the temporal bone (-mastoid). It is a long, bilateral muscle of the neck, which functions to flex the neck both laterally and anteriorly, as well as rotate the head contralaterally to the side of contraction.
Belongs to the superficial layer of the extrinsic muscles of the back, along with latissimus dorsi, rhomboid major and minor, and levator scapulae muscles. The trapezius is largely involved in movements of the shoulder girdle, and is therefore functionally considered as a muscle of the upper limb rather than of the back. |
9. While it is in a slightly extended position for : a. Position b. Symmetry c. Prescence of lumps or masses | Ø Ipa extend mo say bhe Ø Know the position Ø Sym - must be the same and levl Check if there is any bukol or mga masses |
10. Thyroid and cricoid cartilage a. Symmetry and visible masses b. Ask client to hyperextend the head & swallow. c. Observe movement of the thyroid & cricoid cartilage as client swallow. (Bulging of the gland) | Ø Hyperextend means pangatin leeg nya Ø Palunukin mo to know the movement of saliva (pag Hindi gumalaw, di normal) |
11. Cervical Vertebrae by having the client flex neck | Ø The cervical vertebrae also work to allow for maximal motion to occur. The joints of the vertebra allow for flexion, extension, and side bending. protect your spinal cord. The seven bones stacked upon one another form a bony tunnel for your spinal cord to travel through. |
12. Jugular veins : note for distention | Check if meron ibang nakakapa maliban sa ugat na part na yun like pamamaga (distention) |
13. Neck : Range of motion a. Have the client turn chin to right & left shoulder | |
b. Touch each ear to the shoulder | |
c. Touch chin to chest | |
d. Lift chin to ceiling | |
14. Palpation : Describe ALL the possible findings a. Thyroid gland (smoothness, enlargement, masses or nodules) - Observe the anterior neck slightly extended, then have the client - Palpate the anterior neck, then palpate forward from the posterior | To check if there is masses or lumps. You will be touching the adams apply |
b. Trachea (Place your finger in the sternal notch, feeling to each side) - Identify the tracheal rings, isthmus, thyroid cartilage & gland lobes as the client are swallowing. | Ø Sternal Notch - baba sa neck, na may ilalim o parang butas sa bandang adams apply Check the following and ask if there is swalowing movemnet by the saliva. |
c. Lymph Nodes (Size, shape, delimitation, mobility, consistency & tenderness) | Ø Your lymph nodes, also called lymph glands, play a vital role in your body's ability to fight off infections. They function as filters, trapping viruses, bacteria and other causes of illnesses before they can infect other parts of your body. Common areas where you might notice swollen lymph nodes include your neck, under your chin, in your armpits and in your groin.
Ø There are hundreds of lymph nodes in the body, and they are continually filtering lymph fluid and snares for foreign elements.
Your lymph nodes play an important part in your immune health. As part of the lymphatic system, they help filter out bacteria and viruses that might otherwise cause infection throughout your body. |
- Preauricular nodes ( front of ears ) | Ø Sit just in front of the ears. These tiny nodes play a vital role in protecting the body against infections and disease. |
- Postauricular nodes ( behind the ears ) | Ø An enlarged or swollen node may be seen because of its size, or it may be noticed because it is sensitive or painful. |
- Occipital nodes ( posterior base of skull
| Ø The occipital lymph nodes range from 1-10 in number and are divided into superficial and deep groups. The superficial and deep occipital lymph nodes receive lymphatic drainage from the posterior aspect of the scalp, skin of the upper neck and a portion of the deep layers of the neck which borders on the occipital region. |
- Tonsillar nodes ( angle of the mandible, on the anterior edge of the sternocleidomastoid muscle ) | Ø Lateral or tonsillar lymph node (located in the jugulodigastric area) enlargement will appear as these lumps in the neck. In this case it is not prudent to treat it like it is an infection and treat with antibiotics. |
- Submandibular nodes ( medial border of the mandible ) | These lymph nodes filter lymph from the submaxillary (salivary) gland, tongue, mouth, lips, cheek, nose and conjunctiva (the membrane that covers the eyeball and underside of the eyelid). |
- Submental nodes ( a few cm behind the tip of the mandible ) | These lymph nodes are located superficially to the mylohoid muscle. They collect lymph from the central lower lip, the floor of the mouth and the apex of the tongue. |
- Superficial cervical nodes ( superficial to the sternocleidomastoid ) | Ø Divided into the superficial anterior cervical nodes and the posterior lateral superficial cervical lymph nodes. The anterior nodes lie close to the anterior jugular vein and collect lymph from the superficial surfaces of the anterior neck. The posterior lateral nodes lie close to the external jugular vein and collect lymph from superficial surfaces of the neck. BASTA SA ILALIM NG NECK SA LIKOD NG TENGE |
- Posterior cervical nodes ( posterior to the sternocleidomastoid and anterior to the trapezius in the posterior triangle) | Ø Posterior cervical lymph nodes are a group of glands located behind the neck, or in the cervical region of the spine. As part of the immune system, the glands contain scavenging white blood cells that fight off infections. |
- Deep cervical chain nodes ( deep within and around the s.c.m. ) | Ø receive all of the lymph from the head and neck – either directly or indirectly via the superficial lymph nodes. They are organised into a vertical chain, located within close proximity to the internal jugular vein within the carotid sheath. |
- Supraclavicular nodes ( hook fingers over clavicles and feel | Ø can remain asymptomatic while metastasizing. One of the first visible spots where these tumors metastasize is one of the left supraclavicular lymph node. |
- deeply between the clavicles and the s.m.m. Muscles ) | |
15. Auscultate a. Thyroid gland for bruits if the gland is enlarged (use bell) | Ø BRUITS- an audible vascular sound associated with turbulent blood flow. Although usually heard with the stethoscope, such sounds may occasionally also be palpated as a thrill. In the head and neck, these auscultatory sounds may originate in the heart (cardiac valvular murmurs radiating to the neck), the cervical arteries (carotid artery bruits), the cervical veins (cervical venous hum), or arteriovenous (AV) connections (intracranial AV malformations). |
b. Carotid Pulses (quality, character, rhythm and strength of pulse) | Ø Listen to the pitik of your pulse in the carotid area, ganun ganun ba gets mo ba. Ø Tas yung qaulity nya if mabagal o mabilis ba May naririrnig ka ba na kakaiba ganun |
ANALYSIS OF DATA a. Inform client findings as necessary | Ø Clinical findings and inform them. Start the Nursing Diagnosis.
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b. Wash hands | |
c. Document findings and report significant deviation from normal. | |
d. Formulate nursing diagnosis (wellness, risk, actual) | |
e. Formulate nursing interventions. | |
C.ATTITUDE · Answers questions · Shows effort to improve performance · Work harmoniously with the clinical instructor and group mates. · Reports in clean uniform, well-groomed and neat. |
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Skills Performance Checklist: ASSESSMENT OF HEAD & FACE
A. KNOWLEDGE · States the objective / Purpose of the activity · Uses appropriate terms · States the steps of procedure in order. · Explains rationale of every step. | |
B. SKILLS | |
1. Read the patient’s chart. | Ø This helps usidentify significant details and abnormalities related to these organs which are of great help in providing usinformation about a person’s overall health condition. |
2. Wash hands and observe appropriate infection control | Ø Sym - Pantay ba Ø Featurs - may mga lunal sa muka Ø Move - if may involuntary na galaw |
3. Greet and identify the client and introduce yourself. | |
4. Explain the procedure and provide patient privacy. | |
5. Assess the environment, resources and the client's medical condition on how to systematically complete the procedure. | |
HEAD & FACE 6. Inspect the head for size, shape, symmetry of facial appearance. | |
7. Inspect face for symmetry, facial features, movement, expression. | |
8. Palpate the head for consistency a. Size | Ø Check the head consistency Ø Malaki ba o ganun basta |
b. Shape | |
c. Symmetry | |
d. Masses | Mga bukol sa parte ng ulo o muka |
e. Tenderness | Pag hinahawakan o pinipisil sa ibang parte ay masakit |
f. Temporal artery - Range of Motion - Tenderness - Swelling - Elasticity | |
g. Temporomandibular joint - Range of motion - Swelling - Tenderness - Crepitation: Place index finger over the front of each & ask to open mouth | Ø Dito yung buto na ginagaalw pag kumakain o gumagalaw pag may ginagawa sa bunganga. Ø Check rin if may kakaiba kang nahahawakan sa mga parte na yan. Ø Crepitation - grating or popping sounds and sensations experienced under the skin and joints |
h. History of headaches | Ø Tanungin mo kung may iba ba sayng nararamdaman lagi na mga sakit na sa ulo to identify what are the other problems |
ANALYSIS OF DATA 9. Inform client findings as necessary | Ø Clinical findings and inform them. Start the Nursing Diagnosis. |
10. Wash hands | |
11. Document findings and report significant deviation from normal. | |
12. Formulate nursing diagnosis (wellness, risk, actual) | |
13. Formulate nursing interventions. | |
C.ATTITUDE · Answers questions · Shows effort to improve performance · Work harmoniously with the clinical instructor and group mates. · Reports in clean uniform, well-groomed and neat. |
Skills Performance Checklist: ASSESSMENT OF THE EYES
A. KNOWLEDGE · States the objective / Purpose of the activity · Uses appropriate terms · States the steps of procedure in order. · Explains rationale of every step. | |
B. SKILLS | |
1. Read the patient’s chart. | |
2. Wash hands and observe appropriate infection control | |
3. Greet and identify the client and introduce yourself. | |
4. Explain the procedure and provide patient privacy. | |
5. Assess the environment, resources and the client's medical condition on how to systematically complete the procedure. | |
6. Assemble equipment such as cotton tipped applicator, examination gloves, penlight, Snellen’s chart, Millimeter ruler. | |
7. ASSESS: inquire if the client has any history of the following: a. Family history of diabetes, hypertension | Rationale: Understanding the patient's background helps identify potential risk factors for eye problems. These conditions can increase the risk of eye problems like diabetic retinopathy and glaucoma. |
b. Eye disease, injury, or surgery | Past eye issues can indicate susceptibility to future problems. ny previous eye conditions, injuries, or surgeries may have long-lasting effects on the eyes or indicate a higher risk for certain eye problems. |
c. Last visit to an ophthalmologist | Knowing the last eye exam helps determine how long it's been since a professional evaluation. |
d. Current use of eye medications | Certain medications can affect eye health. Some medications can cause side effects or interactions that may affect the eyes or vision. |
e. Use of contact lenses or eyeglasses | Understanding lens use helps assess vision and hygiene practices. Understanding the client's use of corrective lenses is important for assessing vision and potential complications related to lens use. |
f. Hygienic practices for corrective lenses | Poor hygiene practices can increase the risk of eye infections or complications related to contact lens use. |
g. Current symptoms of eye problems | Any present symptoms, such as pain, redness, or visual disturbances, may indicate an underlying eye condition that needs to be evaluated. |
Visual Acuity 8. Assess near vision by providing adequate lighting and asking the client to read from a magazine or newspaper. |
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9. Assess distance vision : Ask the client to sit or stand 6 meters (20 ft) from Snellen’s chart, cover the eye not being tested & identify the letters or characters. |
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10. Take three readings: right eye, left eye, and both eyes. |
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11. Perform functional vision tests if the client is unable to see the top line (20/200) of Snellen’s chart. |
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External Eye Structures : Inspect for the following: 12. Eyelids and lashes (width & position of palpebral fissures, ability to close eyelids, direction of eyelids in comparison with eyeballs, color, swelling, lesions or discharge). | Rationale: Checks for abnormalities in the eyelids, conjunctiva, and tear drainage system.
Examining the width, position, ability to close, direction, color, and any swelling, lesions, or discharge helps detect issues like styes, chalazia, or misdirected lashes. |
13. Position of eyeballs (alignment in sockets, protruding or sunken) |
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14. Bulbar conjunctiva and sclera (clarity, color and texture) |
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15. Palpebral conjunctive (eversion of upper eyelid is usually performed only with complaints of eye pain or sensation of something in the eye). | Eversion of the upper eyelid allows for inspection of the palpebral conjunctiva, which may reveal foreign bodies or signs of irritation or inflammation. |
16. Lacrimal apparatus over the lacrimal glands (lateral aspect of the upper eyelid) and the puncta (medial aspect of lower eyelid). |
Assessment of the lacrimal glands and puncta helps detect abnormalities such as swelling, redness, or drainage, which may indicate issues with tear production or drainage. |
17. Observe for swelling, redness or drainage. | These signs can indicate inflammation, infection, or other pathology affecting the external eye structures. |
18. Palpate the lacrimal apparatus, noting drainage from the puncta when palpating the nasolacrimal duct. | Palpation of the lacrimal apparatus helps assess for tenderness, blockages, or abnormalities in tear drainage. |
19. Inspect the cornea and lens by shining a light to determine transparency. | Rationale: Evaluates the transparency and function of these structures.
Transillumination of the cornea and lens with a light source helps assess their transparency, which is essential for normal vision. |
20. Inspect the iris and pupil for shape and color of the iris and shape of the pupil. |
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21. Test pupillary reaction to light (in a darkened room, have client focus on a distant object, shine a light obliquely into the pupil, and observe the pupil's reaction to light-normally, pupils constrict). |
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22. Test accommodation of pupils by shifting gaze from far to near. |
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Internal Eye Structure 23. Inspect the red reflex by using an ophthalmoscope to shine the light beam towards the client's pupil. | Rationale: Directly visualizes the interior of the eye using an ophthalmoscope. The red reflex provides indirect illumination of the retina, allowing for visualization of any abnormalities such as opacities or tumors. |
24. Inspect the optic disc by using the ophthalmoscope focused on the pupil and moving close to the eye (observe for shape, color, size & physiologic cup). |
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25. Inspect the retinal vessels using the above technique (observe vessels for numbers of sets, color, diameter, arteriovenous ratio & arteriovenous crossings). |
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26. Inspect retinal background for color and the presence of lesions. |
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27. Inspect the fovea and macula for lesions. |
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28. Inspect the anterior chamber for transparency. |
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Extraocular Muscle Function Tests 29. Corneal light reflex (using a penlight to observe parallel alignment to light reflection on corneas). | Rationale: Evaluates how well the eye muscles work together.
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30. Cover test (using an opaque card to cover an eye to observe for eye movement). |
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31. Position test (observing for eye movement). |
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ANALYSIS OF DATA a. Inform client findings as necessary | |
b. Wash hands | |
c. Document findings and report significant deviation from normal. | |
d. Formulate nursing diagnosis (wellness, risk, actual) | |
e. Formulate nursing interventions. | |
C.ATTITUDE · Answers questions · Shows effort to improve performance · Work harmoniously with the clinical instructor and group mates. · Reports in clean uniform, well-groomed and neat. |
Skills Performance Checklist: ASSESSMENT OF THE EARS NOSE MOUTH & THROAT
A. KNOWLEDGE · States the objective / Purpose of the activity · Uses appropriate terms · States the steps of procedure in order. · Explains rationale of every step. | |
B. SKILLS | |
1. Read the patient’s chart. | |
2. Wash hands and observe appropriate infection control | |
3. Greet and identify the client and introduce yourself. | |
4. Explain the procedure and provide patient privacy. | |
5. Assess the environment, resources and the client's medical condition on how to systematically complete the procedure. | |
6. Assemble equipment such as tuning fork, wristwatch, penlight, otoscope, gloves, tongue depressor. | |
7. ASSESS: inquire if the client has any history of the following: a. Family history of ear problems or hearing loss | Family history provides insight into genetic predispositions and potential risk factors for certain ear conditions or hearing loss. |
b. Ear disease, injury, or surgery | Past ear conditions, injuries, or surgeries can affect current ear health and function. Knowing about these issues helps the healthcare provider understand potential risk factors and tailor the examination accordingly. |
c. Hearing problems or loss | Inquiring about hearing problems or loss helps identify any existing issues that may require further evaluation or intervention. |
d. Presence of any ear problems | Knowing about any current ear problems allows the healthcare provider to address them appropriately during the examination. |
e. Medical history and signs & symptoms of ear problems. | Understanding the client's medical history and any signs or symptoms of ear problems helps guide the assessment and evaluation of ear health. |
External Ear Structures 8. Inspect the size, color, auricles (colors, symmetry of size and position), tragus, lobule (size, shape position, discoloration & lesions), External ear canal (discharges, impacted cerumen, inflammation). | Inspection of these structures assesses their appearance, symmetry, and any abnormalities such as inflammation, discharge, or lesions. |
9. Palpate the auricle & mastoid process for tenderness | Palpation helps detect tenderness or pain, which may indicate underlying inflammation or infection. |
Otoscopic Examination 10. Inspect the external auditory canal (discharge, color and consistency of cerumen, consistency & color of canal walls & nodules) | Examination of the external auditory canal assesses for any abnormalities such as discharge, inflammation, or impacted cerumen (earwax). |
11. Inspect the tympanic membrane (color, shape, consistency & landmarks) | Examination of the tympanic membrane evaluates its color, shape, landmarks, and integrity, which can provide information about middle ear health and function. |
12. Have the client to perform Valsalva maneuver, and observe the center of the tympanic membrane for a flutter. (Do not do this on the older client, as it may interfere with equilibrium and cause dizziness.) | The Valsalva maneuver assesses middle ear function by observing the movement of the tympanic membrane in response to pressure changes. However, this maneuver should be avoided in older clients due to the risk of dizziness. |
Hearing and Equilibrium Tests 13. Assess client's response to normal voice tones | This test evaluates the client's ability to hear and respond to normal conversational tones. |
14. Perform the watch tick test | This test assesses the client's ability to hear faint sounds by placing a ticking watch near each ear. |
15. Perform the Whisper test - (Have the client to place a finger on the tragus of 1 ear. Whisper a two-syllable word 1-2 feet behind the client. Repeat on the other ear.) | The Whisper test evaluates the client's ability to hear whispered speech, which assesses high-frequency hearing. |
16. Perform the Weber test - (Use a tuning fork and place the on the center of the head or forehead and ask whether the client hears the sound better in one ear or the same in both ears.) | The Weber test assesses for conductive or sensorineural hearing loss by determining whether sound is heard better in one ear or equally in both ears. |
17. Perform a Rinne test - (Use a tuning fork and place the base on the client's mastoid process. When the client no longer hears the sound, note the time interval, and move it in front of the external ear. When the client no longer hears a sound, note the time interval.) | The Rinne test compares air conduction to bone conduction to evaluate hearing loss and the integrity of the auditory system. |
18. Perform the Romberg test to evaluate the equilibrium. - (With feet together and arms at the side, close eyes for 20 seconds. Observe for swaying.) | The Romberg test assesses balance and equilibrium by observing for swaying with eyes closed, which can indicate vestibular dysfunction. |
Nose 19. Inquire client's history of : allergies, difficulty of breathing through nose, sinus infection, injuries to | Understanding these factors helps assess nasal health and potential risk factors for sinus or nasal conditions. |
nose or face, nose bleeds, any medication taken, changes in sense of smell. | Examination of the external nose assesses its appearance, symmetry, tenderness, and patency of airflow, as well as any abnormalities such as deformities, lesions, or discharges. |
20. Inspect & palpate the external nose for : a. Color | Examination of the internal nose using a nasal speculum evaluates the color, swelling, presence of exudate or bleeding, and the condition of internal structures such as the nasal septum, turbinates, and mucous membranes. |
b. Shape | |
c. Consistency | |
d. Tenderness | |
e. Patency of Air flow | |
f. Flaring or discharge from the nares | |
21. Inspect the internal nose for: | |
a. Color | |
b. Swelling | |
c. Exudate | |
d. Bleeding | |
e. Ulcers | |
f. Perforated septum | |
g. Polyps | |
h. Nasal passage way - Assess interior structures using nasal speculum - Note nasal septum for position, bleeding or perforation - Mucous membranes for hydration and color - Nasal turbinates for color and swelling | |
Sinuses 22. Inquire client’s history of: sinus problems (pain over sinuses) | |
23. Palpate the sinuses for tenderness. a. Frontal Sinuses b. Ethmoid sinuses c. Sphenoid sinuses d. Maxillary sinuses | |
Mouth 24. Inquire client’s history of: mouth problems (tongue, mouth sores, lesions, gum or mouth redness, swelling, bleeding or pain) | |
25. Family history of oral or chronic problems | |
26. Daily practice of oral care, tooth care or denture care. | |
27. Usual diet | |
28. History of smoking & alcohol, use of how much and how often. | |
29. Inspection : Describe ALL the possible findings a. Lips (color, moisture, pigmentation, masses, ulcerations and fissures) | |
b. Teeth (number, arrangement & general condition) | |
c. Gingivae (color, discharges, edema, bleeding & retraction) | 26 |
d. Buccal Mucosa (color, vesicles, ulcerations & masses) | |
e. Pharynx (inflammation, exudates and masses. | |
f. Tongue (position, color, function of the glossopharyngeal and hypoglossal nerve) | |
g. Salivary Glands (swelling and redness) | |
h. Palates (hard and soft palate for color, shape, texture, and presence of bony prominences) | |
i. Uvula (position and mobility. Ask the client to say "ah'' so that the soft palate rises) | |
j. Oropharynx (color and texture using a tongue depressor) | |
k. Conduct gag reflex response | |
Throat 30. Inspect the throat for color & consistency. | |
31. Inspect the tonsils (color, discharge and size) | |
ANALYSIS OF DATA a. Inform client findings as necessary | |
b. Wash hands | |
c. Document findings and report significant deviation from normal. | |
d. Formulate nursing diagnosis (wellness, risk, actual) | |
e. Formulate nursing interventions. | |
C.ATTITUDE · Answers questions · Shows effort to improve performance · Work harmoniously with the clinical instructor and group mates. Reports in clean uniform, well-groomed and neat. |
