1 - NSG 102.2 Health Assessment Laboratory Manual
1 - NSG 102.2 Health Assessment Laboratory Manual
1 - NSG 102.2 Health Assessment Laboratory Manual
PROCEDURES:
➢ Assessing Body Temperature
Oral Temperature
Rectal Temperature
Axillary Temperature
Tympanic Temperature
➢ Assessing A Pulse
Assessing The Radial Pulse
Assessing The Apical Pulse
Assessing The Brachial Pulse
Assessing The Carotid Pulse
Assessing The Dorsalis Pedis Pulse
Assessing The Femoral Pulse
Assessing The Posterior Tibial Pulse
Assessing The Popliteal Pulse
Assessing The Temporal Pulse
Assessing Pulse Deficit
➢ Assessing Respiratory Rate
➢ Assessing Blood Pressure
Taking Bp By Palpatory Method
Taking Bp By Auscultation Method
Taking Bp Using An Automatic Blood Pressure Monitor
Measuring Orthostatic Blood Pressure
GENERAL OBJECTIVE:
➢ To measure and document patient’s temperature, pulse and respiration (TPR) accurately and
safely, recognizing deviations from the norm.
LEARNING OUTCOMES
The student will be able to:
➢ Assess the patient to determine which method to use for temperature measurement and
which pulses should be checked.
➢ Assess the patient to determine readiness for the temperature, pulse and respiration (TPR).
➢ Analyze the assessment data to determine specific concerns that must be addressed prior to
taking the TPR or palpating peripheral pulses.
➢ Choose the appropriate equipment.
➢ Position the patient appropriately for the procedure, maintaining principles of body
mechanics.
➢ Measure the temperature, pulse and respirations accurately.
➢ Evaluate the effectiveness of the process and accuracy of the results
➢ Document the results in the patient record
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
Review medical record for baseline
data factors that influence vital signs.
1.
Identify the client and explain the
procedure. Provide for privacy.
Gather the necessary equipment
(Electronic thermometer or digital
thermometer with disposable
2. protective sheathing, two pairs of non-
sterile gloves, alcohol wipes or cotton
ball with alcohol, and tissues) and bring
to the bedside.
Perform hand hygiene/wash hands,
3.
and apply gloves when appropriate
PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
Initial Preparation
1. Identify the client and explain the procedure to the
client to obtain informed consent.
2. Gather the necessary equipment and then bring to
the bedside.
3. Adhere to local infection control policies and
ensure proper hand hygiene (hand washing)
4. Place client in a comfortable position either in a
sitting or supine position.
5. Provide privacy
A. ASSESSING THE RADIAL PULSE
To check the radial pulse, position the client's arm
along the side of the body or across the upper
6.
abdomen with the client's wrist relaxed and palms
either facing upward or downward.
PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
1. Make the client's position comfortable,
preferably sitting or lying with the head of
the elevated 45 to 60 degrees.
2. After taking the pulse rate, with your
fingers still in place from taking the radial
pulse, or with the stethoscope still in place
from taking the apical pulse; look at the
patient’s chest and observe patient’s
respirations. Observe the rise and fall of
the client’s (one inspiration and one
expiration)
3. Count the number of respirations for 1
minute using a watch with a second hand.
4. Note the rise and fall of the client’s chest
with each respiration.
5. Remove your hand from the patient and
place patient comfortably on bed.
PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
Identify the patient and explain the
1.
procedure.
Gather the necessary equipment and
2.
then bring to the bedside.
3. Do hand washing.
Place patient in a comfortable position
(lying or sitting) and position the arm
at the level of the heart with the palm of
4.
hand facing up. Select appropriate arm
for BP taking. (preferably use left arm
because it is nearer the heart)
Roll the patient’s sleeve and expose the
5.
brachial artery.
A. TAKING BP BY PALPATORY METHOD
OVERALL OBJECTIVE:
LEARNING OUTCOMES
The student will be able to:
➢ Assess generally to obtain brief baseline history or complaint from the patient to
determine what types of data, methods, and further assessment techniques are
needed.
➢ Assess the patient’s readiness for the physical assessment.
➢ Analyze the initial data to determine specific concerns that must be addressed
prior to completing the physical assessment using both objective and subjective
data.
➢ Plan appropriate equipment that will aid the assessment process, and organize
the process, so it flows efficiently.
➢ Position the patient appropriately for the physical assessment while maintaining
principles of body mechanics and privacy for the patient.
➢ Implement the data collection and physical assessment processes that are
appropriate to the situation: comprehensive physical assessment, routine shift
assessment, or mini head-to-toe assessment.
➢ Evaluate the effectiveness of the process and the accuracy of the results
obtained.
➢ Begin to formulate nursing diagnoses based on the data collected.
➢ Document the results in the patient’s record or other facility documentation
form as required.
PROCEDURE RATIONALE
9. It is used to determine:
a. Texture (e.g. hair)
b. Temperature (e.g. skin area)
c. Vibration (e.g. joint)
d. Position, size, consistency, and mobility of
organs and masses.
e. Distention (e.g. urinary bladder).
f. Pulsation
g. Tenderness or pain
12. The dorsum of the hand and fingers are best use to test
skin temperature.
13. Palm of the hand is used to test for vibration.
PERCUSSION- It is the act of striking the body surface to elicit sounds that can be heard or vibrations that
can be felt, used to determine the size and shape of internal organs by establishing their borders.
PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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CONSIDERATIONS BEFORE, DURING and AFTER THE PROCEDURE:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
PROCEDURE RATIONALE C X N R
A. AURICLES
1. Inspect the auricles for position, size,
shape, symmetry, and color. Note for
lesions or drainage.
2. Palpate the auricles for condition of
skin and any areas of tenderness.
3. Pull the auricle upward, downward,
and backward.
4. Fold the pinna forward and push in on
the tragus.
PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE 5 4 3 2
NOSE
1. Inspect the external nose. Note size,
shape, color and flaring or
discharges from the nares.
2. Lightly palpate the external nose.
3. Instruct the client to close his mouth,
occlude one naris, and breathe
through the opposite naris.
4. Repeat the procedure with the other
naris.
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
1. Inspect the outer and inner surface of
the lips noting symmetry of contour,
color, texture and lesions. Ask the
client to purse his lips.
2. Inspect and palpate the inner lips and
buccal mucosa for color, moisture,
texture, and any presence of lesions.
3. Ask client to open his mouth.
4. Remove dentures if any. If able you
may ask the patient to this her/himself
Inspect condition and fit.
5. Inspect teeth and gums for
discoloration and diseased or missing
teeth.
PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
Inspect the neck muscles and condition of the
1 skin. Note for any scars, abnormal swellings,
and masses.
Place the palm of your hand against the client’s
right cheek and tell him move his head against
2
the resistance of your hand. Repeat on the
other side.
Instruct the client to move his head through the
entire range of motion and shrug his shoulders
3
against your arms while he is sitting.
ANTERIOR APPROACH
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
Inspect the client’s wall for asymmetry,
abnormal respiratory rate and pattern,
1 accessory muscle use, masses or scars, or
paradoxical movement
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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PROCEDURE RATIONALE C X N R
CENTRAL VESSELS
To palpate the carotid artery, lightly
1 place your fingers just medial to the
trachea and below the angle of jaw.
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
1. Explain the procedure and provide
privacy.
2. Inspect the breasts for skin condition,
size, symmetry, and contour or shape.
3. Inspect the nipples and areola for size,
shape, symmetry, color, surface
characteristics and any masses, lesions
or discharges.
4. Ask the client to raise her arms over her
head and place it behind her back.
5. Inspect the axillae for skin condition and
hair distribution.
PROCEDURE RATIONALE C X N R
1. Place the client in a supine position with
the head and knees supported with small
pillow or folded sheets with drapes
positioned accordingly
2. Examine the abdomen in this order:
inspection, auscultation, percussion and
palpation.
3. Inspect the abdomen for size, symmetry,
and contour. Observe the condition of the
skin and skin color, hair distribution; and
any presence of lesions, scars, striae, and
superficial veins.
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
1. Introduce self and verify the client’s
identity. Explain the procedure to the
client. Provide privacy.
2. Ask the client to empty her bladder
before the examination begins
3. Perform hand hygiene, apply gloves
and observe appropriate infection
control.
4. Ask the client to remove her
underwear. Place her in a lithotomy
position and drape.
5. Do perineal care.
Abnormal findings:
• Scant pubic hair (may indicate
hormonal problem)
• Hair growth should not extend
over the abdomen.
7. Normal findings:
• Pubic skin intact, no lesions.
• Skin of vulva area slightly
darker than the rest of the
body.
• Labia round, full and relatively
Inspect the skin of the pubic area for symmetric in adult females.
any presence of parasites,
inflammation, swelling, or lesions.
Abnormal findings:
• Lice, lesions, scars, fissures,
swelling, erythema,
excoriations, varicosities, or
leukoplakia.
8. Normal findings:
• Clitoris does not exceed 1cm in
width and 2cm in length.
• Urethral orifice appears as a
With your thumb and index finger small slit and is the same color
separate the labia, and inspect the as surrounding tissues.
clitoris, urethral orifice, and vaginal • No inflammation, swelling, or
orifice. Note position, color, size, and discharge.
presence of drainage or lesions.
Abnormal findings:
• Presence of lesions
• Presence of inflammation,
swelling, or discharge.
9. Palpate the inguinal lymph nodes in
the groin area and the vertical chain
at the inner aspect of the thigh. Not
for any enlargement or tenderness. Normal findings:
• No enlargement or tenderness
Abnormal findings:
• Enlargement and tenderness
PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
1. Introduce self and verify the client’s
identity. Explain the procedure to the
client. Provide privacy.
2. Ask the client to empty her bladder
before the examination begins
3. Perform hand hygiene, apply gloves
and observe appropriate infection
control.
4. Don on clean gloves
5. Ask the client to remove his
underwear. Place him in a supine
position with legs slightly apart, and
drape.
6. Do perineal care.
PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
1. Introduce self and verify the
client’s identity. Explain the
procedure to the client. Provide
privacy.
2. Ask the client to empty her bladder
before the examination begins
3. Perform hand hygiene, apply
gloves and observe appropriate
infection control.
4. Position the client:
• In adults, a left lateral or
Sims’ position with the
upper leg acutely flexed is
required for the
examination.
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
1. Introduce self and verify the client’s
identity. Explain the procedure to the
client. Provide privacy.
2. Perform hand hygiene and observe
appropriate infection control.
3. Compare bilaterally during assessment.
A. Symmetry, contraction and strength
4. Muscle Normal findings:
• Equal size on both sides of body
Inspect the muscles for size.
Comparethe muscles on one side of the
body (e.g., of the arm, thigh, and calf) to Abnormal findings:
the same muscle on the other side. For • Atrophy (a decrease in size) or
any discrepancies, measure the muscles hypertrophy (an increase in size),
with a tape. asymmetry.
9.
NECK
Ask client to move head down towards
the chin and up, move head from side
to side, to bend laterally, and rotate
head.
10. ARMS& SHOULDERS
Ask client to move his arm up and
down, to raise his arms forward, to
bring his arms as far back as possible,
and to bring his arms towards and
away from his body, and to rotate his
arms
11.
ELBOWS
Ask client to bend his elbows forward
and downward, and to move his elbows
from side to side.
12.
WRISTS
Ask the client to move his wrist up and
down, and from side to side.
13.
15.
HIP& KNEES
Ask the client to move each leg forward
and backward, to move leg from side to
side, and to rotate each leg. Ask client
to bend each knee.
16.
ANKLES AND FEET
Ask the client to point his toes up and
down, to move his feet from side to
side, and to spread the toes of each foot
apart.
DEFINITION:
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PURPOSE:
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EQUIPMENT:
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PERFORMANCE INDICATORS:
C –The step was correctly performed
X- The step was not performed
N- The execution of the step needs improvement
R- The step was correctly performed after remediation
PROCEDURE RATIONALE C X N R
A. SENSORY FUNCTION TEST
1. Introduce self and verify the client’s
identity. Explain the procedure to the
client. Provide privacy.
2. Perform hand hygiene and observe
appropriate infection control.
3. The client’s eyes should be closed
whenever possible. Testing should
always be bilateral.
4. LIGHT-TOUCH SENSATION • Sensitivity to touch varies
• Ask the client to close his among different skin areas (1).
eyes. Let him respond “yes” or • This demonstrates whether the
“now” when he feels the client is able to determine tactile
cotton wisp touching his location (point localization) (2).
Normal findings:
• Light tickling or touch sensation
Abnormal findings:
• Anesthesia, hyperesthesia,
hypoesthesia or paresthesia
5. PAIN SENSATION
• Ask the client to close his
eyes.Let him respond “sharp”,
“dull”, or “don’t know” when Normal findings:
he feels the sharp or dull end
of the safety pin or needle is • Able to discriminate “sharp” and
felt. “dull” sensations
• Alternately use the sharp and
dull end of the sterile pin or Abnormal findings:
needle to lightly prick the • Areas of reduced, heightened, or
hand, forearm, abdomen, absentsensation (map them out
lower leg and foot.Do NOT for recordingpurposes)
test the face.
• Allow at least 2 seconds
between each test.
6. KINESTHETIC SENSATION Normal findings:
Ask the client to close his eyes. • Can readily determine the
Grasp the client’s middle finger or big position of fingers and toes
toe by the sides and move it up and
down. Abnormal findings:
Have the client tell you the • Unable to determine the position
orientation of the middle finger or big of one ormore fingers or toes
toe.