2. Nurisng
Definition:-“It is the diagnosis and treatment of
human responses to actual or potential health
problems”(ANA1980)
3. It is assisting the individual, sick or well in the
performance of those activities contributing to
health or its recovery (to peaceful death) that
he will perform unaided, if he had the
necessary strength, will or knowledge and to
do this in such a way as to help him gain
independence as rapidly as possible (Virginia
Henderson 1960).
4. Concepts of health and illness
The World Health Organization defines
health as “a state of complete physical,
mental , social and spiritual well-being,
not merely the absence of disease and
infirmity
5. Models of Health and illness:-
Health models have been developed to help
describe the concepts and relationships
involved in health and illness.
6. a. Host –agent-environment model
• health is an ever-changing state
health and illness depends on interaction of
host,
agent and
environmental factors.
7. When the agent, host and environment
variables are in equilibrium, health is
maintained.
On the other hand when the balance is
disrupted, disease occurs
8. b. The Health illness continuum model
The nurse must be aware that a client may
place himself/herself at different points on the
continuum at any given time depending on
how well he/she believes himself to be
functioning for his illness
9.
10. c. High-level wellness model
functioning to one's maximum potential
while maintaining balance and purposeful
direction in the environment
This model is holistic
11. In High-level wellness model, human
beings are viewed as having five aspects
1. Each individual is functioning as a total
personality
2. Each person possess dynamic energy
3.Each person is at peace with inner and outer
worlds
4. Each person has a relationship between energy
use and self integration
5. Each person has an inner world and an outer
world
12. d. Health Belief Model
what people perceive, or believe,in relation to health
1) perceived susceptibility,
2) perceived seriousness and
3) perceived value of action
13. Health and illness dimensions
Physical dimension: genetic make up, age,
developmental level, race and sex
Emotional dimension: how the mind and
body interact to affect to body function
Eg. long term stress affects the body
systems, anxiety affects health habits
14. Intellectual dimension
encompasses cognitive abilities, educational
background and past experiences.
Environmental dimensions
Housing sanitation, climate, pollution of air,
food and water are aspects of the
environmental dimension.
15. Sociocultural dimensions
health practices are strongly influenced by a
person's economic level, life style, family
and culture.
Spiritual dimensions- spiritual and religious
beliefs and values are important
components of how a person behaves in
health and illness.
16. The development of modern
Nursing
Nightingale worked to free nursing from the bonds of
the church’
She saw nursing as a separate profession from the
church
During the Crimean war, Florence nightingale was
asked to recruit a contingent of female nurses
The Jamaica nurse Mary Grant was the first nurse
recruited to provide care to the sick and injured in the
Crimean war.
17. queen of England awarded her the Order of Merit
established the nightingale school of nursing, in 1860.
18. History of Nursing Ethiopia
illness was considered to be punishment from sins or
magic
The religious people were providing care for the sick
or injured in the monks' hospital in Debra libanos
In 1917 Sister Karin Holmer came as trained nurse to
Ethiopia
In 1908, Emperor Menelik II established the 1st
Governmental public health services,
In 1909, the first hospital Menelik II was built in
Ethiopia.
19. ministry of health, established in 1948.
The Princes Tsehai memorial Hospital 1951,
now known as Army Hospital
1939 Tsehai graduated as children's nurse
1942 Tsehai died of child birth complication
Princess Tsehai, the emperor youngest
daughter was the first graduated national
nurse from Ormand street hospital London.
20. In 1951, two school of Nursing was established:
one at the princess Tsehai memorial only for female nurses
and
the other one was in Nekemt at the Teferie Mekonnen
Hospital.
In 1954 the Gonder Health College and training center
opened and gave training to community nurses.
In 1958 fifteen (15) community nurses graduated from this
center
In 1959 the post basic training started at princess Tsehai
memorial hospital for midwifery nursing and four nurses
graduated in 1960..
21. Assessment
Assessment is the first and most critical phase of
the nursing process.
Incorrect nursing judgment arises from
inadequate data collection and may adversely
affect the remaining phases of the nursing
process: diagnosis, planning, implementation,
and evaluation.
Assessment is a key component of nursing
practice.
22. Types of assessment
1. Initial assessment
Done with in specified time after admission
To establish base line data for future comparison
2. Focused (ongoing) assessment
Detailed nursing assessment of specific problem(s) Of
the patient
3. Emergency assessment
during any physiologic and psychological crisis
ABC, Suicidal attempt on violence assessment
24. Purpose of assessment
• To identify the client’s health status, actual or
potential health problems or needs.
• To establish plans to meet the identified
needs and.
• To deliver specific nursing interventions to
meet those needs
27. Using COLDSPA mnemonic
The COLDSPA mnemonic is a
useful memory aid for exploring each
symptom of health concern
.
28. Mnemonic General Question
Character
Describe the sign or symptom
(appearance, feeling, sound, smell, or
taste)
Onset When did it begin?
Location
Where is it? Does it radiate? Does it
occur anywhere else?
Duration How long does it last? Does it recur?
Severity
How bad is it? How much does it
bother you?
Pattern What makes it better or worse?
Associated factors
What other symptoms occur with it?
How do it affect you?
29. History of Present Health Concerns
takes into account several aspects of the
health problem and asks questions to get a
detailed description of the concern.
Past Health History
These are questions to elicit data related to
the client’s past, strengths, and weaknesses
in their health history
30. Family Health History
The family history should include as many generic
relatives as the client can recall
Lifestyle and Health Practices
used to assess how the clients are managing their
lives, their awareness of health, and unhealthy living
patterns.
These are usually open-ended questions to
promote dialogue with the client.
31. Physical Assessment Guide
where we’ll start the head-to-toe assessment.
We’ll start with the general survey and
identify the patient’s chief complaint, then the
assessment of each body system.
32.
33. Gather as much information as possible by
observation first
Examine least intrusive areas first (eg.
Hands, arms)and pain full and sensitive
assessment last
Determine what parts of the exam is to be
completed before possible crying , which
may be seen in some children(heart, lungs
and abdomen)
35. observe with your eyes, ears, or nose.
skin color, location of lesions, bruises or rash,
symmetry, size of body parts and abnormal
findings, sounds, and odors.
36. During the time of inspection:
Expose the area being inspected while draping
the rest of the client
Look before touching
Use adequate lighting
Provide a warm room for examination
The use of ophthalmoscope ,speculum, x-ray
,lab tests facilitate inspection
37. Palpation using sense of touching
light palpation: press the skin about ½ inch to ¾ inch
with the pads of your fingers.
deep palpation: press the skin approximately 1½ inches
to 2 inches.
Light palpation allows you to assess for texture,
tenderness, temperature, moisture, pulsations, and
masses.
Deep palpation is performed to assess for masses and
internal organs.
38. PERCUSSION : used to elicit
tenderness or sounds
Press the distal part of the middle finger of your non
dominant hand firmly on the body part.
Keep the rest of your hand off the body surface.
Flex the wrist, but not the foreman, of your dominant
hand.
Using the middle finger of your dominant hand, tap
quickly and directly over the point where your other
middle finger contacts the patient’s skin, keeping the
fingers perpendicular.
Listen to the sounds produced
39.
40. These sounds may include:
Tympany
Resonance
Hyperressonance
Dullness
Flatness
41. Tympany sounds like a drum and is heard
over air pockets.
Resonance is a hollow sound heard over
areas where there is a solid structure and
some air (like the lungs).
Hyperressonance is a booming sound
heard over air such as in emphysema.
Dullness is heard over solid organs or
masses.
Flatness is heard over dense tissues
including muscle and bone
42. AUSCULTATION
Auscultation is usually performed following
inspection, especially with abdominal
assessment.
The abdomen should be auscultated before
percussion or palpation to prevent
production of false bowel sounds.
43. Patient assessment steps
1. General Appearance/Survey
is the first step in a head-to-toe assessment
provides clues about the overall health of
the client.
includes the overall impression of the client,
mental status exam, and vital signs.
44. Result will be: -
Well looking – if there is no relevant finding
Acutely sick looking
With signs of distress
In pain
Highly fatigue
45. 2. Chief Complaint
The 2nd and main reason why a client is seeking
medical attention.
It is the symptom or problem that is most
concerning to the patient and
is the focus of visit.
46. 3. Health History
is an excellent way to begin the assessment
process
provides a focus for the physical
examination.
47. Head-to-Toe Framework
General survey
Vital signs
Head
Hair, scalp, face
Eyes and vision
Ears and hearing
Nose
Mouth and oropharynx
52. Lower extremities
Skin and toenails
Gait and balance
Joint range of motion
Popliteal, posterior tibial, and dorsalis
pedis pulses
53. Nursing Assessments Addressing
Selected Client Situations
Situations Physical Assessment
Client complains of
abdominal pain
Inspect, auscultate, percuss,
and palpate the abdomen;
assess vital signs.
Client is admitted with
a head injury
Assess level of consciousness
using Glasgow Coma Scale*
,assess pupils for reaction to
light and accommodation;
assess vital signs
to administer a cardio
tonic drug to a client.
Assess apical pulse and
compare with baseline data
54. The client has just
had a cast applied
to the lower leg.
Assess peripheral perfusion of
toes, capillary blanch test,
pedal pulse if able, and vital
signs
The client’s fluid
intake is minimal
Assess tissue turgor, fluid
intake and output, and vital
signs
55. Glasgow coma scale
(eye response)
Response Interpretation
4 can open eyes and keep them open with
no assistance
3 only open eyes when someone tells to do
so. eyes stay closed otherwise.
2 eyes only open in response to feeling
pressure.
1 eyes don’t open for any reason
56. Verbal response
Response Meaning
5 oriented. can correctly answer questions
related to time(date), person. Place
4 confused. can answer questions, but
answers show not fully aware of what’s
happening.
3 can talk , but responses to questions don’t
make sense.
2 can’t talk and can only make sounds or
noises
1 can't speak or make sounds
57. Motor responses
Response Meaning
6
follow instructions on how and when to
move.
5
intentionally move away from something
that presses on
4 only move away from something pressing on him as
a reflex
3 flex muscles (pull inward) in response to pressure
2 extend muscles (stretch outward) in response to
pressure
1 Doesn’t move in response to pressure.
58. GCS =15 fully awake, responsive, No memory problem
GCS=<8 coma
GCS=<3 sever coma (death)
Can be stated as
A score of 15 would be “E4V5M6.” A score of 3 would be
“E1V1M1.”
59. GCS ranges for head injuries
The ranges are:
13 to 15: Mild traumatic brain injury (mTBI). Also
known as a concussion.
9 to 12: Moderate TBI.
3 to 8: Severe TBI.
60. The GCS has its limits.
such as when someone is on a ventilator
doesn’t speak the same language as their healthcare
provider.
if vision or hearing loss happened .
61. Positions for physical assesment
Position Areas Assessed Cautions
Female genitals,
rectum, and
female
reproductive
tract
May be
contraindicated for
clients who have
cardiopulmonary
problems
62. Head, neck, axillae,
anterior
thorax, lungs, breasts,
heart,
vital signs, abdomen,
extremities, peripheral
pulses
Tolerated
poorly by
clients with
cardiovascul
ar and
respiratory
problems
Head, neck, posterior
and anterior thorax,
lungs, breasts, axillae,
heart, vital signs,
upper and lower
extremities, reflexes
Older adults
and weak
clients may
require
support
64. Equipment and Supplies Used for a
Health Examination
Equipment Figure Use
Flash light viewing of the pharynx
Determine pupil reflex
Ophthalmoscope visualize the interior of
the eye
Otoscope visualize the eardrum
and external auditory
canal
Percussion
(reflex) hammer
to test reflexes
65. Tuning fork To test hearing
acuity and
vibratory sense
Cotton Tip
applicators
To obtain
specimens
Gloves To protect the
nurse
Tongue blades
(depressors)
To depress the
tongue during
assessment of the
mouth and
pharynx
67. Characterizing mass (if..)
Location—site on the body, dorsal/ventral surface
Size—length and width in centimeters
Shape—oval, round, elongated, irregular
Consistency—soft, firm, hard
Surface—smooth, nodular
Mobility—fixed, mobile
Pulsatility—present or absent
Tenderness—degree of tenderness to palpation
69. Assessment of the Integument
To perform a complete and accurate assessment, the
nurse needs to collect data about current symptoms,
the client’s past and family history, and lifestyle and
health practices
70. History of present health concern
Skin
Are you experiencing any current skin problems such as
rashes, lesions, dryness, oiliness, drainage, bruising,
swelling, or increased pigmentation?
What aggravates the problem? What relieves it?
Describe any birthmarks, tattoos, or moles, changes in
their color, size, or shape.
Have you noticed any change in your ability to feel pain,
pressure, light touch, or temperature changes?
Are you experiencing any pain, itching, tingling, or
numbness?
71. Hair and Nails
Have you had any hair loss or change in the condition of
your hair? Describe.
Have you had any change in the condition or appearance
of your nails? Describe.
72. Past health history
Describe any previous problems with skin, hair, or
nails, including any treatment or surgery and its
effectiveness.
Have you ever had any allergic skin reactions to food,
medications, plants, or other environmental
substances?
Have you had a fever, nausea, vomiting, GI, or
respiratory problems?
For female clients: Are you pregnant? Are your
menstrual periods regular?
73. Family history
Has anyone in your family had a recent illness, rash,
other skin problems, or allergy? Describe.
Has anyone in your family had skin cancer?
74. Lifestyle and health practices
Do you sunbathe? How much sun or tanning
booth exposure do you get? What type of
sun protection do you use?
In your daily activities, are you regularly
exposed to chemicals that may harm the
skin?
Do you spend long periods of time sitting or
lying in one position?
75. Have you had any exposure to extreme temperatures?
What are your daily routine for skin, hair, and nail care?
What kinds of foods do you consume in a typical day?
How much fluid do you drink each day?
Do skin problems limit any of your normal activities?
Describe any skin disorder that prevents you from
enjoying your relationships.
How much stress do you have in your life? Describe.
Do you perform a skin self-examination once a month?
76. Inspection of the skin
Inspect general skin coloration. Keep in
mind that the amount of pigment in the
skin accounts for the intensity of color as
well as hue.
Inspect for color variations. Inspect
localized parts of the body, noting any color
variation.
77. Check skin integrity. Especially carefully in
pressure point areas (e.g. sacrum, hips, elbows); if
any skin breakdown is noted use a scale to
document the degree of skin breakdown.
Inspect for lesions. Observe the skin surface to
detect abnormalities; note color, shape, and size of
lesion; if you suspect a fungus, shine a Wood’s light
(an ultraviolet light filtered through a special
glass) on the lesion.
78. Example
Pallor(whitish): inadequate circulating blood or
hemoglobin and subsequent reduction in tissue
oxygenation
Look : conjunctiva, buccal mucous membranes,
nail beds, palms of the hand, and soles of the feet
Cyanosis: (a bluish tinge) is most evident in the nail
beds, lips, and buccal mucosa -insufficient oxygen
Jaundice (a yellowish tinge): may first be evident in the
sclera of the eyes and then in the mucous membranes
and the skin
Erythema: is skin redness associated with a variety of
rashes and other conditions
79. Vitiligo: seen as patches of hypopigmented skin, is
caused by the destruction of melanocytes in the area
Albinism : is the complete or partial lack of melanin
in the skin, hair, and eyes.
alopecia : hair loss
Clubbing : is a condition in which the angle between
the nail and the nail bed is 180 degrees, or greater
Clubbing may be caused by a long-term lack of oxygen
80. Macule: Flat, unelevated change in color 1 mm to 1 cm
(0.04 to 0.4 in.) in size and circumscribed
81. Papule : Circumscribed, solid elevation of skin.
Papules are less than 1 cm (0.4 in.). Examples: warts, acne
82. Plaque : are elevated larger than 1 cm (0.4 in.).
Examples: psoriasis
83. Nodule, Tumor: Elevated, solid, hard mass that
extends deeper into the dermis than a papule
Tumors are larger than 2 cm (0.8 in.) and may have an
irregular border.
84. Pustule Vesicle or bulla filled with pus.
Examples: acne vulgaris, impetigo
85. Cyst : A 1-cm (0.4 in.) or larger, elevated
encapsulated, fluid filled or semisolid mass arising
from the subcutaneous tissue or dermis
86. Wheal A reddened, localized collection of edema
fluid; irregular in shape. Size varies.
Examples: hives, mosquito bites
87. Palpation of the skin
Palpate skin to assess texture. Use the palmar
surface of the three middle fingers to palpate
skin texture.
Palpate to assess thickness. If lesions are noted
when assessing skin thickness, put gloves on and
palpate the lesions between the thumb and
finger; observe the drainage or other
characteristics.
Palpate to assess moisture. Check under skin
folds and in unexposed areas.
88. Palpate to assess temperature. Use the dorsal
surfaces of the hands to palpate the skin.
Palpate to assess mobility and turgor. Ask the
client to lie down; using two fingers, gently pinch
the skin on the sternum or under the clavicle.
Palpate to detect edema. Use your thumbs to
press down on the skin or the feet or ankles to
check for edema.
89. Hair
Inspect the scalp and hair. Have the client
remove any hair clips, hair pins, or wigs, then
inspect the scalp and hair for general color and
condition.
Inspect and palpate for cleanliness, dryness
or oiliness, parasites, and lesions. ; wear gloves
if lesions are suspected or if hygiene is poor.
Inspect the amount and distribution of scalp,
body, axillae, and pubic hair. Look for unusual
growth elsewhere in the body.
90. Inspection of the nails
Inspect nail grooming and cleanliness. Normal
findings would be the nails should be clean and
manicured.
Inspect nail color markings. Normal findings
should be pink tones should be seen; some
longitudinal ridging is normal.
Inspect shape of nails. There is normally a 160-
degree angle between the nail base and the skin.
Editor's Notes
The Glasgow Coma Scale (GCS) is a system to “score” or measure how conscious the patient is .
Psoriasis =skin cells multiply too quickly because of overactive immune system
