1 the nursing process assessment

Fundamentals of nursing
• Basic principles & procedures, techniques, calculations etc.
• Nursing care.
• Fundamental needs of humans.
• Fundamentals of nursing care in different health settings.
• Learning the proper way of treating and dealing with patients is essential to be effective and
competitive.
• Basic nursing skills, client safety, and time management in a laboratory setting to apply the
theory learned in class to the “real world”.
• “Fundamental nursing skills and concepts gives an introduction to nursing and gives details on
nursing care, the procedure of nursing and ethical and legal aspects when it comes to nursing.
This contains communication, main symptoms and assessment of health, infection and details
on key medication for various diseases. The concluding stage includes the physiological
understanding of a range of practices needed to be a nurse”.
14/Feb/19 COMPILED BY C SETTLEY 2

Fundamentals of Nursing: HISTORY OF NURSING
•Florence Nightingale laid the foundation for professional nursing practice through her
work in the Crimea in the 1850s. She later established her own nursing school. Through
her teaching and emphasis on sanitary care of patients, the nursing field progressed.
•Nightingale was the first nurse epidemiologist.
•The Civil War (1860–1865) furthered the expansion of the nursing field. Nurses were
needed to tend to patients’ wounds, and the field began to grow as additional women
were trained.
•It was also during this time that the American Red Cross was founded.
• The American Red Cross, also known as The American National Red Cross, is a
humanitarian organization that provides emergency assistance, disaster relief, and
disaster preparedness education in the United States.

Florence Nightingale
• Between 1860 and 1900, Nightingale established
400 nursing training schools and helped improve
the conditions of hospital-based care.
•In 1956, the first Health Amendment Act gave
nurses the financial aid needed for training and
school.
• The lamp- It is an international symbol of
nursing, accompanying the most important
ceremonies. It symbolizes a lit lamp used by of
Florence Nightingale while caring for injured
soldiers during the Crimean war.

Nursing & Midwifery Council. (2015). The code:
Professional standards of practice and behaviour for
nurses and midwives.
• Practice in accordance with the NMC (2004) code of professional
conduct, performance, when caring for adult patients including
confidentially, informed consent, accountability, patient advocacy and a
safe environment.
•Demonstrating fair and anti-discriminatory behaviour, acknowledging
differences in the beliefs, spiritual and cultural practices of individuals.
•Understanding the rationale for undertaking and documenting, a
comprehensive, systematic and accurate nursing assessment of
physical, psychological, social and spiritual needs.

Nursing & Midwifery Council. (2015). The code:
Professional standards of practice and behaviour for
nurses and midwives.
•Interpreting assessment data to prioritise interventions in
evidence based plan of care.
•Discussing factors that will influence the effective working
relationships between health and social care teams.
•Demonstrating the ability to critically reflect upon practice.

Questions to Ponder…
• What is Critical Thinking?
• Reasoned thinking
• Openness to alternatives
• Ability to reflect
• A desire to seek truth
•Why is Critical Thinking Important to
Nurses?
• Nurses deal with complex situations
• Our clients are unique
• Nurses apply knowledge to provide
holistic care
• Nursing is an applied discipline
• Nursing uses knowledge from other
fields
• Nursing is fast paced

Nurses must use COMPLEX THINKING
in every aspect of their work:
• Problem solving—identifying problem and finding solution
• Decision making—choosing the best action to take to produce
desirable outcome
• Clinical reasoning—Reflective (asking yourself),
• Creative thinking about care, logical thinking.
• ETHICAL & MORAL DILEMMAS

Important concepts in nursing
• Plan of Care: over arching long term plan that includes all levels of care and all
team members (including patient).
• Care plan: disease-specific set of related problems or health concerns with
interventions completed by a specific discipline.
• Problem: a stand-alone problem for a single patient issue (nausea and
vomiting, for example).
• Goal: the defined patient outcome to be achieved during hospital stay, by
discharge, or by the end of a phase of care.
• Interventions: actions taken to maximize the prospects of achieving the goals.
• Outcome evaluation: status, at one or more points during care; response to
care.

Important concepts in nursing-
See additional notes on Blackboard for more concepts and definitions
•Infection
•Inflammation
•Clinical judgment
•Professionalism
•Leadership
•Fluids and electrolyte
balance
• Nutrition
• Elimination
• Safety
• Gas exchange
• Perfusion

1. Identify the rationale for performing a nursing assessment.
2. Differentiate between objective data and subjectivedata.
◦ Give examples of each.
3. Identify sources of observation that the nurse uses when developing
a plan of care for a client (Primary & secondary).
◦ Give examples of each source.
4. Differentiate between the terms nursing history and medical history.
5. Identify methods of organizing data for use in a nursing care plan.

What is the Nursing process? – pg. 315 VanRooyen
• Definition:
•A systematic problem-solving process that guides all nursing
actions
•Purpose:
•To help the nurse provide goal directed, client centered care.
•It allows the nurse to obtain both subjective and objective
information to determine the health care problem.
•Helps nurse to deliver holistic, patient-focused care.

1. Assessment
• The nursing process begins as soon as you enter a nurse-client
relationship.
• Nursing assessment is the systematic and continuous
collection and analysis of information about a client.
• The assessment begins with collecting data and putting the
data into an organized format.
• Prioritization of data is very important.

1. Assessment
•During the data-collection assessment phase, the nurse begins
to perceive and identify existing problems or needs.
• Existing needs often are the priority over potential needs,
which are often listed as at risk for.
• For example, the goals and needs for a client recovering from a
cerebrovascular accident (stroke) have priority over a potential
need, such as at risk for infection.
• However, the risk for infection is still a priority concern because
the client may be at risk for infection of the lungs (pneumonia),
which is a hazard of immobility.

1. Assessment: Data collection
• The best sources of information about the client are the client (Primary
source) and family (Secondary source) .
• Other members of health team (primary)
• Doctors, Physician Assistants, Nurses, Pharmacists, Dentists, Technologists
and technicians, Therapists and rehabilitation specialists, Emotional, social
and spiritual support providers, Administrative and support staff,
Community health workers, Physiotherapists, etc.
• Health records (secondary)
• Physical exam

• Lab reports (See additional documents on Blackboard for normal values
of lab reports)
• Blood cholesterol test, blood culture, blood gasses, blood glucose, blood
type, electrolyte test, full blood counts, etc.
• Data obtained can be Objective or Subjective…………

Objective Data
• Objective data include all the measurable and observable information.
• Precise, accurate measurements or clear descriptions.
• Therefore, other healthcare providers can verify objective data.
• As a nurse, you measure the client’s vital signs, height, weight, and urine volume.
•You use specific descriptions about the size and color of a wound.
•Measurements of body structure and function that involve extent, rate, rhythm,
amount, and size are usually made with instruments—such as a stethoscope or
sphygmomanometer— or are the results of laboratory tests or radiologic
diagnostic tools.

Objective Data
• The critical thinking skills that you use while collecting objective data about
the client involve asking key questions.
• What are the client’s vital signs?
• What can you directly observe?
• Have you read the physician’s history and progress notes?
• What do the other members of the healthcare team have to say about the
client?
• What do laboratory reports tell you about the client’s condition?

Vital signs- pg. 334, Van Rooyen
• Vital signs are used to measure the body's basic functions.
• These measurements are taken to help assess the general
physical health of a person, give clues to possible diseases, and
show progress toward recovery.
•The normal ranges for a person's vital signs vary with age,
weight, gender, and overall health.
•There are 4 main vital signs: body temperature, blood pressure,
pulse (heart rate), and breathing rate.

• The facilitation of the maintenance of bodily regulatory mechanisms and
functions in a patient;
• This includes taking of vital signs;
• Providing care when imbalance is occurring in vital signs;
• The facilitation of the maintenance of nutrition of a patient and
• The prevention of disease and promotion of health and family planning by
teaching to and counseling with individuals and groups of persons;
R2598 Scope of Practice

Body temperature
• The normal body temperature of a
person varies depending on gender,
recent activity, food and fluid
consumption, time of day, and, in
women, the stage of the menstrual
cycle, age, exercise, pain, illness .
• Normal body temperature can range
from 36.4°C - 37.3°C for a healthy adult.
•Distribution of body heat.
• Cellular metabolism
• Liver & muscle slightly higher temp.
• Best reflection: heart & brain.
• Body core temperature (BCT)

Body temperature: Heat balance
controlled by:
• Heat conservation. Responses that promote conservation (in
hypothalamus):
• Vasoconstriction: the narrowing of the blood vessels.
• Piloerection: involuntary erection or bristling of hairs.
• Shivering: generates heat.
• Reduced sweating: facilitates heat conservation.
• Behavioral.

Body temperature: Heat balance
controlled by:
• Heat loss. Responses that promote conservation (in hypothalamus):
• Vasodilatation: the dilatation of the blood vessels.
• Increased sweating: facilitates heat loss.
• Increased respiration: promotes heat.
• Decrease in cellular metabolism: reduces heat production.
• Behavioral.

Body temperature
• Pyrexia: raised body temperature;
fever.
• Hyperpyrexia/ Hyperthermia: when
the body’s temperature exceeds 40°C
due to failure of heat loss
mechanisms.
• Hypothermia: the condition of having
an abnormally (typically dangerously)
low body temperature (below 35°C ).
• Pathophysiology

Celsius to Fahrenheit, e.g. temp 36
Formula:
(36°C × 9/5) + 32 = 96.8°F
Fahrenheit to Celsius, e.g. temp 90
(90°F − 32) × 5/9 = 32,222°C

Body temperature: assessment tools
• electronic thermometers
• tympanic thermometers
• single use thermometers
• glass and mercury thermometers

A person's body temperature can be
taken in any of the following ways:
• Orally. Temperature can be taken by mouth using either the classic glass
thermometer, or the more modern digital thermometers that use an electronic
probe to measure body temperature.
• Rectally. Temperatures taken rectally usually is higher than normal.
• Armpit (axillary). Temperatures can be taken under the arm using a glass or
digital thermometer.
• By ear. A special thermometer can quickly measure the temperature of the
eardrum.
• By skin. A special thermometer can quickly measure the temperature of the
skin on the forehead.

Pulse
• The number of times the heart beats per minute.
• As the heart pushes blood through the arteries, the arteries expand and contract with
the flow of the blood.
• Heart rhythm
• Strength of the pulse
• The normal pulse for healthy adults ranges from 60 to 100 beats per minute.
• The pulse rate may fluctuate and increase with exercise, illness, injury, and emotions.
• Females ages 12 and older, in general, tend to have faster heart rates than do males.
• Athletes, such as runners, who do a lot of cardiovascular conditioning, may have heart
rates near 40 beats per minute and experience no problems.

Pulse
• Regularity
• Volume
• Normal
• Bounding
• when a person feels their heart
beating harder or more vigorously
than usual
• Thready
• difficult to feel or felt easily with
slight pressure.
• Absent
• Using the first and second fingertips, press
firmly but gently on the arteries until you feel a
pulse.
•Begin counting the pulse when the clock's
second hand is on the 12.
•Count your pulse for 60 seconds (or for 15
seconds and then multiply by 4 to calculate
beats per minute).
•When counting, do not watch the clock
continuously, but concentrate on the beats of
the pulse.
•If unsure about your results, ask another person
to count for you.

Arteries

Sites to assess pulse

Blood pressure
• Blood pressure is the force of the blood pushing against the artery walls during contraction and
relaxation of the heart.
•Each time the heart beats, it pumps blood into the arteries, resulting in the highest blood pressure as
the heart contracts. When the heart relaxes, the blood pressure falls.
•Two numbers are recorded when measuring blood pressure.
•The higher number, or systolic pressure, refers to the pressure inside the artery when the heart
contracts and pumps blood through the body.
•The lower number, or diastolic pressure, refers to the pressure inside the artery when the heart is at
rest and is filling with blood.
• Both the systolic and diastolic pressures are recorded as "mm Hg" (millimeters of mercury).

•

Respiration
• The respiration rate is the number of breaths a
person takes per minute.
• The rate is usually measured when a person is at
rest and simply involves counting the number of
breaths for one minute by counting how many
times the chest rises.
• Respiration rates may increase with fever, illness,
and with other medical conditions.
• When checking respiration, it is important to
also note whether a person has any trouble
breathing.
• Normal respiration rates for an adult person at
rest range from 12 to 16 breaths per minute.

Vital signs- Terminology
1.Apical-Pertaining to the apex or pointed end of the heart
2.Apical Pulse- Pulse taken with a stethoscope and near the apex of the heart
3.Apnea- Absence of respirations. Especially during sleep.

5.Axilla-Armpit, the area of the body under the arm
6.Auscultation-The act of listening for sounds within the body
7.Blood Pressure- Pressure of circulating blood against the walls of the arteries
8.Bradycardia-Slow heart rate, usually below 60 beats a minute
9.Bradypnea-Slow respiratory rate, usually below 10 respirations a minute

10.Capillary Refill-is the rate at which blood refills empty capillaries. It can be
measured by holding a hand higher than heart-level (prevents venous reflux),
pressing a fingernail until it turns white, and taking note of the time needed for
color to return once the nail is released . Normal capillary refill time is usually less
than 2 seconds.
11.Cardiac Arrest- Sudden stopping of heart action

12.Carotid Pulse- felt along the long carotid artery on either side of the neck
13.Clinical Thermometers-may be used to record temperatures
14.Constrict-To get smaller
15.Cyanosis-A dusky, bluish discoloration of the skin, lips, and/or nail beds as a
result of decreased oxygen and increased carbon dioxide in the bloodstream.
16.Diastolic Blood Pressure- The pressure remaining in the arteries during
ventricular relaxation
17.Dilate-To get larger
18.Dyspnea-Difficult or labored breathing

19.Electronic Thermometers- This type of thermometer registers the temperature
on a viewer in a few seconds.
20.Fever-Elevated body temperature.
21.Height-Is the measurement of the length of the human body, from the bottom
of the feet to the top of the head, when standing erect
22.Homeostasis-Is the ideal health state in the human body.
23.Hypertension-High blood pressure
24.Hyperthermia-Occurs when the body temperature exceeds 40 degrees.
25.Hypotension-Low blood pressure

26.Hypothermia-A low body temperature.
27.Oral temperatures- Are taken in the mouth. This is usually the most common,
convenient, and comfortable method of obtaining a temperature.
28.Palpation-Technique used to feel the texture, size, consistency, and location of
parts of the body with the hands
29.Percussion-Technique of tapping with the fingertips to evaluate size, borders,
and consistency of internal structures of the body

30.Pulse-Pressure of the blood felt against the wall of an artery as the heart
contracts or beats.
31.Pulse deficit- The difference between the rate of an apical pulse and the rate of
a radial pulse
32.Pulse pressure- The difference between systolic and diastolic blood pressure
33.Pupil-The black center of the eye
34.Radial Pulse- The pulse felt at the wrist
35.Rate- Number per minute, as with pulse and respiration counts

36.Reactivity-In the pupil of the eyes, reacting to light by changing size
37.Rectal temperatures-Are taken in the rectum and is the most accurate of all methods
38.Respiration-the process of taking in oxygen (02) and expelling carbon dioxide (CO2) from the
lungs and respiratory tract.
39.Rhythm-Referring to regularity; regular or irregular
40.Sign-An indication of a patient's condition that is objective, or can be observed by another
person; an indication that can be seen, heard, smelled or felt by the medical practitioner
41.Sphygmomanometer-instrument calibrated for measuring blood pressure in millimeters of
mercury (mm Hg)
42.Stethoscope-Instrument used for listening to internal body sounds

43.Symptom-An indication of a patient's condition that cannot be observed by
another person but rather is subjective, or felt and reported by the patient
44.Systolic Blood Pressure- The pressure created in the arteries by the blood
during ventricular contraction
45.Tachycardia-Fast, or rapid, heartbeat (usually more than 100-120 beats per
minute in an adult)
46.Tachypnea-Respiratory rate above 25 respirations per minute.
47.Temperature-The balance between heat lost an heat produced by the body
48.Thermometer-Instrument used to measure temperature

Height & Weight
• Height
• Measured in meters.
• Adults and children >2yrs must stand with their backs against a wall or
scale.
• Heels, buttocks & backs of shoulders should touch the wall.
• Movable rod is placed on top of head, parallel to floor.
• For children under 24 months, length is measured
• Child is placed on back, knees and legs flat in table and body is extended.
• Measured with tape
• Head, abdominal, chest circumference (cm)

Height measuring scale:
Adults

Measurement of head chest abdominal
circumference and crown to heel length in
children under 24 months

Weight
• To ensure you take reliable measurements using body weight scales you must:
• Zero the scales before the client steps onto them
• Ask the client to remove any ‘heavy’ items from their pockets (key’s, wallets etc)
and remove any heavy items of clothing or apparel (big jackets, shoes, woollen
jerseys etc)
• Ensure you note the clients state and time of day for testing to ensure any
subsequent tests can be taken under identical conditions (check state of
hydration, food consumed recently etc)
• When measuring weight – ask client to look straight ahead and stay still on the
scales. Wait for the needle/digital screen to settle before recording the
measurement
• BMI

•Body Mass Index (BMI) is a measurement calculated using weight
and height.
•It is used to ascertain whether an adult is within a healthy weight
range for their height
•Sometimes it is not possible to measure a person’s height and in
these cases other measurements can be used to estimate height, e.g.
forearm (ulna) length
•In situations where neither height nor weight is known, the BMI can
be estimated from MUAC (Mid Upper Arm Circumference)
Body Mass Index (BMI)

BMI Body Type Chart (WHO 1993)
BMI BODY TYPE CHART
Underweight (BMI less than 18.5)
Normal weight (BMI between 18.5 & 24.9)
Overweight (BMI > 25)
Pre-obese (BMI between 25.0 & 29.9)
Obese Class 1 (BMI 30.0 – 34.9)
Obese Class 2 (BMI 35 – 39.9
Obese Class 3 (BMI > 40)

Body Mass Index:
BMI= weight in kg ÷ (height x height)
or
BMI = weight in kg ÷ (height)²
Example: Mrs Grey weighs 90kg and her height is 1.82m. Calculate Mrs Grey’s BMI
BMI= weight in kg ÷ (height x height)
= 90 ÷ (1.82x1.82)
= 90 ÷ 3.31
= 27.19
How to calculate the BMI

CONVERT POUNDS TO KG
To get kilograms, divide by 2
then take off 1/10th of your
answer
Eg 100 pounds…
Divide by two = 50 Kg. Take off
1/10th = (50 – 5) = 45 Kg.
CONVERT INCHES
Tocm
◦ E.g. 1inch x 2.54= answer in cm
Tom
◦ Multiply by 0.0254
1 cm = 0.01 m
1 m = 100 cm
Example: convert 15 cm to m: 15 cm = 15 × 0.01 m = 0.15 m
1 m = 100 cm
1 cm = 0.01 m
Example: convert 15 m to cm: 15 m = 15 × 100 cm = 1500 cm

Exercise!!!!
A 54-year-old woman with is seen in the clinic for her initial
evaluation after a recent diagnosis of hepatitis C infection. She is
167.6 cm tall and weighs 159 pounds (72 kg). Calculate the woman’s
BMI and classify her BMI.
Answer: 25.6 Pre-obese (BMI between 25.0 & 29.9)

Exercise!!!!
Patient Weight Height BMI + Classification
Jane Doe, 33 year old
woman
76 kg
? ?
Chuck Meliis, 77 year old
male
90 kg
? ?
Phillip Oswald, 15 year old
male
56 kg
? ?

Answers:
Patient Weight Height BMI + Classification
Jane Doe, 33 year
old woman
76 kg 182 cm
= 1.82 m
22.9
Normal weight (BMI between 18.5 &
24.9)
Chuck Meliis, 77
year old male
90 kg 149 cm
= 1.49 m
40.5
Obese Class 3 (BMI > 40)
Phillip Oswald, 15
year old male
56 kg 67.0“
= 170.1 cm
= 1.701 m
19.4
Normal weight (BMI between 18.5 &
24.9)

Weight: Calculation of BMI

•Non dominant arm.
•Patient stands with arm flexed 90 degrees at elbow.
•Measuring point is half way between the lateral aspect of the
acromion process of the scapula and the tip of the olecranon
process of the ulna.
•Arm hangs loosely down during measurement
•The mid-upper arm circumference is the circumference of the
upper arm at that same midpoint, measured with a non-stretchable
tape measure
Mid Upper Arm Circumference (MUAC)

Mid Upper Arm Circumference (MUAC)
a measurement in the green zone means the child is properly nourished;
a measurement in the yellow zone means that the child is at risk of malnutrition;
a measurement in the orange zone means that the child is moderately malnourished;
a measurement in the red zone means that the child is severely malnourished.

Rapid Urine test: MACROSCOPIC
URINALYSIS
• Urinalysis can reveal diseases that have gone unnoticed
because they do not produce striking signs or symptoms.
• Examples include diabetes mellitus, various forms of
glomerulonephritis, and chronic urinary tract infections.
•The most cost-effective device used to screen urine is a paper or
plastic dipstick.
•The color change occurring on each segment of the strip is
compared to a color chart to obtain results.

URINALYSIS
• The first part of a urinalysis is direct visual observation.
• Normal, fresh urine is pale to dark yellow or amber in color and clear.
• Normal urine volume is 750 to 2000 ml/24hr.
• Cloudiness may be caused by excessive cellular material or protein in the urine or may develop from
crystallization or precipitation of salts upon standing at room temperature or in the refrigerator.
• A red or red-brown (abnormal) color could be from a food dye, eating fresh beets, a drug, or the
presence of either hemoglobin or myoglobin.
• If the sample contained many red blood cells, it would be cloudy as well as red.

URINALYSIS

Urine dipstick chemical analysis
• A dipstick is a paper strip with patches impregnated with
chemicals that undergo a color change when certain
constituents of the urine are present or in a certain
concentration.
•The strip is dipped into the urine sample, and after the
appropriate number of seconds, the color change is compared
to a standard chart to determine the findings.

Patient assessment (adult) physical examination

Approach to patient
Ensure privacy
Exposure to a minimum only when
absolutely necessary
Explain procedure to patient
Make sure patient is comfortable

Approach to patient
Continue to build on trust
established during history
taking
Talk to patient, reassure explain
steps of examination
Continue to ask questions

The physical examination
• Symptoms: the history tells the nurse what the symptoms are.
• Signs: the physical examination will reveal the signs related to
the patient’s health problems.

Techniques used during the physical
examination
Inspection Palpation

Techniques used during the physical
examination
Percussion Auscultation

Principle features of the general physical
assessment
• Patient’s name, age & gender
• Take vital signs
• Carry out systematic physical
assessment

General examination of the patient:
inspection
General appearance of the
patient – grooming/ hygiene:
yes/no
Posture & gait: upright bent

Status of special senses
Hearing (the ear)
Sight/Vision (the eye)
Smell (the nose)
Taste (the tongue)
Touch (skin)

Emotional status
• Cheerful/withdrawn
• Calm/fearful

Glasgow Coma Scale
• A patient is assessed against the criteria of the scale, and the resulting points give a patient
score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the
more widely used modified or revised scale).

Nutritional & oral status
Build & general nutritional state
state/well nourished

• Fluid intake normal/restricted
• Ability to chew/swallow

LYMPH GLANDS
1. SUBMENTAL
2. SUBMANDIBULAR
3. PAROTID
4. PREAURICULAR
5. POSTAURICULAR
6. OCCIPITAL
7. ANTERIOR CERVICAL
8. SUPRACLAVICULAR
9. POSTERIOR CERVICAL

Condition of oral cavity
◦Mucosa
◦Mouth/lips

Motor ability status
• Current mobility: ambulant/non ambulant
easy/difficult
• Movements: coordinated/ uncoordinated
• Prosthesis no/yes

Status of physical rest & comfort
• Sleep & rest pattern: good/poor
• Substances: unnecessary/required
• Pain: absent/present

Elimination status
• Bowel habits: regular/ changed
• Incontinent: faeces no/yes
• Medication needed: no/yes

Elimination status
• Stoma: no/yes
• Haemorrhoids

Elimination status
• Micturition: normal/abnormal
• Urinary output: normal/abnormal
• Incontinent: urine no/yes
• Urinary stoma

Reproductive system: male
• Urinary stream
◦continuous/broken
• Past STI: no/yes
• Current symptoms: no/yes

Reproductive system: female
• Breasts: present/absent
• Menstrual cycle: regular absent/irregular
• Contraceptive use: no/yes/method

REPRODUCTIVE SYSTEM: Female
• Pregnant: no/yes/gestation
• Past STI: no/yes
• Current symptoms STI
STI sexually transmitted infections

Self examination of the breast/ changes

Physiological status
• Respiratory status
◦chest shape

• Character of respiration
◦ regular/irregular
◦ easy some difficulty
• Cough: absent/present
• Tracheostomy: no/yes

• Circulatory status
• Perfusion adequate/poor
• Pulses: all extremities: present/ absent
◦ rhythm regular/irregular
◦ volume: strong/weak
• Extremities: warm/cold L R
• Pacemaker no/yes

• Oedema: no/yes
• Fluid balance status
• Skin turgidity normal/ loss of turgidity
hydration: adequate/ inadequate

• Skin turgidity normal/ loss of turgidity
• Hydration: adequate/ inadequate

Status of skin & appendages
• Skin integrity: intact/ broken areas/lesions/wounds

• Pressure sores: no/yes

• Scars: no/yes
• Bruises:no/yes

• Rash: no/yes

• Skin feels: warm/cold
• Skin colour: normal/abnormal

STATUS OF SKIN & APPENDAGES
• Hair –texture, parasites

• Arms/hands

• Legs/feet

Anatomical Position and Directional
Terms:
ANATOMICAL POSITION
ANATOMICAL POSITION IS PLACED FACE-
DOWN, IT IS IN THE PRONE POSITION.
110

Terms:
IF THE ANATOMICAL POSITION IS PLACED
FACE-UP, IT IS IN THE SUPINE POSITION.
111

Terms:
112
HERE ARE SOME COMMONLY USED DIRECTIONAL TERMS:
Anterior At or near the front of the body (front view)
Posterior At or near the back of the body (back view)
Midline An imaginary vertical line that divides the body equally (right down the middle)
Lateral Farther from midline (side view)
Medial Nearer to midline (side view)
Superior Toward the head/upper part of a structure (bird’s-eye view, looking down)
Inferior Away from the head/lower part of a structure (bottom view, looking up)
Superficial Close to the surface of the body
Deep Away from the surface of the body
Proximal Nearer to the origination of a structure
Distal Farther from the origination of a structure

Midline laparotomy:

Superficial injury:

Distal vs proximal injuries

Anatomical Position and Directional Terms: DirectionalTermsAppliedto theHumanBody.
Paireddirectionaltermsareshown asappliedto thehumanbody.
116

In many instances, these terms can be paired. For example, a
posterosuperior view combines the posterior and superior, giving
us a view in which we are looking down at the back of the body:

B) anterosuperior!
Remember, the anterior is the
front view and the superior is
the top view—combine the
two and you’ve got yourself a
bird’s-eye view of the front of
the body.

Body Planes: A section is a two-dimensional surface of
a three-dimensional structure that has been cut.
•The sagittal plane is the plane that divides the body or an organ
vertically into right and left sides. If this vertical plane runs directly
down the middle of the body, it is called the midsagittal or median
plane. If it divides the body into unequal right and left sides, it is
called a parasagittal plane or less commonly a longitudinal section.
•The frontal plane is the plane that divides the body or an organ into
an anterior (front) portion and a posterior (rear) portion.
•The transverse plane is the plane that divides the body or organ
horizontally into upper and lower portions.

Body Planes: A section is a two-dimensional surface of
a three-dimensional structure that has been cut.

Dorsal and Ventral Body Cavities. The ventral cavity includes the
thoracic and abdominopelvic cavities and their subdivisions. The
dorsal cavity includes the cranial and spinal cavities.

Abdominal Regions and Quadrants

Anatomical terms of motion

Subjective Data
• Subjective data consist of the client’s opinions or feelings about
what is happening.
• Only the client can tell you that he or she is afraid or has pain.
Sometimes the client communicates through body language:
gestures, facial expressions, and body posture.
• To obtain subjective data, you need sharp interviewing, listening,
and observing skills. Always be sure to consider cultural factors, such
as specific body postures and use of eye contact, the client’s beliefs
about health and illness.

Cultural differences in body language:
How much eye contact?
• In many Asian cultures, avoiding eye contact is seen as a sign of
respect.
•However, those in Latin and North America consider eye contact
important for conveying equality among individuals.
•In Ghana, if a young child looks an adult in the eye, it is considered
an act of defiance.

Cultural differences in body language:
Touch
•In America, for example, using a firm handshake is considered appropriate to greet a
stranger or another business professional.
•In France, however, it is common to kiss someone you greet on both cheeks.
•Touching children on the head is fine in North America. Yet in Asia, this is considered
highly inappropriate, as the head is considered a sacred part of the body.
• In the Middle East, the left hand is customarily used to handle bodily hygiene.
Therefore, using that hand to accept a gift or shake hands is considered extremely
rude.
•There are also a wide range of cultural viewpoints on the appropriate rules regarding
physical contact between both similar and opposite genders.

Cultural test

Subjective Data
• The following considerations are critical thinking questions to ask yourself
when obtaining subjective data about the client:
• What is the client saying about how he or she is feeling? (subjective data)
• Do the client’s words and behaviors say the same thing? (congruence)
• What does the client say is the reason for coming to the healthcare facility?
• What is working and what is not working?
• How is the client coping with the immediate environment (home, hospital, nursing home)?

EFFECTIVE COMMUNICATION IS A KEY COMPONENT IN OBTAINING SUBJECTIVE
DATA ABOUT THE CLIENT. THE NURSE MUST TAKE INTO CONSIDERATION THE
CLIENT’S BODY LANGUAGE, INCLUDING POSTURE, GESTURES, AND FACIAL
EXPRESSIONS, AS WELL AS WHAT THE CLIENT SAYS.

Methods of Data Collection
• Observation
• Interview
• Laboratory and other diagnostic tests
• Physical examination
• Accurate information
• When analyzing data, a holistic picture emerges that may include physical,
psychosocial, and socioeconomic problems, concerns, and needs.
• The nurse individualizes the data, prioritizes the information, and shares this
information with other team members. The confidentiality of this information
must be maintained at all times.
• Data must be factual, unbiased, impartial, and updated continuously.

Methods of Data Collection: Observation
•Observation is an assessment tool that relies on the use of the five
senses (sight, touch, hearing, smell, and taste).
• Visual Observation.
•Body movements, general appearance, mannerisms, facial
expressions, mode of dress, nonverbal communication, interaction
with others, use of space, skin color and appearance, and cleanliness
•Tactile Observation.
•Touch, palpation, swelling

Methods of Data Collection: Observation
• Auditory Observation.
• Auscultation of organs
•Olfactory or Gustatory Observation.
• The sense of smell identifies odors that can be specific to a client’s condition or
state of health.
• Infections, wounds, gangrene
• DKA
• Body odors, cancers
• Halitosis
• Rotten teeth

Methods of Data Collection: The interview
• Also called nursing history/ admission interview.
• When a physician obtains this information, it is called a medical
history.
• The RN assesses the data and works with the team to formulate a
nursing diagnosis and plan of care.
• Each facility has its own health forms for you to complete in partnership with the
client and the other members of the healthcare team (e.g., rehabilitation after a
hip replacement) or may be organized according to body system (e.g.,
integumentary, digestive, cardiovascular).
• The nursing progress notes are commonly referred to as the nurses’ notes.

Methods of Data Collection: The interview
•During the health interview:
•Guide interview
•Direct/indirect questions
•Plan ahead
•Effectiveness
• When gathering information:
•Open-ended questions and
closed-ended
•Consider the client’s level of
pain, comfort, exhaustion, or
physical

1. Assessment: Samples of Questions to
Ask at the Initial Client Interview

1. Assessment
• Remember, clients have the right to refuse to answer questions.
• You may need to talk with family members because some clients are
too ill or confused to respond or too young to speak for themselves.
• Even when the client can respond, family members may give you
additional information.
• Keep in mind that you must protect the confidentiality of the client,
never revealing any information previously unknown to the family
without the client’s permission.

1. Assessment: Information from the
patient:
•Biographical data: Includes name, age, birth date, spouse, support person,
children, address, phone number, occupation, financial status, insurance,
and so forth.
•Reason for coming to the healthcare facility: Addresses the primary reason,
also described as the client’s chief complaint (CC) or perception of the
illness. What does the client expect to happen in the healthcare facility?
•Recent health history: Includes symptoms of recent disease treated with
medications and/or surgery, and exposure to communicable diseases.

1. Assessment
•Important medical history: Includes family history of disease, allergies,
immunizations, medications, and use of alternative/complementary
therapies and herbal supplements.
•Psychosocial information: Addresses family relationships, employment,
living conditions, emotional stability, sexual relationships, substance use or
abuse, medications, and so forth.
•Activities of daily living (ADL): Involves how well the client is able to meet
basic needs, such as eating, drinking, bathing, dressing, and toileting. Does
the client get adequate exercise, food, rest, and sleep?

1. Assessment: Data collection (re-cap)
Methods of Data Collection: Physical examination
• To determine the general status of the patient’s health.
• Observations (vital signs, height, weight, etc)
• May be specific:
• Rectal exams
• Skin
• Eye
• Abdominal
• Renal
• Neurological

The aims of assessment:
pg. 317 in Van Rooyen & Jordan
• Determine the needs and potential needs of the person and
their family
• Gather info on which a plan of care may be based
• Document information that will provide a basis for
reassessment and evaluation
• Act as a mechanism for quality care
• Fulfil statutory obligations
• Aid the structure of nursing knowledge

Assessment may be:
• Complex
• Time consuming
• performed jointly
• Creates partnership
• Person-centred
• Holistic in nature
• Unconscious/impaired mental state
• Confidential

Holistic assessment
A holistic approach acknowledges and addresses the physiological,
psychological, sociological, developmental, spiritual and cultural needs of
the patient.
There are five main aspects of personal health: physical, emotional, social,
spiritual, and intellectual. In order to be considered "well," it is imperative
for none of these areas to be neglected.

The Waterlow scale – pg. 323

Determine the risks of the following
cases: SDL

Medical History versus Nursing History
• Medical History: Physicians diagnose and treat illness.
• Nursing History: Nurses diagnose and treat the patient’s response to a
health problem.

The environment during patient
assessment
• Quiet Environment free from interruptions or distractions and provide
privacy (private room is preferred)
•Patient is comfortable
•Room is warm and well lit
•Let patient use assistant devices (i.e., eye glasses, hearing aid, etc. ) if
needed to avoid misperception during assessment

The environment during patient
assessment
• Rationale for asking question/ assessment
• Tell patient the time frame of the interview/assessment
• Inform patient if you are to document (obtain consent if needed) and assure confidentiality
• Start with the patient’s perceived problem
• Avoid excessive note taking – sends message to patient that health history is more important than
he/she.
• Maintain eye contact and observe for nonverbal messages
• Work at the same level of your patient
• Take into consideration of ethnic or cultural background ,age, and developmental level
• Use open-ended questions to elicit patients perspective
• Attend to acute problems, such as pain, before going to detailed history
• Quality is more important than quantity of information

Follow these links and watch these
videos as listed in Subject guide:
Head To Toe Nursing Assessment:http://youtu.be/9Fxb8icOTOA
Sandhills Nursing Basic Head to Toe: http://youtu.be/iRpt7eUZM0Y
Nursing Process Dance Instructional Video:http://youtu.be/Jsrp5oahJlc
Nursing Process Part1:http://youtu.be/6SHTAWyDGqw
Nursing Process Part2:http://youtu.be/9ZYna4vI4YQ
Nursing Process Part3:http://youtu.be/E90FPLKlaLQ

Reference list
https://www.alamy.com/stock-photo-florence-nightingale-1820-1910-english-nurse-writer-and-statistician-
37970956.html
https://brilliantnurse.com/fundamentals-of-nursing/
https://dukepersonalizedhealth.org/2018/07/the-importance-of-addressing-language-barriers-in-the-us-health-
system/
UKEssays. November 2018. Reflection on Nursing Communication Scenario. [online]. Available from:
https://www.ukessays.com/essays/nursing/communication-is-a-vital-part-of-the-nurses-role-nursing-
essay.php?vref=1 [Accessed 26 January 2019]
Nursing & Midwifery Council. (2015).The code: Professional standards of practice and behaviour for nurses and
midwives. London: NMC.
https://slideplayer.com/slide/9065773/
https://www.simplypsychology.org/maslow.html
https://germannconsultinggroup.com/establishing-goals-aligning-for-best-outcomes/

Reference list
https://germannconsultinggroup.com/establishing-goals-aligning-for-best-outcomes/
https://nurseslabs.com/8-pneumonia-nursing-care-plans/2/
 https://www.scribd.com/doc/80520859/Medical-History-Vs-Nursing-History-Setting-the-Scene
 Sorrentino: Mosby's Textbook for Nursing Assistants, 8th Edition
https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=85&ContentID=P00866
https://www.78stepshealth.us/skeletal-muscle-2/body-temperatures-and-heat-transfer-in-the-body.html
http://motherchildnutrition.org/early-malnutrition-detection/detection-referral-children-with-acute-
malnutrition/screening-for-acute-malnutrition.html#Mid-upper%20Arm%20Circumference%20(MUAC)
https://www.visiblebody.com/blog/anatomy-and-physiology-anatomical-position-and-directional-terms
https://opentextbc.ca/anatomyandphysiology/chapter/1-6-anatomical-terminology/

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