Nursing Process and its Components, Diagnosis

Unit 4: Nursing Process
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Definition
An organized, systematic method of giving individualized nursing care
that focuses on identifying and treating unique responses of individuals
or groups to actual or potential alterations in health.
Alfaro
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Contd.
Nursing process is a critical thinking process that professional nurses
use to apply the best available evidence to care giving and promoting
human functions and responses to health and illness.
(American Nurses Association, 2010)
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Contd.
Nursing process is a five part systematic decision making method
focusing on identifying and treating responses of individuals or group to
actual or potential alteration of health.
NANDA (1990)
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Characteristics of Nursing Process
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Purpose of Nursing Process
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Importance of Nursing Process
• For client
• For the nurses
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Skills needed for Nursing Process
• Cognitive or intellectual skill
• Technical or manual skill
• Interpersonal skill
• Legal/ Ethical skill
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Components of nursing process
Assessment
Nursing
Diagnosis
Planning
Implementation
Evaluation
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Definition of Nursing Assessment
Assessment is the systematic collection of data to determine the
patient’s health status and to identify any actual or potential health
problems.
It is the deliberate and systematic collection, organization, validation
and documentation of data to determine the health status of the patient.
It starts with the admission of the patient and continues till the patient
is under the care of the nurse.
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Purpose of nursing assessment
• To establish baseline information on the client
• To identify the patient’s nursing problems
• To identify the health care needs such as:
 Health promotion needs
 Health risk factors
Potential/ risk health problems
Actual health problems
• To evaluate the effectiveness of nursing care provided to the patient
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Types of assessment
• Comprehensive/ full or complete health assessment
• An interval or abbreviated assessment
• A problem focused assessment
• An assessment for special populations
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Comprehensive or complete health assessment
• Thorough health history and physical examination
• Done during:
 *Admission to a health care setting
*Continuation of patient care
*When patient is stable
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An interval or abbreviated assessment
• Rapid assessment usually done
during emergency situation to
identify any life threatening
situation. (ABCI/ OPS)
 Airway
Breathing
Circulation
In (What’s gong inside the patient)
Out (What is coming out)
Pain and overall comfort level
Safety
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Problem Focused Assessment
• It addresses a particular problem or issue and may be done in response to:
Changing health status
Presentation of episodic problems such as a sore throat
Determine the progress of specific potential or actual health problem
Determine effectiveness of an intervention e.g., relief of pain by position
change and/or medication
Assumption of care by a new care provider e.g. during shift change
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An Assessment for Special Populations
Examples of special populations include obstetric examination during
pregnancy, labor and delivery, and the postpartum period, newborn
assessment, pediatric assessment, and geriatric assessment.
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Steps of assessment
Collection of
data
Organization
of data
Validation of
data
Documentation
of data
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I. Collection of data
• Process of gathering information about the patient that begins with the first client contact.
• It includes the health history physical examination results of laboratory and diagnostic
tests, and material contributed by other health personnel.
• Data must be:
Complete
Factual
Accurate
Relevant
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Types of data
Subjective: Covert data, are clear only to the person affected. It shows his or
her perception, understanding, and interpretation of what is happening.
• Example is patient’s statement: “The pain begins in my lower back and runs
down my left leg.”
• To obtain subjective data there is need of sharp interviewing, listening and
observation skills.
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Contd.
Objective: Overt data, facts that are observable and measurable. They can be seen,
heard, felt, or smelled and they are obtained by observation or physical examination
• Example: vital signs, lab reports, reports from different diagnostic procedures
• Should be and accepted if the data is:
Precise
Accurate
Clear
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Sources of data
• Primary source: Direct source of information. Patient is the primary
source. If patient is unable, minor or mentally unable then family
members or significant others are the sources of information.
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Contd.
• Secondary source: Indirect source and data is collected from other than the patient
 Patient’s family
Admission sheets
Physician’s history
Lab or diagnostic procedure’s results
Information from other care givers
Current nursing literatures
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Methods of data collection
• Observation
• Health interview
• Physical examination
• Laboratory data
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II. Data organization
• Collected data is organized systematically and scientifically so that it
becomes meaningful and can also be used by other health care professions
involved in patient care process.
• Missed data should be collected and organized again.
• Assessment models:
 By Abraham Maslow
Body system Model or Medical Model (Organization of data based on body
systems)
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III. Data Validation
• The information gathered during the assessment is “double-checked”
or verified to confirm that it is accurate and complete.
• The findings of subjective and objective data should match.
• Needed to keep data free from error, bias and misinterpretation as
possible.
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IV. Documentation of data
• To complete the assessment phase nurse must record the client’s data.
• Accurate documentation is essential to communicate patient’s information to other co workers in
order to ensure quality care and should include all data collected about the patient’s health status.
• While documenting the data nurses records subjective data in the patient’s own words.
• Eg:
 Patient said “ I am having pain in abdomen.”
Patient said “ I am having a headache since morning.”
Patient said “ I had 3 episodes of vomiting today before coming to the hospital.”
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Examples of Documenting Assessment
Subjective data
Patient said “I am
having pain in
abdomen.”
Objective data
Vital sign
T =
P =
R =
Facial Grimaces
Pain score
Type of Pain
Onset
Location
Severity
Aggravating factor
Alleviating factor
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Contd.
Subjective data
Patient said “I am having
headache since morning
.”
Objective data
Vital sign
T =
P =
R =
Facial Grimaces
Pain score
Type of Pain
Onset
Location
Severity
Aggravating factor
Alleviating factor
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Contd.
Subjective data
Patient said “I had 3
episodes of
vomiting today
before coming to
the hospital .”
Objective data
Vital sign
T =
P =
R =
Intake =
Output =
Type of contents =
Color of contents =
Consistency of contents =
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Nursing Diagnosis
• A diagnosis is a clinical judgment about the client’s response to actual
or potential health conditions or needs.
• “A clinical judgement concerning a human response to health
conditions/ life processes, or a vulnerability for that response, by an
individual, family, group, or community.”
- NANDA
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Purposes of the Nursing Diagnosis
• Identify nursing priorities.
• Provides a basis for evaluation to determine nursing care.
• Promotes use of standardize language process.
• Organized decision making.
• Promote accountability.
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Types of nursing diagnosis
1. Actual diagnosis
• It is client problem, that is present at the time nursing assessment.
• It is clinically validated by the presence major defining characteristics.
• It is based on the presence of associated sign and symptoms.
E.g. Ineffective airway clearance related to copious trachea bronchial
secretions as evidenced by cough, shortness of breaths.
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Contd.
2. Risk nursing diagnosis
• It is a clinical judgment that a problem doesn’t exist, but the presence of risk
factors indicate that the problem is likely to develop unless nurses
intervenes.
• E.g. High risk for infection related to surgical incision.
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Contd.
3. Wellness Nursing diagnosis
• This type of diagnosis describes human responses to levels of wellness in an
individual, family or community that have a readiness for enhancement.
• It is a used when the client wishes to or has achieved optimal level of health.
• E.g Readiness for enhanced spiritual well being.
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Contd.
4. Possible nursing diagnosis
• Suspected problem for which current and available data are insufficient to
validate the problems.
• E.g Evidence about the health problem is unclear or incomplete.
• Additional data may be needed to support it.
• E.g. fluid volume deficit a
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Contd.
5. Syndrome diagnosis
• The diagnosis associate with cluster of other diagnosis is the syndrome
diagnosis.
• Is useful and efficient way to describe a complex problem without
documenting each component of the problem as a distinct nursing diagnosis.
• E.g. risk for disuse syndrome(many physical problems), rape trauma syndrome
etc.
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Formulating nursing diagnosis according NANDA
Problem-focused nursing diagnoses have three components: (1) nursing diagnosis, (2)
related factors, and (3) defining characteristics. Examples of actual nursing diagnoses
are:
• Ineffective Breathing Pattern related to pain as evidenced by pursed-lip breathing, reports
of pain during inhalation, use of accessory muscles to breathe.
• Anxiety related to stress as evidenced by increased tension, apprehension, and expression
of concern regarding upcoming surgery.
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Contd..
• Acute Pain related to decreased myocardial flow as evidenced by
grimacing, expression of pain, guarding behavior.
• Impaired Skin Integrity related to pressure over bony prominence
as evidenced by pain, bleeding, redness, wound drainage.
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Full form of NANDA
• N =North
• A =American
• N =Nursing
• D =Diagnosis
• A =Association
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Difference between nursing and medical diagnosis
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Planning
• It is the third step in nursing process.
• It refers to formulating and documenting measurable, realistic and
client-focused goals.
• Planning is a category of nursing behaviors in which client centered
goals and expected outcomes are established and nursing interventions
are selected.
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Purpose of planning
• To promote client participation.
• To plan care that is realistic and measurable.
• To evaluate the effects of nursing care as a part of health care.
• To determine the goals or care and the course of actions to be undertaken
during the implementation phase.
• To promote continuity of care.
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Setting priorities
• Nursing diagnosis are ranked in order of importance.
• Survival needs or imminent life threatening situations takes the highest
priority.
• For example, the needs for air, water and food are survival needs.
• Nursing diagnostic categories that reflect these high priorities needs
include: ineffective airway clearance and deficient fluid volume.
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Writing Nursing goals
• Write in terms of client behavior.
• Make sure that the goal statement clearly relates to the nursing
diagnosis and the outcome criteria relate to the goal.
• Goals and outcome criteria should be compatible with the work and
therapies of other professionals.
• Use observable, measurable terms avoid words that are vague.
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Nursing goals may be short term or long term
1.Short term goal:
Goals are expected to be achieved within few hours or days, usually less than a
week. E.g Client will achieve comfort with in 24 hours post operatively
2. Long term goal:
Long term goals are goal which are likely to take over weeks or months to
achieve. E.g. Client will adhere to post operative activity restrictions for one
month.
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Example
• Short term goal: Client will raise right arm to shoulder height by
Friday.
• Long term goal: Client will regain full use of right arm in 6 weeks.
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Examples of Action Verbs
Apply Help Select
Assist Identify Share
Breath Choose Compare
Define Demonstrate Describe
Discuss Explain Give
Inject Sleep List
State Move Talk
Name Prepare Turn
Provide Verbalize Report
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Types of Planning
• Initial planning
• Ongoing planning
• Discharge planning
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Implementation
Implementation is the fourth step of nursing process in which the care
is given according to the plan.
Its aims is to achieve the stated goal.
To achieve this outcome, one should select nursing implementation such
as
• Offering fluids frequently
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Contd.
• Positioning frequently
• Teaching deep breathing exercise
• Monitoring vitals signs
• Administering oxygen etc..
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Process of implementation
1. Assessing or reassessing
2. Determining the nurses need
3. Implementing nursing intervention
4. Supervising the delegated care
5. Documenting nursing activities.
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Implementing activities
• To implement nursing care, the nurse performs following activities: such as
- Communication
- Caring
- Teaching
- Counseling
- Managing
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Evaluation
• It is the final step of the nursing process.
• It is the process of comparison of client behavior and/or response to the
established outcome criteria.
• In this step, nurses examines if nursing interventions are working and
determines whether nursing interventions are terminated or must be
reviewed or changed and determines changes needed to help client reach
stated goals.
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Purposes of Evaluation
• To appraise the extent to which goals and outcome criteria of nursing
care have been achieved.
• To analyze patient’s response to nursing care, utilizing the results of
evaluation of nursing care.
• To analyze if goals have been met, is in progress toward reaching
goals of care, no progress is being made toward reaching goal of care.
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Practice Question 1
A patient had hip surgery 16 hours ago. During the previous shift the patient had 40
mL of drainage in the surgical drainage collection device for an 8-hour period. The
nurse refers to the written plan of care, noting that the health care provider is to be
notified when drainage in the device exceeds 100 mL for the day. On entering the
room, the nurse looks at the device and carefully notes the amount of drainage
currently in it. This is an example of:
• 1. Planning.
• 2. Evaluation.
• 3. Intervention.
• 4. Diagnosis. Nabina Paneru

Practice Question 2
A 67-year-old patient will be discharged from the hospital in the
morning. The health care provider has ordered three new medications for
her. Place the following steps of the nursing process in the correct order.
____ 1. The nurse returns to the patient’s room and asks her to describe
the medicines she will be taking at home.
____ 2. The nurse talks with the patient and family about who will be
available if the patient has difficulty taking medicines and considers
consulting with the health care provider about a home health visit.
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____ 3. The nurse asks the patient if she is in pain, feels tired, and is
willing to spend the next few minutes learning about her new medicines.
____ 4. The nurse brings the containers of medicines and information
leaflets to the bedside and discusses each medication with her.
____ 5. The nurse considers what she learns from the patient and
identifies the patient’s nursing diagnosis.
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History taking
• It is the process by which information is gained by asking specific
questions to the patient with the aim of obtaining information useful in
formulating a diagnosis and providing nursing care to the patient.
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History Taking
Is carried out under the following headings:
• Personal bio data: Includes name, age, sex, address, I.P no, diagnosis, date
of admission, education, occupation, economic status, marital status,
religion, nationality, language spoken etc.
• Informant: Name, age, education, occupation, relationship with the patient
and duration of relationship
• Source of referral
• Reason for coming at this particular period (Provisional Diagnosis)
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Contd.
• Presenting Complaints (with duration) Chronological order
 According to patients
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Contd.
• History of Present Illness (HOPI) (Pnemonic: OLD- CARTS)
 Onset
Location
Duration
Character
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* Mode of onset and duration gives clues to the cause and its
implications on prognosis
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Contd.
 Aggravating factors
Relieving factors
Timing (Mode of onset): sudden (within 48 hours), abrupt (more than
48 hours but within 2 weeks)/ acute (1-2wks)/ subacute (more than 2
wks)/ insidious (more than 4 wks)
Severity (Mild, moderate and severe)
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History Taking contd.
• Past Medical and Surgical History
Hospitalization (should mention when, where, and why)
History of medical illness e.g. TB, DM, HTN, Neurological illness or
surgical history
• Allergic history
• Menstrual and obstetric history
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Contd.
Menstruation: Regular/Irregular/Dysmenorrhoea, heavy, light
bleeding
Obstetric: (if married: no of children, number of miscarriages,
amenorrhoea, last menstrual period)
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Contd.
• Family History
 Family Tree
 Types of family (joint/ nuclear/ extended)
 Family Health History: History of hereditary disease like HTN, DM,
Asthma
Socio economic
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Index of Family Tree
: Death
: Female
: Male
: Patient
: Sex unknown
: Indicates Consanguinity
: Monozygotic twins
: Dizygotic twins
: Child adopted out of family
: Child adopted in to the family
: Separation/Divorce
: Present Patient
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Contd.
• Personal History
(Brief and comprehensive information of the patient right from the
prenatal period onwards)
 Birth: Type of birth, any complications during pregnancy, birth
weight, any complications during birth
Developmental milestones: motor, psychosocial, immunization etc
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Personal History contd.
 Habit of substance abuse
Smoking and alcohol intake(if yes should mention how many or how much
per day)
Dietary pattern: Veg/Non veg or special diet
Sleep and rest patterns
Elimination habit: Number of bowel movement per day, frequency of
micturation
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Personal History contd.
 Recreational activities and hobbies
Self care activities
 Psychological history
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Contd.
• Environmental History: Method of waste disposal, sanitation
• Cultural beliefs and health practices
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Contd.
• Physical Examination
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Physical Examination
• The physical examination or physical assessment is a systematic data
collection method that uses observation (i.e., the senses of sight,
hearing, smell, and touch) to detect health problems.
• It involves collecting objective data using the techniques of inspection,
palpation, percussion, and auscultation as appropriate.
• It provides the foundation for the nursing care plan.
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Contd.
• Approach used: Cephalocaudal or head-to-toe approach or body system
approach
• Cephalocaudal approach begins the examination at the head; progresses to
the neck, thorax, abdomen, and extremities; and ends at the toes.
• Body systems approach involves investigation of each system individually,
that is, the respiratory system, the circulatory system, the nervous system,
and so on.
• In case of infant, examination of heart and lung function should be done
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Contd.
• A physical examination can be any of three types:
(1) a complete assessment (e.g., when a client is admitted to a health
care agency),
(2) examination of a body system (e.g., the cardiovascular system), or
(3) examination of a body area (e.g., the lungs, when difficulty with
breathing is observed).
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Purposes
• To obtain baseline data about the client’s functional abilities.
• To supplement, confirm, or refute data obtained in the nursing history.
• To obtain data that will help establish nursing diagnoses and plans of care.
• To evaluate the physiological outcomes of health care and thus the progress
of a client’s health problem.
• To make clinical judgments about a client’s health status.
• To identify areas for health promotion and disease prevention.
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Techniques of Physical Examination
• Inspection
• Palpation
• Percussion
• Auscultation
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Inspection
• Use of the senses of vision, smell and hearing to observe the normal
condition or any deviations from normal of various body parts.
• Types:
Direct
Indirect
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Palpation
• Examination of the body parts using the sense of touch.
• Palpation is used to determine (a) texture (e.g., of the hair); (b)
temperature (e.g., of a skin area); (c) vibration (e.g., of a joint); (d)
position, size, consistency, and mobility of organs or masses; (e)
distention (e.g., of the urinary bladder); (f) pulsation; and (g)
tenderness or pain.
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Parts of hand used
• Texture: use fingertips (roughness, smoothness)
• Temperature: use back of hand (warm, hot, cold)
• Moisture: (dry, wet or moist)
• Organ location and size
• Consistency of structure (solid, fluid filled)
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Percussion
• It is striking the body’s surface with a finger to produce sound and
vibration that determine the location, size and density of underlying
structures to verify abnormalities assessed by palpation and
auscultation.
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Types of Percussion
• Direct percussion
• Indirect percussion
• Direct fist percussion
• Indirect fist percussion
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Characteristics of sounds
• Pitch (frequency or number of oscillations generated per second by
vibrating objects)
• Loudness
• Quality
• Duration
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Types of sounds heard
• Flatness (extremely dull sound produced by very dense tissues such as
muscle or bone)
• Dullness (Sound produced by dense tissues such as liver, spleen or heart)
• Resonance (Hollow sound produced by area filled with air, eg normal
lungs)
• Tympany (musical or drum like sound produced from air filled abdomen)
• Hyper – resonance (Not produced in normal body, can be heard over
emphysematous lungs)
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Percussion Sounds
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Auscultation
• It is the process of listening to sounds produced within the body.
• Can be direct or indirect
 Direct auscultation is done by the use of the unaided ear.
Indirect auscultation is done by the use of stethoscope, which
amplifies the sounds and conveys them to the nurse’s ear.
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Contd.
• Auscultation is done to :
 Listen body sounds
Identify movement of air (lungs)
Determine blood flow (heart)
Assess fluid & gas movement (bowels)
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Contd.
• Best performed in a quiet environment
• Note:
Intensity
Pitch
Duration
Quality
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Stethoscope
• Used to evaluate sounds created by cardiovascular, respiratory, and
gastrointestinal systems
• Position stethoscope between index and middle fingers.
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Other techniques used in physical assessment
• Olfaction (While assessing a client, the nurse should be familiar with
the nature and source of body odors.)
• Clinical measurement
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Preparation for Examination
• Infection control: If patient have any open skin lesions and any
drainage, nurse has to maintain infection control and avoid infection.
- Use gloves
- Use apron
- Use mask
- Use gown
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Environment
• Privacy
• Well equipped examination room
• Adequate lighting
• Sound proofed room
• Comfort environment
• Examination table
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Preparation of patient
• Physical preparation
- Bladder and Bowel elimination
- Draped properly
- Dressed properly
- Positioning
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Contd.
• Psychological preparation
- Explain procedure
- If both (nurse and client) are opposite sex third person is necessary.
- Observe facial expression
- Clarify client doubt
- Pace or time the examination process according to the patient’s physical and
emotional tolerance.
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Preparation of the equipment
• Height scale
• Weight scale
• A tray containing
- Disposable gloves (1 pair)
- Watch with second hand
- Thermometer
- Stethoscope
- BP cuff
- Measuring tape
- Scale
- Eye chart (Snellen chart)
- Torchlight or penlight
- Spatula
- Spirit swab
- Reflex hammer (Knee
hammer)
- Otoscope (If available)
- Ophthalmoscope
- Tuning fork
- Cotton swabs and cotton gauze
pad
- Paper bag
- Record form
- Pen/pencil
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Anthropometric measurement
• Height
• Weight
• Abdominal girth
• Mid arm circumference
• Vital signs
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General Appearance and Behavior (Inspection)
• Physical appearance (Age, sex)
• General state of health
• Facial expression
• Body structure (Stature, Nutrition,
Symmetry, Gait and posture, Position)
• Behavior
• Mood and affect
• Cleanliness/ hygiene
• Body odor
• Attitude
• Level of consciousness
• Orientation (person, place and time)
• Communication (Verbal and Non Verbal)
• Memory
• Speech
PGFBB-MCB-ALO-CMS
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Integumentary System (Inspection)
• Skin- Reveals variety of condition including changes in oxygenation,
circulation, nutrition, local tissue damage and hydration.
(Cyanosis  Central and peripheral) - Cheeks, nose, ears, and oral
mucosa are the best areas to assess cyanosis as the skin in
these areas is thin, and blood supply is good.
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Contd.
Cyanosis Contd.
In dark-skinned clients, close inspection of the palpebral conjunctiva
(the lining of the eyelids) and palms and soles may also show evidence
of cyanosis.
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Inspection Contd.
Peripheral Cyanosis
• Localized cyanosis affecting only extremities.
• Pink tongue as mucous membranes are almost never involved.
• Cold extremities as compared to warm extremities in central cyanosis.
• Clubbing is absent.
• Pulse volume usually low.
• Capillary refill time more than 2 sec.
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Contd.
• Hair
• Color of skin Palm, soles of the feet, lips, tongue and nail beds. Look
for jaundice, pallor and vitiligo. Skin vascularity like: Ecchymosis,
Petechiae
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*Pallor
- It is usually characterized by the absence of underlying red tones in the
skin and may be most readily seen in the buccal mucosa.
- In brown-skinned clients, pallor may appear as a yellowish brown
tinge; in black-skinned clients, the skin may appear ashen gray.
- Pallor in all people is usually most evident in areas with the least
pigmentation such as the conjunctiva, oral mucous membranes, nail
beds, palms of the hand, and soles of the feet.
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Contd.
Vitiligo Ecchymosis Petechiae
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Contd.
Erythema Albinism Macule Papule
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Plaque Nodules Pustules Vesicle
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Integumentary System (Palpation)
• Moisture: Hydration of skin (Dry or moist)
• Temperature: (Warmth)
• Texture: the feel, appearance, or consistency of a surface (localized
changes may result from trauma, surgical wounds or lesions)
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Contd.
• Turgor (Skin Elasticity): Pinch the skin over the back of the hand, on
the abdomen, or over the front of the chest under the collarbone.
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Contd.
• Edema
- It is mainly assessed on the medial malleolus, the bony portion of the
tibia, and the dorsum of the foot.
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Contd.
• Edema
- Localized and generalized
- Pitting and non pitting
 Non - Pitting Edema: If swollen area is pressed with finger and it
doesn’t cause an indentation in the skin, it’s considered non-pitting
edema.
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Contd.
 Pitting edema: When skin is pressed with finger, it’ll leave an
indentation, even after removal of finger. Chronic pitting edema is
often a sign of liver, heart, or kidney problems. It can also be a
symptom of a problem with nearby veins.
Nabina Paneru

Grading pitting edema
Grade Edema Depth Time taken to
revert
Remarks
Grade 0 None
Grade 1 Trace 2 mm Disappear
rapidly
Associated with interstitial fluid
volume 30% above normal
level
Grade 2 Moderate 4mm 10-15 s
Grade 3 Deep 6 mm More than 1
min
Skin swelling obvious by
general inspection
Grade 4 Very deep 8 mm 2 – 5 min Frank (Obvious) swelling Nabina Paneru

Nail (Inspection)
Nabina Paneru

Nail
• Shape (Convex)
• Angle
• Texture (smooth, base firm and non tender)
• Colour (pinkish nail beds with translucent white
tips)
• Capillary refill
Nabina Paneru

Contd.
• Capillary Refill
- Normal return within 2 seconds
Nabina Paneru

Abnormal nails
• Clubbed finger nails
- Can be caused due to different underlying diseases (Pulmonary
diseases, cardiovascular diseases, GI issues , Hyperthyroidism)
Nabina Paneru

Abnormal nails
Spooned nails
(Koilonychias)
Thin brittle
nails
Central nail
ridge
Nabina Paneru

Contd.
Central
nail
canals
Rough
nail
surfaces
Nail
thickening
Nabina Paneru

Contd.
Indentations (Beau’s line) Paronychia
Nabina Paneru

Head
• Inquire if the client has any history of the following: recent use of hair
dyes, rinses, or curling or straightening preparations; recent
chemotherapy (if alopecia is present); presence of disease, such as
hypothyroidism, which can be associated with dry, brittle hair.
Nabina Paneru

Head
Hair
Assessment Normal Findings Deviations from
Normal
Inspect the evenness of
growth over the scalp
Evenly distributed hair Patches of hair loss (i.e.,
alopecia)
Inspect hair thickness or
thinness
Thick hair Very thin hair(e.g., in
hypothyroidism)
Inspect hair texture and
oiliness
Silky, resilient hair Brittle hair (e.g.,
hypothyroidism):
excessively oily or dry
hair
Nabina Paneru

Contd.
Assessment Normal
Findings
Deviations from Normal
Note presence of infections or
infestations by parting the hair
in several areas, checking
behind the ears and along the
hairline at the neck
No infection or
infestation
Flaking, sores, lice, nits
(lice eggs), and ringworm
Insect amount of body hair Variable Hirsutism (excessive
hairiness) in women:
naturally absent or sparse
leg hair (poor circulation)
Nabina Paneru

Contd.
Alopecia Ringworm Infestation
(Tinea Capitis)
Lice infestations Hirsutism
Nabina Paneru

Head (Skull and Face)
Assessment Normal Findings Deviations from Normal
Inspect the skull for
size, shape and
symmetry
Rounded
(normocephalic and
symmetric with frontal,
parietal, and occipital
prominences); smooth
skull contour
Lack of symmetry; increased
skull size with more prominent
nose and forehead; longer
mandible (may indicate
excessive growth hormone or
increased bone thickness)
Inspect the facial
features (e.g.,
symmetry of
structures and of the
distribution of hair)
Symmetric or slightly
asymmetric facial
features; palpebral
fissures equal in size;
symmetric nasolabial
folds
Increased facial hair; low hair
line;
Thinning of eyebrows;
asymmetric features;
exophthalmos; myxedema
facies; moon face Nabina Paneru

Contd.
Insect the eyes for edema
or hollowness
No edema Periorbital edema; sunken
eyes
Note symmetry of facial
movements. Ask the
patient to elevate he
eyebrows, frown, or lower
the eyebrows, close the
eyes tightly, puff the
cheeks and smile and show
the teeth.
Symmetric facial
movements
Asymmetric facial
movements (e.g., eye
cannot close completely);
drooping of lower eyelid
and mouth; involuntary
facial movements (i.e., tics
or tremors)
Nabina Paneru

Eye Examination
Equipment
- Newspaper
- Index card
- Snellen Eye chart
- Cotton tipped applicator
- Penlight
- Opthalmoscope
- Small ruler
Nabina Paneru

Contd.
Chalazion Stye Ectropian Entropian
Nabina Paneru

Palpebral and Bulbar Conjunctiva
Nabina Paneru

Eye functions
• Check visual acuity (Near and far sight)
• Check peripheral vision
• Check accommodation
• Check extra ocular eye movements
• Check corneal reflex
• Check pupillary reflex
• Color vision test
Nabina Paneru

Extra ocular movements
Nabina Paneru

Examination of Ear
Nabina Paneru

Examination of ear
Inspect the auricles for color,
symmetry
of size, and position.
To inspect position, note the
level at which the superior
aspect of the auricle attaches
to the head in relation to the
eye.
Color same as facial skin
Symmetrical
Auricle aligned with outer
canthus of eye,
about 10°, from vertical
Bluish color of earlobes
(e.g., cyanosis); pallor (e.g.,
frostbite); excessive redness
(inflammation or fever)
Asymmetry
Low-set ears (associated
with a congenital
abnormality, such as Down
syndrome)
Nabina Paneru

Contd.
Assessment Normal Findings Deviations
Palpate the auricles for texture,
elasticity, and areas of tenderness.
• Gently pull the auricle upward,
downward, and backward.
• Fold the pinna forward (it should
recoil).
• Push in on the tragus.
• Apply pressure to the mastoid
process.
Mobile, firm, and
not tender; pinna
recoils after it is
folded
Lesions (e.g., cysts); flaky,
scaly skin (e.g., seborrhea);
tenderness when moved or
pressed (may indicate
inflammation or infection of
external ear)
Nabina Paneru

Contd.
Assessment Normal Findings Deviation from Normal
External Ear Canal and Tympanic Membrane
Inspect the external ear
canal for cerumen, skin
lesions, pus, and blood.
Distal third contains hair
follicles and glands
Dry cerumen, grayish-tan
color; or sticky, wet
cerumen in various shades
of brown
Redness and discharge
Scaling
Excessive cerumen
obstructing canal
Nabina Paneru

Contd.
Auditory Function tests:
• Whispering test
• Tuning fork test
Weber Test
Rinne’s Test
Nabina Paneru

Examination of nose
Inspect the external nose
for any deviations in
shape, size, or color and
flaring or discharge from
the nares.
Symmetric and straight
No discharge or flaring
Uniform color
Asymmetric
Discharge from nares
Localized areas of redness
or presence of skin lesions
Lightly palpate the
external nose to determine
any areas of tenderness,
masses, and displacements
of bone and cartilage.
Not tender; no lesions Tenderness on palpation;
presence of lesions
Nabina Paneru

Contd.
Assessment Normal Findings Deviations from normal
Determine patency of both nasal
cavities.
Ask the client to close the
mouth, exert pressure on one
naris, and breathe through
the opposite naris.
Repeat the procedure to assess
patency of the opposite naris.
Air moves freely as the client
breathes through the nares
Air movement is restricted in
one or both nares
Inspect the inside of the nose
with pen torch carefully to
detect any abnormalities or
deformities in nasal mucosa,
nasal septum
Nasal mucosa redder than the
oral mucosa.
No bleeding, swelling, deviation
of the septum, polyps, ulcers or
foreign bodies
Deviation of the lower septum.
In rhinitis, the mucosa is
reddened or swollen.
Fresh blood or crusting
indicates trauma Polyps, Ulcers
Nabina Paneru

Contd.
Assess olfactory function
Instruct the patient to close
the eyes and occlude one
ala of nose.
Provide a familiar scent
such as coffee, toothpaste
for the person to smell.
Test both nares
Can detect the sense of
smell
Could not detect when
upper respiratory
infection, sinusitis is
present or loss of smell
with tobacco smoking or
cocaine use
Nabina Paneru

Contd.
Palpate for sinus
tenderness
Press up on the frontal
sinuses from under the
bony brows, press upon
the ethmoid, sphenoid and
maxillary sinuses
No tenderness, swelling Local tenderness, swelling
Nabina Paneru

Examination of Mouth
Nabina Paneru

Examination of Mouth
Lips and Buccal Mucosa
Inspect the outer lips for
symmetry of contour,
color, and texture.
Ask the client to purse the
lips as if to whistle.
Uniform pink color
(darker, e.g., bluish
hue, in Mediterranean
groups and dark skinned
clients)
Soft, moist, smooth texture
Symmetry of contour
Ability to purse lips
Pallor; cyanosis
Blisters; generalized or
localized swelling;
fissures, crusts, or scales
(may result from excessive
moisture, nutritional
deficiency, or fluid deficit)
Inability to purse lips (may
indicate facial
nerve damage)
Nabina Paneru

Contd.
Assessment Normal Findings Deviation from
Normal
Inspect and palpate the inner
lips and buccal mucosa for
color, moisture, texture, and the
presence of lesions.
Uniform pink color
(freckled brown
pigmentation in dark-
skinned clients)
Pallor; leukoplakia
(white patches), red,
bleeding
Ask the client to relax the
mouth, and, for better
visualization, pull the lip
outward and away from the
teeth.
Grasp the lip on each side
between the thumb and index
finger.
Moist, smooth, soft,
glistening, and elastic
texture (drier oral mucosa
in older clients due to
decreased salivation)
Excessive dryness
Mucosal cysts;
irritations from
dentures; abrasions,
ulcerations; nodules
Nabina Paneru

Contd.
• Oral Kaposi Sarcoma
Nabina Paneru

Examination of neck
• Inspection
• Movement (Neck Rigidity)
• Lymph Node Examination
• Trachea Examination
• Thyroid Gland (Inspection and Palpation)
Nabina Paneru

Examination of Chest and Thorax
• Inspection (Anterior and posterior)
Nabina Paneru

Supraclavicular Retractions
Nabina Paneru

Contd.
• Palpation (Anterior and Posterior)
 Temperature
Chest Excursion
Tactile Fremitus
Nabina Paneru

Contd.
• Percussion (Anterior and Posterior)
Nabina Paneru

Contd.
• Auscultation (Anterior
and posterior)
Normal Breath Sounds
Nabina Paneru

Contd.
• Auscultation Contd.
Abnormal breath Sounds (Adventitious Breath Sounds)
Nabina Paneru

Examination of heart
Nabina Paneru

Abdominal Examination
• Inspection
• Auscultation
• Percussion
• Palpation
Nabina Paneru

Straie or Stretch Marks
Nabina Paneru

Engorged Abdominal Veins
Nabina Paneru

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