1st Week Purposes of the Nursing Process

 To identify the client’s health status

The Nursing Process and its stages  To identify actual (existing) or
 a systematic method of providing care potential (possible) health care
to clients (step by step) problems
 allows nurses to communicate plan  To identify client’s needs
and activities to: clients, other  To establish a plan to meet the
healthcare professionals and, families identified needs
 Formulate nursing care plan – blueprint  To deliver specific nursing
- Deficient fluid volume – dehydration interventions to meet the identified
(medical diagnosis) needs
 Lead your patient into a good
progress/recovery (goal of nursing Phases of the Nursing Process
process) Assessment – collecting subjective and
- Progress badly  lead to objective data
complications Diagnosis – analyzing subjective and objective
Diabetes – maintain blood sugar into normal data to make a professional nursing
level judgement
Process: “A series of steps or acts that lead to Planning – determining outcome criteria and
accomplishment of some goal or purpose” developing a plan
Purpose is to provide client care that is: Implementation – carrying out the plan
 Individualized – fit in to one patient Evaluation – assessing whether outcome
 Holistic – general criteria have been met
 Effective – be able to achieve
something Phases and Activities in the Nursing Process
 Efficient – steps -- chronologic 1. Assessing
5 steps: - Collection of data
1. Assessment - Organizing
2. Diagnosis - Validating – checking the credibility
3. Planning - Documenting – writing down
4. Implementation 2. Diagnosing
5. Evaluation - Analysis of data – clustering
 Build on each other - Identifying health problems, risks and
 Not linear strengths
- Formulating the diagnostic
Characteristics statements
 Decision making is involved in every 3. Planning
phase of nursing process - Prioritizing problems/diagnoses
 Interpersonal and collaboration – (Maslow’s hierarchy of needs)
communicated w/ other healthcare - Formulation of goals/desired
professionals/ co-nurses outcomes
 Universally applicable - Selecting nursing interventions
- Writing nursing interventions
 Use a variety of critical thinking skills
4. Implementing
 Data from each phase provide input
- Reassessing the client
into the next phase – continuity (plan)
- Determining the nurse’s need for
 Client centered
assistance
 Adaptation of problem solving
- Implementing nursing intervention
- Supervise delegated activities
- Documenting nursing activities
Collaborative intervention – involving other
healthcare professionals INTRODUCTION TO HEALTH ASSESSMENT
Dependent – doctor/nursing action based on  refers to a systematic method of
the instruction of another professional collecting and analyzing data for the
Independent – nurse/requires no supervision purpose of planning patient-centered
5. Evaluating care
- Collect data related to the outcomes  nurse collects health data from the
- Compare data with outcomes patient and compares these with the
- Relate nursing actions to client ideal state of health
goals/outcomes INTRODUCTION:
- Draw conclusions about problem  is the first and most critical phase of
status the nursing process
- Continue, modify, or terminate the  ongoing and continuous throughout
client’s care plan all the phases of the nursing process
Met – client response is the same as the  collection of data about an
desired outcomes individual’s health state
Partially met – either a short term goal was Focus of Health Assessment in Nursing
achieved but the long term was not, or the  to collect subjective and objective
desired outcome was only partially attained data
Not met – goal was not met  to determine a client’s overall level of
functioning in order to make a
Critical Thinking professional clinical judgment.
 nursing practice is a discipline specific, The nurse collects physiologic, psychological,
reflective reasoning process that sociocultural, developmental, and spiritual
guides a nurse in generating, data about the client.
implementing and evaluating Thus the nurse performs holistic data
approaches for dealing with client collection.
care and professional concerns
 it is essential to safe, competent, Four Basic Types of Assessment
skillful nursing practice - each varies in the amount and type of
Where does nurses use Critical Thinking data collected
Skills: 1. Initial comprehensive assessment
- Nurses use knowledge from other  involves collection of subjective data
subjects and fields about the client’s:
- Nurses deal with change in stressful - perception of her health of all body parts
environment or systems
- Nurses make important decisions - past health history
Creativity – one major component of critical - family history
thinking - lifestyle and health practices
- Thinking that results in development of  objective data gathered during a step-
new ideas and products by-step physical examination.
- Ability to develop and implement new 2. Ongoing or Partial assessment
and better solutions  consists of data collection that occurs
- Nurses can generate many ideas rapidly after the comprehensive assessment is
and generally flexible and natural established
- Create original solutions to problems  consists of a mini-overview of the
- Tend to be independent and self- client’s body systems and holistic health
confident, even when under pressure patterns as a follow-up on his health
- Demonstrate individuality status.
 problems that were initially detected in
the client’s body system or holistic
 health patterns are reassessed in less Body Systems Framework
depth to determine any major changes  focuses on the pathophysiology
from the baseline data. involved within specific body systems
3. Focused or problem-oriented approach may be used during the
assessment focused assessment of an acutely or
 does not take the place of the critically ill client
comprehensive health assessment.  commonly used when the purpose of
 It is performed when a the examination is to determine
comprehensive database exists for a function of a particular body system
client who comes to the health care
agency with a specific health concern. Steps of Health Assessment
 consists of a thorough assessment of  Collection of Subjective Data
a particular client problem and does Subjective data – are sensations or symptoms
not cover areas not related to the (e.g., pain, hunger), feelings (e.g., happiness,
problem. sadness), perceptions, desires, preferences,
4. Emergency Assessment beliefs, ideas, values, and personal
 Very rapid assessment performed in information that can be elicited and verified
life-threatening situations only by the client.
 in such situations (choking, cardiac  To elicit accurate subjective data,
arrest, drowning), immediate learn to use effective interviewing
diagnosis is needed to provide skills with a variety of clients in
prompt treatment different settings.
Frameworks for Health Assessment  Collection of Objective Data
Three major frameworks for organizing  is obtained by general observation
assessment data: and by using the four physical
1. Functional health framework – examination techniques: inspection,
nursing health history palpation, percussion, and
2. Head to toe framework – physical auscultation.
assessment  another source of objective data is
3. Body systems framework the client’s medical/health record
 Helps nurses to organize the Objective data may also be observations
information they collect and ensure noted by the family/significant others about
that they don’t inadvertently omit the client.
important assessment data
Functional Health Framework  Validation of Data
 Evaluates the effects of the mind,  crucial part of assessment that often
body, and environment in relation to occurs along with collection of
a person’s ability to perform the tasks subjective and objective data.
of daily living.  serves to ensure that the assessment
 Organizes data collection in terms of process is not ended before all
Gordon’s 11 functional health relevant data have been collected,
patterns and it helps to prevent
Head – to – Toe Framework documentation of inaccurate data
 a system for collecting data in an
organized manner, starting from head  Documentation of Data
and proceeding systematically  an important step of assessment
downward to the toes because it forms the database for the
 used to improve efficiency and to entire nursing process and provides
expedite the actual physical data for all other members of the
examination health care team.
 Thorough and accurate
documentation is vital to ensure valid
conclusions are made when the data
are analyzed in the second step of the
nursing process
2nd Week

COLLECTION OF OBJECTIVE DATA:

Introduction to Physical Examination PREPARING THE ENVIRORNMENT
 The time for the physical assessment
should be convenient to both the
APPROACHES FOR PHYSICAL ASSESSMENT client and the nurse.
Two methods are used for completing a total  The environment needs to be well
physical assessment: lighted and the equipment should be
1. Systems approach organized for use.
- allows for a thorough assessment of each  Providing privacy is very important.
system, doing all assessments related to  Family and friends should not be
one system before moving on to the next present unless the client asks for
- Better for a focused assessment someone.
2. Head-to-toe assessment  The room should be warm enough to
- includes the same examinations as a be comfortable for the client.
systems assessment, but you assess each
region of the body before moving on to PREPARING ONESELF
Eye protection: splash goggles, face shield, or
the next
procedure mask with visor
- Better for a complete assessment
Mask: a fluid-resistant procedure mask is
Purposes of the Physical Examination: required. Staff have the option of using an
 To obtain baseline data about the N95 respirator
client’s functional abilities. Gown: yellow isolation gown, tied at the back
- Health history + physical Gloves: non-sterile procedure gloves
examination/assessment + diagnostic
test = nursing problem/diagnosis PREPARING THE CLIENT
 To supplement, confirm, or refute Most clients need an explanation of the
data obtained in the nursing history. physical examination. The nurse should
 To obtain data that will help establish explain:
nursing diagnoses and plans of care.  When and Where will it take place?
 To evaluate the physiological  Why is it important?
outcomes of health care and thus the  What will happen during the
progress of a client’s health problem. examination?
 To make clinical judgments about a Examinations are usually painless; however, it
client’s health status. is important to determine in advance any
 To identify areas for health promotion positions that are contraindicated for a
and disease prevention. particular client.

To become proficient with physical  The nurse assists the client to undress
assessment skills, the nurse must have basic and put on a gown.
knowledge in three areas:  Clients should empty their bladders
I. Types of and operation of equipment before the examination, to help them
needed for the particular examination feel more relaxed and facilitates
II. Preparation of the setting, oneself, palpation of the abdominal and pubic
and the client for the physical area.
assessment - If urinalysis is required, the urine should
III. Performance of the four assessment be collected in a container for that
techniques: inspection, palpation, purpose.
percussion, and auscultation
  Plan assessment procedures SIMS’
carefully so as not to overtire o Side-lying position with lowermost
geriatric and frail clients arm behind the body, uppermost leg
flexed at hip and knee, upper arm
POSITIONING flexed at shoulder and elbow
 It is important to consider the client’s o Rectum, vagina (anal area)
ability to assume a position
 client’s physical condition, energy PRONE
level, and age should also be taken o Lies on abdomen with head turned to
into consideration. embarrassing and the side, with or without a small
uncomfortable positions should not pillow
be maintained for long. o Posterior thorax, hip joint movement
 minimizing the number of position o Less ang maa-assess
changes needed
Draping
CLIENT POSITIONS AND BODY AREAS  Drapes should be arranged so that the
ASSESSED area to be assessed is exposed and
SITTING other body areas are covered.
o A seated position, back unsupported  Exposure of the body is frequently
and legs hanging freely embarrassing to clients.
o Head, neck, posterior and anterior  Drapes provide not only a degree of
thorax, lungs, breasts, axillae, heart, privacy but also warmth.
vital signs, upper and lower  Drapes are made of paper, cloth, or
extremities, reflexes bed linen

SUPINE (horizontal recumbent) EQUIPMENT AND SUPPLIES USED FOR A

o Back-lying position with legs HEALTH EXAMINATION
extended; with or without pillow
under the head FLASHLIGHT OR PENLIGHT – assist viewing of
o Head, neck, axillae, anterior thorax, the pharynx or to determine the reactions of
lungs, breasts, heart, vital signs, the pupils of the eye
abdomen, extremities, peripheral
pulses (abdominal area) OPHTHALMOSCOPE – a lighted instrument to
visualize the interior of the eye
DORSAL RECUMBENT
o Back-lying position with knees flexed TOUNGE BLADES (depressor) – to depress the
and hips externally rotated; small tongue during assessment of the mouth and
pillow under the head; soles of feet pharynx
on the surface
o Female genitals, rectum, and female GLOVES – to protect the nurse
reproductive tract
PERCUSSION (reflex) HAMMER – an
LITHOTOMY instrument with a rubber head to test reflexes
o Back-lying position with feet
supported in stirrups; the hips should TUNING FORK – a two-pronged metal
be in line with the edge of the table instrument to test hearing acuity and
o Female genitals, rectum, and female vibratory sense
reproductive tract
o Specific sa females OTOSCOPE – a lighted instrument to visualize
the eardrum and external auditory canal
(a nasal speculum may be attached to the Palpation is used to determine:
otoscope to inspect the nasal cavities) ✓ texture (e.g., of the hair)
✓ temperature (e.g., of a skin area)
COTTON APPLICATORS – to obtain specimen ✓ vibration (e.g., of a joint)
✓ position, size, consistency, and mobility
CARDINAL TECHNIQUES OF PHYSICAL of organs
ASSESSMENT
✓ distention (e.g., of the urinary bladder)
Inspection
✓ pulsation
- Means conscious observation of the
patient for general appearance; physical ✓ tenderness or pain
characteristics and behavior; odors; and  Skin Temperature – best to use
any specific details related to the body the dorsum (back) of the hand
systems and fingers, where the examiner’s
Palpation skin is thinnest.
- Involves use of the hands to feel the  Vibration – the nurse should use
firmness of body parts, such as the the palmar surface of the hand.
abdomen General guidelines for palpation include the
Percussion following:
- Using tapping motions with hands to  hands should be clean and warm, and
produce sounds that indicate solid or air – the fingernails short.
filled spaces over the lungs and other  Areas of tenderness should be
areas palpated last.
Auscultation  Deep palpation should be done after
- Involves use of a stethoscope to hear superficial palpation.
movements of air or fluid in the body over
the lungs and abdomen There are two types of palpation:
1. LIGHT (SUPERFICIAL) PALPATION
INSPECTION - nurse extends the dominant hand’s
 is the visual examination, which is fingers parallel to the skin surface and
assessing by using the sense of sight presses gently while moving the hand in a
 nurse inspects with the naked eye and circle. With light palpation, the skin is
with a lighted instrument slightly depressed.
 Assessment includes: moisture, color, - to determine the details of a mass, the
and texture of body surfaces, as well nurse presses lightly several times rather
as shape, position, size, color, and than holding the pressure.
symmetry of the body. 2. DEEP PALPATION
 Lighting must be sufficient; either - is done with two hands (bimanually) or
natural or artificial light can be used. one hand
Colors: DEEP BIMANUAL PALPATION
Jaundice – yellow (hepa)  top hand applies pressure while the
Cyanotic – bluish (lack of oxygen) lower hand remains relaxed to
Erythema – redness of the skin perceive the tactile sensations.
Pale – maputla (anemia) DEEP PALPATION (ONE HAND)
 the finger pads of the dominant hand
PALPATION press over the area to be palpated
 other hand is used to support from
 the examination of the body using the
below
sense of touch
 pads of the fingers are used because
PERCUSSION
their concentration of nerve endings
- act of striking the body surface to elicit
makes them highly sensitive to tactile
sounds that can be heard or vibrations
discrimination.
that can be felt
- used to determine the size and shape of AUSCULTATION
internal organs by establishing their - process of listening to sounds produced
borders. within the body.
- indicates whether tissue is fluid filled - Auscultation may be direct or indirect.
(stomach/abdominal), air filled Direct auscultation – is performed using the
(respiratory), or solid (bones) unaided ear.
Indirect auscultation – is performed using a
Two types of percussion: stethoscope, which transmits sounds to the
1. Direct percussion – nurse strikes the nurse’s ears.
area to be percussed directly with the Stethoscope – used primarily to listen to
pads of two, three, or four fingers or sounds from within the body, such as bowel
with the pad of the middle finger. sounds or valve sounds of the heart and blood
 strikes are rapid, and the movement pressure.
is from the wrist. - It should have both a flat-disk diaphragm
 not generally used to percuss the and a bell-shaped amplifier
thorax but is useful in percussing an  Diaphragm – best transmits high-
adult’s sinuses pitched sounds (e.g., bronchial
sounds)
2. Indirect percussion – is the striking of  Bell – best transmits low-pitched
an object (e.g., a finger) held against sounds such as some heart sounds.
the body area to be examined.  earpieces of the stethoscope should
 middle finger of the non- fit comfortably into the nurse’s ears,
dominant hand, referred to as the facing forward.
pleximeter, is placed firmly on the  amplifier of the stethoscope is placed
client’s skin. firmly but lightly against the client’s
Only the distal phalanx and joint of this finger skin.
should be in contact with the skin.
 Using the tip of the flexed middle  All four assessment techniques are used
finger of the other hand, called to perform a complete assessment
the plexor, the nurse strikes the Remember:
pleximeter  Inspect for abnormalities and normal
Usually at the distal interphalangeal joint or a variations of visible body parts.
point between the distal and proximal joints.  Palpate to identify surface
characteristics, areas of pain or
Percussion elicits five types of sound: tenderness, organs, and
1. Flatness – extremely dull sound abnormalities, including masses and
produced by very dense tissue, such fremitus.
as muscle or bone.  Percuss to determine the density of
2. Dullness – thud-like sound produced underlying tissues and to detect
by dense tissue such as the liver, abnormalities in underlying organs.
spleen, or heart.  Auscultate for sounds made by body
3. Resonance – hollow sound such as organs, including the heart, lungs,
that produced by lungs filled with air. intestines, and vascular structures.
4. Hyper-resonance – not produced in
the normal body. It is described as
booming and can be heard over an
emphysematous lung. (COPD)
5. Tympany – musical or drum-like
sound produced from an air-filled
stomach.
LABORATORY AND DIAGNOSTIC TESTS INTRATEST
 Tests may be used for basic  focuses on specimen collection and
screening as part of a wellness performing or assisting with certain
check. diagnostic testing.
 Frequently tests are used to help  nurse uses standard precautions and
confirm a diagnosis, monitor an sterile technique as appropriate.
illness, and provide valuable  nurse provides emotional and
information about the client’s physical support while monitoring the
response to treatment. client as needed
 Nurses require knowledge of the  nurse ensures correct labeling,
most common laboratory and storage, and transportation of the
diagnostic tests specimen to avoid invalid test results
 Nurses must also know the
implications of the test results in POST-TEST
order to provide the most  Focus: nursing care of the client and
appropriate nursing care for the follow-up activities and observations.
client.  nurse compares the previous and
current test results and modifies
DIAGNOSTIC TESTING PHASES nursing interventions as needed
PRETEST  nurse also reports the results to
 major focus: client preparation appropriate health team members.
 thorough assessment and data
collection assist the nurse in - Base line – desired data (compare)
determining communication and
teaching strategies. Three components of specimen quality are:
Prior to radiologic studies it is important to 1. proper specimen selection (i.e., the
ask female clients if pregnancy is possible. correct type of specimen must be
- nurse also needs to know what submitted)
equipment and supplies are needed for 2. proper specimen collection
the specific test. 3. proper transport of the specimen to
- laboratory at the facility can act as a the laboratory.
resource for information Artery (arterial) – bright, has pulsation, deep-
sited
PREPARING FOR DIAGNOSTIC TESTING Vein (venous) – dark, has no pulsation,
 Instruct the client and family about the superficial
procedure for the diagnostic test ordered
 Explain the purpose of the test.  random
 Instruct the client and family about  clean catch urine
activity restrictions related to testing  mid-stream urine
 Instruct the client and family on the
reaction the diagnostic test may produce BLOOD TEST
 Provide the client with detailed COMPLETE BLOOD COUNT
information about the diagnostic testing  Specimens of venous blood are taken
equipment. for a complete blood count (CBC)
 Inform the client and family of the time  It includes hemoglobin and
frame for when the results will be hematocrit measurements,
available erythrocyte (red blood cells) count,
 Instruct the client and family to ask any red blood cell indices, leukocyte
questions so that the health care provider (white blood cell) count, and a
can clarify information and any fears differential white cell count.
  basic screening test and one of the  blood samples for peak and trough
most frequently ordered blood tests levels to determine if the blood serum
levels of a specific drug are at a
BLEEDING TIME therapeutic level and not a sub
 Measures the duration of bleeding therapeutic or toxic level
after standardized skin incision  monitor the effectiveness of the
 It depends on the elasticity of the medication
blood vessel wall and the number and
function of platelets ARTERIAL BLOOD GASES (ABG)
- 2-9 mins. – stop the bleeding  Arterial Blood Gases Measurement of
- 1-2 mins. – normal patient arterial blood gases is another
important diagnostic procedure
PROTHROMBIN TIME (PT)  important to prevent hemorrhaging
 Plasma protein produced by liver by applying pressure to the puncture
 Measures the time required for side for about 5 to 10 minutes after
fibrin clot to form after addition removing the needle.
of calcium ions and tissue
thromboplastin. CAPILLARY BLOOD GLUCOSE
 Test of choice for monitoring oral  taken to measure the current blood
anticoagulant therapy. glucose level when frequent tests are
required or when a venipuncture
SERUM ELECTROLYTES cannot be performed.
 are often routinely ordered for any  this technique is less painful than a
client admitted to a hospital as a venipuncture and easily performed
screening test for electrolyte and  clients can perform this technique on
acid–base imbalances themselves
 are routinely assessed for clients at
risk, for example, clients who are BLOOD CHEMISTRY TEST
being treated with a diuretic for CK (creatine kinase)
hypertension or heart failure.  An enzyme found in the heart and
Normal electrolyte values for adults: skeletal muscles.
Venous blood Normal Values  Has three isoenzymes: MM or CK3,
Sodium 135 – 145 mEq/L MB or CK2, and BB or CK1
Potassium 3.5 – 5.0 mEq/L  Status of the heart
Chloride 95 – 105 mEq/L CKMM – muscle – tumataas kung merong
Calcium 4.5 -5.5 mEq/L, or 8.5 – damage sa skeletal muscle
(total) (ionized) 10.5 mg/dL CKMB – heart
Magnesium 1.5-2.5 mEq/L or 1.6-2.5 CKBB – brain
mg/dL
Phosphate 1.8-2.6 mEq/L Troponin I/Troponin T
(phosphorous)  Cardiac troponin is highly
concentrated in the heart muscle.
 hyperkalemia – high potassium  This test is used in the early diagnosis
 hypokalemia – low potassium of MI.
 hyper/hyponatremia – sodium Troponin I – tumataas – heart attack/damage
sa heart muscle
THERAPEUTIC DRUG MONITORING Troponin T – late nagrereact
 often conducted when a client is
taking a medication with a narrow AMMONIA
therapeutic range (e.g., digoxin).  Test helps to monitor severe hepatic
disease and effectiveness of therapy
BILIRUBIN INSTRUCTION:
 Evaluates liver function  Defecate in a clean bedpan or bedside
 Major product of hemoglobin commode.
catabolism  Do not contaminate the specimen
 Significant in neonates because with urine or menstrual discharge.
excessive unconjugated bilirubin can  Do not place toilet tissue in the
accumulate in the brain, causing bedpan after defecation.
irreversible damage  Notify the nurse as soon as possible
after defecation
Aspartate aminotransferase (AST)
 Helps to diagnose acute hepatic SPUTUM SPECIMENS
disease and IM (Myocardial  Sputum is the mucous secretion from
Infarction) the lungs, bronchi, and trachea.
 monitor patients with cardiac and  It is important to differentiate it from
hepatic disease saliva, the clear liquid secreted by the
 tissue of liver and heart salivary glands in the mouth,
sometimes referred to as “spit.”
Alanine aminotransferase (ALT) Sputum specimens are usually collected for
 Helps to detect and evaluate one or more of the following reasons:
treatment of acute hepatic disease - For culture and sensitivity to identify a
 Assesses the hepatotoxicity of some specific microorganism and its drug
drugs sensitivities.
 tissue of liver - For acid-fast bacillus (AFB), which also
requires serial collection, often for 3
AMYLASE consecutive days, to identify the presence
 An enzyme that helps the body digest of tuberculosis (TB).
starch and glycogen in the mouth, - To assess the effectiveness of therapy
stomach and intestine
 Helps to helps evaluate possible VISUALIZATION PROCEDURES
pancreatic injury - Clients with Gastrointestinal Alterations
Direct visualization techniques include:
LIPASE  Endoscopy – hanggang stomach
 Converts triglycerides and other fats  Anoscopy – viewing of the anal canal
into fatty acids and glycerol  Proctoscopy – viewing of the rectum
 Diagnose acute pancreatitis  Proctosigmoidoscopy – viewing of the
rectum and sigmoid colon
URINE TESTS  Colonoscopy – viewing of the large
Urinalysis intestine.
 Screens for renal or urinary tract
disease and helps detect metabolic - Clients with Urinary Alterations
and systemic disease Visualization procedures also may be used to
These include tests for: evaluate urinary function.
- specific gravity, pH  An x-ray of the
- presence of abnormal constituents: kidneys/ureters/bladder is commonly
- glucose, ketones, protein, and occult referred to as a KUB are taken to
blood. evaluate urinary tract structures.
 Renal ultrasonography is a
STOOL SPECIMENS noninvasive test that uses reflected
 Analysis of stool specimens can sound waves to visualize the kidneys
provide information about a client’s
health condition.
  Cystoscopy, the bladder, ureteral - bones of the body commonly used for a
orifices, and urethra can be directly bone marrow biopsy are the sternum,
visualized using a cystoscope iliac crests, anterior or posterior iliac
Nurses are responsible for preparing clients spines, and proximal tibia in children.
before these studies and for follow-up care.

- Clients with Cardiopulmonary Alterations

A number of visualization procedures can be
done to examine the cardiovascular system
and respiratory tract.
 Electrocardiography (ECG) – provides
a graphic recording of the heart’s
electrical activity.
 Echocardiogram (2D echo) – is a
noninvasive test that uses ultrasound
to visualize structures of the heart
and evaluate left ventricular function.

ASPIRATION/BIOPSY
 Aspiration is the withdrawal of fluid
that has abnormally collected or the
obtaining of a specimen
 Biopsy is the removal and
examination of tissue. Biopsies are
usually performed to determine a
diagnosis or to detect malignancy.
 Both aspiration and biopsy are
invasive procedures and require strict
sterile technique.

Lumbar Puncture – cerebrospinal fluid (CSF) is

withdrawn through a needle inserted into the
subarachnoid space of the spinal canal
between the third and fourth lumbar
vertebrae or between the fourth and fifth
lumbar vertebrae.

Abdominal Paracentesis – carried out to

obtain a fluid specimen for laboratory study
and to relieve pressure on the abdominal
organs due to the presence of excess fluid.

Thoracentesis – to remove the excess fluid or

air to ease breathing.

Bone Marrow Biopsy

- removal of a specimen of bone marrow
for laboratory study
- used to detect specific diseases of the
blood, such as pernicious anemia and
leukemia.
3rd Week PHYSICAL APPEARANCE
Age:
GENERAL SURVEY - The person appears his/her age
 first part of the physical exam that - Appears older than stated years (chronic
begins the moment the nurse meets alcoholism/illness)
the client. Progeria – rare genetic condition that results
 requires the nurse to use all of her in a child’s body aging rapidly
observational skills while interviewing
and interacting with the client. Sex:
 Outcome: provides the nurse with an M – 9 – 14 y.o
overall impression of the client’s F – 8 – 13 y.o
whole being - Sexual development is appropriate for
 During the interview nagra-run na gender and age
yung GS - Delayed or precocious puberty (child’s
 General health state body begins changing into that of an adult
too soon)
 Antecubital area – anterior to the
elbow Level of consciousness:
- The person is alert and oriented, attends
- It is a study of the whole person, covering to questions and responds appropriately
the general health state and any obvious - Confused, drowsy, lethargic
physical characteristics.
- It should give an overall impression, “a Skin color:
gestalt”, of the person - Color tone is even, skin is intact with no
obvious lesions
PURPOSES - Pallor, cyanosis, jaundice, erythema, any
1. Conduct general survey of the client’s lesions
health by gathering subjective and
objective data. Facial features:
2. Use collected data to help assess - Symmetric
client’s general health. - Asymmetric, drooping, masklike
3. Differentiate expected versus
unexpected findings in the physical No signs of distress:
assessment. - DOB, pain, facial grimace

PREPARATIONS BODY STRUCTURE

 Knowledge of norms or expected Stature:
findings is essential in determining - The height appears within the normal
the meaning of the data as one range for age
proceeds. - Excessively short or tall: dwarfism,
 Identify client and introduce self. gigantism
 Provide the client for privacy.
 Perform hand hygiene and adhere to Nutrition:
standard precautions. - Weight appears within normal range for
height
- Underweight, overweight, obesity

Symmetry and posture:

- Body parts look equal bilaterally and are
relatively proportion to each other, stand
comfortably erect at appropriate for age
- Asymmetric body part, unilateral atrophy, DRESS
shoulders slumped, rigid spine and neck - Clothing is appropriate to the climate,
S-shaped – scoliosis looks clean, and fits the body, and is
C-shaped – kyphosis appropriate to the person’s culture and
Unilateral atrophy – progressive atrophy of age group.
one side of body organ - Consistent wear of certain clothing may
provide clues; long sleeves may conceal
Position: needle marks of drug abuse. Wearing
- Person sits comfortably in a chair or on fitted dress may somehow indicate hiding
the bed examination table, arms relax at pregnancy
sides
- Tripod, curled up in fetal position PERSONAL HYGIENE
- Person appears clean and groomed
Body build, contour: appropriately for his/her age, occupation
- Body parts are proportion and socioeconomic growth. However,
- Missing extremities/digits, not proportion culture consideration must be valued.
extremities - Lack of grooming may become sources of
diseases.
MOBILITY
Gait: - person’s manner of walking
Deviations Related to Physical Development,
- Foot placement is accurate, walk smooth,
Body Build, and Fat Distribution
even and we-balanced
- Shuffling, dragging, non-functional leg
Dwarfism – occurs when there is short supply
Range of motion: of GH (growth hormone) in childhood
- note full mobility for each joint, and that Gigantism
movement is deliberate, accurate, Acromegaly – disorder that occurs when your
smooth, and coordinated body makes too much GH
- Limited joint range of motion, paralysis Cushing’s syndrome – moon-shaped face with
(absent of movement) uncoordinated reddened cheeks and increased facial hair

BEHAVIOR ASSESSING VITAL SIGNS

Facial Expression
- expressions are appropriate to the VITAL SIGNS/CARDINAL SIGNS – are
situation measurements of the body's most basic
- Flat, depresses, angry, sad, anxious functions
Mood and affect Four main vital signs routinely monitored by
- comfortable and cooperative with the medical professionals and healthcare
examiner and interacts pleasantly providers include: body temperature, pulse
- Distrustful, suspicious, crying rate, respiration rate, blood pressure, pain
Speech (5th VS)
- articulation is clear and understandable,  They reflect changes in function that
conveys ideas clearly otherwise might not be observed
- Dysphagia, speech defect, garbled speech,
extremes of few words or of constant WHEN TO TAKE VITAL SIGNS
talking o When the client is admitted to a
Schizophrenia – delusions, hallucinations, health care facility
disorganized speech, trouble with thinking o In a hospital or care facility on a
and lack of motivation. routine schedule according to the
 physician’s order or the institution’s 5. Increased temperature of the body
standards of practice cells (fever) – increases the rate of
o Before and after a surgical procedure cellular metabolism and increases
o Before and after an invasive body temperature further.
diagnostic procedure
o Before, during, and after the PROCESS INVOLVED IN HEAT LOSS:
administration of medications 1. Radiation – transfer of heat from the
o When the client’s general physical surface of one object to the surface of
condition changes another without contact between the
o Before and after nursing interventions two objects. (60%)
influencing a vital sign 2. Conduction – transfer of heat from
o When the client reports nonspecific one surface to another. It requires
symptoms of physical distress temperature difference between the
two surfaces. (3%)
BODY TEMPERATURE 3. Convection – dissipation of heat by air
 balance between the heat produced currents. (15%)
by the body and the heat lost from 4. Evaporation – continuous
the body. vaporization of moisture from the
 Measured in degree Celsius/ skin, oral mucous, lungs. (22%)
Fahrenheit.
 normal body temperature: 36.7 C (98 FACTORS AFFECTING TEMPERATURE
F) and 37 C (98.6 F).  36.5 – 37.5 1. Age
2 types: - infant’s body temperature is greatly
1. Core Temperature – deep tissues of affected by the temperature of the
the body environment.
2. Surface Temperature – skin, Elder people are at risk of hypothermia due
subcutaneous tissue and fat to:
 decreased thermoregulatory controls,
FACTORS THAT AFFECT THE BODY’S HEAT  decreased subcutaneous fat
PRODUCTION:  inadequate diet and sedentary
1. Basal Metabolic Rate (BMR) activity.
- rate of energy utilization in the body 2. Diurnal Variations
required to maintain essential activities Highest temperature is usually reached
such as breathing between 4:00PM to 6:00PM
- Decreases with age Lowest temperature is reached between 4:00
- The younger the person, the higher the and 6:00 AM
BMR; the older the person, the lower the 3. Exercise – strenuous exercise
BMR. increases metabolic rate thus, the
body temperature to as high as 38.3 C
2. Muscle Activity – increases metabolic to 40 C. measured rectally.
rate (exercise, swimming, shivering) 4. Hormones – (e.g. progesterone,
3. Thyroxine Output – increases cellular thyroxine, norepinephrine, and
metabolic rate – chemical epinephrine increase body
thermogenesis temperature; estrogen decreases
4. Epinephrine, norepinephrine, and body temperature)
sympathetic stimulation – increases Progesterone – pregnant (increase BT)
the rate of cellular metabolism Thyroxine – goiter
Estrogen – decrease BT
 5. Stress – sympathetic nervous system - Wash the thermometer before use, from
stimulation increases the production the bulb to the stem, after use, from the
of epinephrine and norepinephrine, stem to the bulb.
thereby increasing the metabolic rate - Take oral temperature 2-3minutes.
and heat production.
6. Environment – extremes in  Rectal – most accurate measurement
environmental temperatures can - assist client to assume lateral position
affect a person’s temperature - apply clean gloves
regulatory system. - lubricate thermometer before insertion
- instruct client to take a slow deep breath
ALTERATIONS IN BODY TEMPERATURE during insertion of the thermometer to
 Pyrexia – body temperature above the relax the internal sphincter
normal range. (also hyperthermia, fever) - hold the thermometer in place for 2 mins
 Hyperpyrexia – very high fever, 41 C (for neonates, 5 minutes)
(105.8 F) and above. - do not force insertion of thermometer
 Hypothermia - subnormal core body into a newborn
temperature. This may be caused by
excessive heat loss, inadequate heat  Axillary – safest and most non-
production or impaired hypothalamic invasive
function. - Least accurate and least reliable
Febrile – may fever yung patient - pat dry the axilla
- place the bulb of the thermometer in the
TYPES OF FEVER center of the client’s axilla
1. Intermittent fever: temperature
fluctuates between periods of fever  Ear (Tympanic membrane)
and periods of normal/subnormal - Temperature is easily and safely
temperature. measured
2. Remittent fever: temperature - Reflect core temperature
fluctuates within a wide range over - Permits rapid temperature reading
the 24-hour period but remains above - Infection control is less concern
normal range.
3. Relapsing fever: temperature is LIFESPAN CONSIDERATIONS
elevated for few days, alternated with NEWBORN, INFANTS AND CHILDREN
1 or 2 days of normal temperature. - Newborn have ineffective
4. Constant fever: Body temperature is thermoregulation, environment greatly
consistently high. Very high body affect their temperature
temperatures (41-42 C) cause - Tympanic and Axillary temperature is
irreversible brain cell damage. preferred measurement in infant over 2
mos and children
METHODS OF TEMPERATURE-TAKING ADULTS
 Oral – most accessible and - Alcoholic clients are at risk for
convenient. hypothermia
- allow 30 minutes to elapse between a
client’s intake of hot or cold food or Pulse – wave of blood created by contraction
smoking and the measurement. of the left ventricle of the heart
- Place the thermometer under the tongue, - Regulated by the autonomic NS
directed towards the side of the frenulum
Characteristics of pulse: D. Brachial
RATE/ FREQUENCY:  At the inner aspect of the upper arm
Refers to the number of pulsation per minute (biceps muscles) or medially at the
(ADULT: 60 – 100 beats per minute) antecubital space.
(INFANT: 100 – 160 beats per minute)  Used in BP taking
RHYTHM – refers to the regularity of  Used in cardiac arrest of infants
pulsation occurs E. Femoral
QUALITY – refers to the strength of the  Where the femoral artery passes
palpated pulsation alongside the inguinal ligament.
 Deep palpation may be required
FACTORS AFFECTING PULSE RATE  Used to determine circulation to the
1. AGE leg
INFANT – high pulse rate
ADULT – low pulse rate METHODS OF EXAMINATION
2. AUTONOMIC NERVOUS SYSTEM  Pulse is palpated using first and
- Stimulation of autonomic nervous system second or second and third fingers of
3. MEDICATIONS one hand
Cardiac Meds: Digoxin  Light pressure initially to locate the
Diuretics: Furosemide area of strongest pulsation
- Other medications that mimic or block  Count the rate, determine rhythm
ANS and assess the quality of pulsation
 Count the number for 15, 30, or 60
PULSE SITES seconds and multiply as necessary to
A. Temporal yield pulse per minute
 Over the temporal bone of the head;  Irregular or abnormally slow or fast
superior and lateral to the eye. pulse rates are best assessed for 1 full
 Used when radial pulse is not minutes
accessible
B. Carotid ASSESSING PULSE CHARACTERISTICS
 At the lateral aspect of the neck; Rate
below the ear lobe. The normal pulse rates per minute are as
 Used during cardiac arrest/shock in follows:
adults
 Used to determine circulation to
the brain
 Never palpate bilateral
C. Apical
 Reflects contraction of heart
Tachycardia. Pulse rate above 100 beats/min
ventricles
Bradycardia. Pulse rate of 60 beats/min or
 At the left midclavicular line (MCL)
less
fifth Intercostal space (ICS).
 Routinely used for infants and
children up to 3yrs old
 Used in conjunction in some
medications
RESPIRATION  Cheyne – stokes: with periods of
Respiration: the act of breathing. increased respiratory rate and depth
Ventilation – the movement of gases in and alternating with period of apnea
out of the lungs.  Kussmaul: Increase rate and depth of
 Inhalation (Inspiration) respirations
 Exhalation (Expiration)
Two Types of Breathing: 3. QUALITY
Coastal (thoracic) – involves movement of the - Usually automatic, quiet, and effortless
chest. ABNORMAL FINDINGS:
Diaphragmatic (abdominal) – involves  DYSPNEA: respirations that require
movement of the abdomen. excessive effort
 ORTHOPNEA: Ability to breath only in
MAJOR FACTORS AFFECTING RESPIRATORY upright position
RATE  STRIDOR: harsh inspiratory sounds
Exercise – increases RR that can sound like crowing. It may
Stress – increases RR indicate an upper airway obstruction
Environment – increased temperature –  WHEEZING: high – pitched musical
decreases RR; decreased temperature – sound. It is usually heard on
increases RR. expiration but may be heard on
Increased altitude – increases RR. inspiration. associated with partial
Medications (e.g. narcotics decrease RR) obstruction
Fever – respiratory system releases extra heat  RALES/CRACKLES: small bubbling, or
rattling sounds in lungs. Heard when a
ASSESSING RESPIRATION person inhales
1. RATE: changes with age normal
respiratory rates by age:
 Newborn - 30-80 breaths/min
 1year - 20-40
 5-8years - 15-25
 10years - 15-25
 Teen - 15-20
 Adult - 12-20
 Older adult - 15-20
TACHYPNEA: abnormally fast respiration
BRADYPNEA: abnormally slow respiration BLOOD PRESSURE
APNEA: absence of respiration (synonymous  a measure of the pressure exerted by
to respiratory arrest) the blood as it pulsates through the
arteries
2. RHYTHM AND DEPTH  stated in millimeters of mercury
- It should be regular in rhythm and depth. (mmHg)
- Regularity refers to the pattern of
inspiration and expiration  Systolic Pressure – pressure of blood
- Expiration is normally twice as long as as a result of contraction of the
inspiration ventricles.
ABNORMAL FINDINGS:  Diastolic Pressure – pressure when
 Biot’s: cyclic breathing pattern with the ventricles are at rest.
shallow breathing alternating with  Pulse Pressure – difference between
period of apnea the systolic and diastolic pressures.
 (S – D = P.P.) Normal is 30-40mmHg.  Medications – some medications may
 average BP of healthy adult is 120/80 increase or decrease BP.
mmHg.  Diurnal Variations – BP is lowest in
the morning, and highest in the late
Hypertension – abnormally high blood afternoon or early evening.
pressure over 140mmHg systolic and/or  Disease Process – diabetes mellitus,
90mmHg diastolic for at least two consecutive renal failure, hyperthyroidism,
readings. Cushing’s disease causes increase in
Hypotension – abnormally low blood BP.
pressure, systolic pressure below 100mmHg.
sound heard during BP taking is
DETERMINANTS OF BLOOD PRESSURE Korotkoff sound.
 Blood Volume – hypervolemia raises systolic pressure in the popliteal
BP – hypovolemia lowers BP. artery is usually 10 to 40mmHg higher
 Peripheral Resistance – than that in the brachial artery, the
vasoconstriction elevates the BP, diastolic pressure is usually the same.
vasodilation decreases BP If the bladder cuff is too narrow, BP
 Cardiac Output – when the pumping reading is erroneously high; if too
action of the heart is weak (decreased wide, it is erroneously low.
c.o.), the BP decreases.
 Elasticity or Compliance of Blood
Vessels – in older people, elasticity of
blood vessels decreases thereby
increasing the BP.
 Blood Viscosity (Viscosity increases
markedly when the Hct is more than
60 to 65%) – increases blood viscosity
raises the BP.

FACTORS AFFECTING BLOOD PRESSURE

 Age – older people have higher BP
due to decreased elasticity of blood
vessels.
 Exercise – increases cardiac output;
hence the BP.
 Stress – sympathetic nervous system
stimulation causes increased BP.
 Race – hypertension is one of the 10
leading causes of death among the
Filipinos.
 Obesity – BP generally is elevated
among overweight and obese people.
 Sex/Gender – after puberty and
before age 65 years, males have
higher BP. After age 65 years, females
have higher BP due to hormonal
variations in menopause.
4th Week  Mental status examinations provide
information about cerebral cortex
Assessing Mental Status, Psychosocial, function.
Cognitive, and Moral Development Cerebral abnormalities - disturb the client’s
intellectual ability, communication ability, or
Assessing Mental Status emotional behaviors.
Conceptual Foundations - Assessing mental status often performed
 Mental status – refers to a client’s at the beginning of the head-to-toe
level of cognitive functioning examination.
(thinking, knowledge, problem
solving) and emotional functioning A Quick Check of Mental Status
(feelings, mood, behaviors, stability).
- One cannot be totally healthy without
“mental health.”
- Mental health is an essential part of one’s
total health and is more than just the
absence of mental disabilities or
disorders.

Neurologic Examination
- May take 1 to 3 hours Level of Consciousness
- routine screening tests are usually done Alert/Full Consciousness
first.  Follows commands and responds
If the results of these tests raise questions, appropriately to stimuli
more extensive evaluations are made. Lethargic
Three major considerations determine the  Drowsy and has delayed responses to
extent of a neurologic exam: the client’s verbal stimuli
1. chief complaints Obtunded
2. physical condition  Difficult to arouse and needs constant
3. willingness to participate and stimulation in order to follow a simple
cooperate. command.
Levels of Neurologic Function  May respond verbally with 1 0r 3
- Mental Status & Speech words
- Level of Consciousness Stuporous
- Cranial Nerve Function  Requires vigorous stimulation for a
- Sensory Function response. A painful stimulus is
- Motor Function required.
- Reflexes  May moan briefly but doesn’t follow
 A complete neurologic examination commands.
consists of evaluating the following Comatose
five areas: mental status, cranial  Doesn’t respond to verbal or painful
nerves, motor/sensory system, stimuli
reflexes
 examinations may be performed in an GLASGOW COMA SCALE
order that moves from a level of - was first published in 1974 at the
higher cerebral integration to a lower University of Glasgow by neurosurgery
level of reflex activity professors Graham Teasdale and Bryan
Jennett.
  developed to predict recovery from a VERBAL RESPONSE
head injury Response Score
 However, it is used by many Oriented, converses 5
professionals to assess LOC. Disoriented, converses 4
Three major areas: Uses inappropriate words 3
 EYE response Makes incomprehensible 2
 VERBAL response sounds
 MOTOR response No response 1
- 15 points indicates the client is alert and
completely oriented. Oriented
- comatose client scores 7 or less  It is the highest level of response and
implies awareness of self and
EYE OPENING environment.
- useful as a reflection of the intensity of  The person should be able to provide
impairment of activating functions answers to at least three questions,
Response Score 1. who they are
Spontaneous 4 2. where they are
To verbal command 3 3. the date – at least in terms of the year the
To pain 2 month and day of the week
No response 1 Confused conversation
 It is recorded if the patient engages in
Spontaneous Eye Opening: conversation but is unable to provide
 It indicates arousal mechanisms brain any of the foregoing three points of
stems are active information.
 It does not imply awareness.  The key factor is that the person can
Eye Opening in Response to Speech produce appropriate phrases or
 It is sought by speaking or shouting at sentences.
the patient. Inappropriate Speech
 Any sufficiently loud sound can be  It is assigned if the person produces
used, not necessarily a command to only one or two words, in an
open the eyes. exclamatory way, often swearing.
Eye Opening Response to Pain  It is commonly produced by
 It is assessed if the person is not stimulation and does not result in
opening their eyes to sound. sustained conversation exchange.
 should not cause unnecessary injury Incomprehensible Sounds
to the patient.  It is consisting of moaning and
 stimulus should be pressure on the groaning but without any
bed of a fingernail or supraorbital recognizable words.
nerve.  It is commonly produced by
Absence of Eye Opening stimulation and does not result in
 It implies substantial impairment of sustained conversation exchange.
brain stem arousal mechanisms. No Verbal Response
 Substantial effort should be made  No verbal response upon pain
earlier to ensure that this is not due stimulus.
to an inadequate stimulation.  Substantial effort should be made
earlier to ensure that this is not due
to an inadequate stimulation.
MOTOR RESPONSES
- The assessment of motor responsiveness
becomes important in a person not
conversing to at least a confused level
Response Score
To verbal command 6
To localized pain 5
Flexes and withdraws 4
Flexes abnormally 3
Extends abnormally 2 Growth and Development
No response 1  No single theory has been formulated
to embrace all aspects of why humans
Obeying Commands behave, think, or believe the way they
 It is the best response possible. do.
 Confirmation of the specificity of the  New theories continue to emerge in
response by squeezing and releasing an attempt to explain human conduct.
the fingers or holding up the arms or  The developmental theories
other movement elicited by verbal presented in this chapter focus on the
command. GROWTH (addition of new skills or
Localization components) and DEVELOPMENT
 It is done with the application of (refinement, expansion or
pressure on the supraorbital notch improvement of existing skills or
 Localizing should be recorded only if components) of an individual
the person’s hand reaches above the throughout the life span.
clavicle in an attempt to remove the  Each theorist varies on how to
stimulus. categorize the phases of the life cycle
 If in doubt, stimulation can be applied (e.g., infancy, adolescence,
to more than one site to ensure that adulthood).
the hand attempts to remove it Life Stages
Withdrawal Response 1. Infancy (birth – 2 years)
 It is recorded if the elbow bends away 2. Early Childhood (2 – 6 years)
from pain stimulus, but the movement 3. Middle Childhood (6 to 12 years)
is not sufficient to achieve localization 4. Adolescence (12 – 18 years)
Abnormal Flexion Response (Decorticate) 5. Early Adulthood (18 – 35 years)
 It is recorded if the elbow bends in 6. Middle Adulthood (35 – 60 years)
decorticate posturing, the movement is 7. Late Adulthood/Old Age (61 years and
not sufficient to achieve localization above)
Extension Response (Decerebrate)
 It is recorded if the elbow only Functions of Developmental Theories
straightens, the movement is not  Organize the knowledge that we
sufficient to achieve localization already have
Absence of Motor Response  Help us make predictions about new
 It is recorded if no limb movement upon information that we can investigate
pain stimulus and test

Growth
- refers to an increase in physical size of the 3. SUPEREGO – concept of the
whole body or any of its parts conscience or sense of right or wrong
- a quantitative change in the child’s body (based more on moral value)
Development - Morality (I should)
- refers to a progressive increase in skill and
capacity of function Psychosexual Stages of Development
- a qualitative change in the child’s  At each stage, sexual energy is
functioning invested in a different part of the
- can be measured through observation body, and gratification of the urges
associated with those areas of the
THEORY OF PSYCHOSEXUAL DEVELOPMENT body is particularly pleasurable
Sigmund Freud (1935) – a Viennese physician,  The way in which gratification of
developed the first formal theory of urges is handled during each of these
personality stages determines the nature of the
- originated the concept of psychoanalysis adult’s personality and character
and that believed personality Fixation: getting stuck or fixated in one of the
development was based on first three stages if needs are not adequately
understanding the individual life history met at that stage, or if so much gratification
of a person. was received that the person is not willing to
move on to another stage, that person will
Freud’s Major Concepts and Terms then exhibit characteristics of that stage later
A. Parts of the Mind According to Freud in life.
1. CONSCIOUSNESS – whatever a person
is sensing, thinking about, or 1. ORAL STAGE (birth – 18 months)
experiencing at any given moment.  Pleasure derived from the mouth—such
2. PRECONSCIOUSNESS – involves all of as sucking, eating, chewing, biting, and
a person’s memories and stored vocalizing—serve to reduce the infant’s
knowledge that can be recalled and tension.
brought to the conscious level.  id controls this stage
3. UNCONSCIOUSNESS – largest and oral fixation: overeating, smoking, chewing
most influential. socially unacceptable
sexual desires, shameful impulses, 2. ANAL STAGE (18 months – 3 years)
irrational wishes, as well as anxieties pleasure zone: anus
and fears. stage task: control bodily urges
 Pleasure involves the elimination of
Parts of Personality According to Freud feces. As the ego develops, the child
1. ID – part of personality that consists decides to expel or retain the bowel
of basic drives, such as sex and movement
hunger (pleasure principle) anal compulsive: over controlled, everything
- Instincts (I want) has to be in its place
2. EGO – part of personality that anal expulsive: disorganized
contends with the reality of the world
based more on what others will think 3. PHALLIC STAGE (3 – 6 years)
or what the consequences of an  Pleasure is derived from the genital
action could be (controls basic drives region.
and reality principle)  This can involve exploring and
- Reality (I will) manipulating the genitals of self and
others.
  A child can express curiosity about how
a baby is “made” and born.
stage task: learn to identify with parent of
same sex
Electra complex – girls imagine marrying their
fathers
Oedipus complex – boys imagine marrying
their mothers

4. LATENCY STAGE (6 – 11 years)

pleasure zone: none
stage task: transfer interest from parents to
1. TRUST vs MISTRUST (Infancy)
peers
 As infants, we depend on our caregivers
 child develops more intellectual and
to provide for our basic needs, and
social skills.
develop trust when these needs are
 a time of school activities, hobbies,
met. Otherwise, we may grow up to be
sports, and for developing friendships
suspicious and mistrustful.
with members of the same sex.
2. AUTONOMY vs SHAME vs DOUBT
5. GENITAL STAGE (12 years and above)
(Infancy – Early Childhood)
pleasure zone: genitals
 Learn skills to cope with the world in a
stage task: form intimate relationships
confident way, failure to gain self-
 individual will develop heterosexual
control leads children to doubt their
attachments outside of the family
abilities
 Romantic love can lead to successful
marriage and parenting.
3. INITIATIVE vs GUILT (Early Childhood)
 Children must learn how to initiate own
activities or have a sense of inadequacy
or guilt to be on their own

4. INDUSTRY vs INFERIORITY (Middle

Childhood)
 During this time, children feel proud of
their accomplishments or, at times, fear
that they do not measure up

THEORY OF PSYCHOSOCIAL DEVELOPMENT 5. IDENTITY vs ROLE CONFUSION

Erik Erikson – was a psychoanalyst who (Adolescence)
adapted and expanded Sigmund Freud’s  As teens, adolescents typically try to
psychosexual theory. understand who they are, but this can
 Stages of development based on a sometimes lead to confusion.
central conflict to be resolved
involving the social world and the
development of identity 6. INTIMACY vs ISOLATION (Early
 Resolving conflict lays the Adulthood)
groundwork for the next stages of  Adults often seek intimacy in order to
development avoid feeling isolated
  Reliance of thinking processes on
7. GENERATIVITY vs STAGNATION perception more than logic
(Middle Adulthood) Symbolic Thinking – the ability to use symbols
 Adults focus on establishing their to represent things.
careers and families. If they are - A tin can can represent telephone
unsuccessful, they can feel stagnant. - A Stop Sign means to STOP!
Egocentrism - child is aware only of himself
and his own likes, dislikes, and wants
8. INTEGRITY vs DESPAIR (Late
- they cannot see other people’s
adulthood/Old Age) perspectives
 Adults contemplate the integrity of
their lives and accomplishments. If they 3. CONCRETE OPERATIONAL STAGE
do not feel accomplished, they may - Lasts from 7-11 years of age
experience despair  The child has the ability to do simple
math and measurement, with
COGNITIVE DEVELOPMENT: Jean Piaget manipulatives
- suggests that children move through four  they begin to understand cause &
different stages of mental development. effect
 Piaget believed that children take an  they can think about real, concrete
active role in the learning process, things in systematic ways, but cannot
understand abstract concepts
acting much like little scientists as
 no longer egocentric (he can now
they perform experiments, make
understand other people’s points of
observations, and learn about the
view)
world.  Conservation - idea that the
 As kids interact with the world around amount of a substance remains
them, they continually add new the same regardless of its
knowledge, build upon existing container shape or how many
knowledge, and adapt previously held pieces and shapes the substance
ideas to accommodate new is transformed into.
information.
 Classification - ability to group
1. SENSORIMOTOR STAGE objects on the basis of common
- Lasts from birth to 2 years of age characteristics.
The child:
 Seriation - ability to put objects in
 Dependence of thinking processes and
order by height, weight, or some
understanding on sensory and motor
other quality.
processing (e.g., tasting, touching,
grasping)  Reversibility - the ability to
 begins to use language to imitate and mentally trace back how a
represent the environment substance that has changed into a
Object Permanence - idea that object exists certain state may revert to its
even when they can’t be seen. original state
ex. 1+1 = 2 ; 2 – 1 = 1

2. PRE-OPERATIONAL STAGE 4. Formal operational stage

- Lasts from 2-7 years of age - Lasts from about 12 years to adulthood
 child begins to represent the world  A child is able to think and reason in
with words and images. purely abstract terms (in his head,
 without having concrete items in - At this age, children's decisions are
front of him) primarily shaped by the expectations of
 able to use logic and abstract thinking adults and the consequences for
 They question previously accepted breaking the rules.
thoughts, ideas and values. There are two stages within this level:

THEORY OF MORAL DEVELOPMENT

Stage 1 (Obedience and Punishment)
Lawrence Kohlberg – a psychologist,
Stage 2 (Individualism and Exchange)
expanded Piaget’s thoughts on morality; in
doing so, he developed a comprehensive  At the individualism and exchange
theory of moral development. stage of moral development, children
- proposed, individual morality has been account for individual points of view
viewed as a dynamic process that and judge actions based on how they
extends over one’s lifetime, primarily serve individual needs.
involving the affective and cognitive  Reciprocity is possible at this point in
domains in determining what is “right” moral development, but only if it
and “wrong.” serves one's own interests
- It has also been frequently associated LEVEL 2 – Conventional Morality
with those requirements necessary for  The next period of moral
people to live together and coexist in a development is marked by the
group.
acceptance of social rules regarding
what is good and moral.
STAGES OF MORAL DEVELOPMENT
- Broken down into 3 primary levels  During this time, adolescents and
- each level of moral development, there adults internalize the moral standards
are two stages. they have learned from their role
- similar to how Piaget believed that not models and from society.
all people reach the highest levels of  This period also focuses on the
cognitive development acceptance of authority and
- Kohlberg believed not everyone conforming to the norms of the
progresses to the highest stages of group.
moral development. There are two stages at this level of morality:

Stage 3 (Developing Good Interpersonal

Relationships)
 Often referred to as the "good boy-
good girl" orientation, this stage of
the interpersonal relationship of
moral development is focused on
living up to social expectations and
roles.
 There is an emphasis on conformity,
being "nice," and consideration of
how choices influence relationships.

LEVEL 1 – Pre-conventional Morality

- Earliest period of moral development.
Stage 4 (Maintaining Social Order)
- It lasts until around the age of 9.
 This stage is focused on ensuring that
social order is maintained.
  At this stage of moral development,
people begin to consider society as a
whole when making judgments.
 The focus is on maintaining law and
order by following the rules, doing
one’s duty, and respecting authority.

LEVEL 3 – Post-conventional Morality

- At this level of moral development,
people develop an understanding of
abstract principles of morality.
The two stages at this level are:

Stage 5 (Social Contract and Individual

Rights)
 The ideas of a social contract and
individual rights cause people in the
next stage to begin to account for
the differing values, opinions, and
beliefs of other people.
 Rules of law are important for
maintaining a society, but members
of the society should agree upon
these standards.

Stage 6 (Universal Principles)

 Kohlberg’s final level of moral
reasoning is based on universal
ethical principles and abstract
reasoning.
 At this stage, people follow these
internalized principles of justice, even
if they conflict with laws and rules.

Kohlberg believed that only a

relatively small percentage of people
ever reach the post-conventional
stages (around 10 to 15%).
One analysis found that while stages
one to four could be seen as universal
in populations throughout the world,
the fifth and sixth stages were
extremely rare in all populations.
5th Week  Albinism – generalized loss of
pigmentation
Nursing Assessment of Physical Systems  Erythema – skin redness and warmth
SKIN, HAIR AND NAIL ASSESSMENT is seen in inflammation, allergic
reactions, or trauma
Physical Assessment: Skin Erythema in the dark-skinned client: affected
1. Inspection skin feels swollen and warmer than the
1.1 Inspect General skin coloration surrounding skin
 Pallor (loss of color) – seen in arterial Common skin variations
insufficiency, decreased blood supply, o Freckles – flat, small macules of
and anemia. pigment that appear following sun
 Cyanosis – may cause white skin to exposure
appear blue-tinged, especially in the o Seborrheic Keratosis – warty or crusty
perioral, nail bed, and conjunctival pigmented lesion
areas. o Vitiligo – may be related to a
- Dark skin may appear blue, dull and dysfunction of the immune system
lifeless in the same areas. o Striae – sometimes called stretch
Central cyanosis – results from a marks
cardiopulmonary problem o Scars – suggest a healed injury or
Peripheral cyanosis – local problem resulting surgical intervention
from vasoconstriction. o Cutaneous tag – raised yellow
- To differentiate the two by look for papules with a depressed center.
central cyanosis in the oral mucosa. o Cherry angiomas – small raised spots
Circumoral cyanosis – blue discoloration (1–5 mm wide) typically seen with
around the mouth only aging. (common sa mapuputi)
Tetralogy of fallot – causes low oxygen levels o Mole (also called nevus) – flat or
in the blood raised tan/brownish marking up to 6
Acrocyanosis – blueness of the extremities mm wide
(the hands and feet) and the center of your
face like the nose and ears 1.3 Check skin integrity
- especially carefully in pressure point
 Jaundice – in light- and dark-skinned areas
people is characterized by yellow skin  Skin breakdown is initially noted as a
tones, from pale to pumpkin, reddened area on the skin that may
particularly in the sclera, oral mucosa, progress to serious and painful
palms, and soles. pressure ulcers
 Acanthosis nigricans – roughening  reddened areas may not be
and darkening of skin in localized prominent: skin may feel warmer in
areas, especially the posterior neck. the area of breakdown

1.2 Inspect for color variations Bedridden – bedsores

 Rashes – reddish (in light-skinned - mas bumibigat yung katawan
people) - turn the patient every 2hrs.
- darkened (in dark-skinned people)
 Butterfly rash – across the bridge of
the nose and cheeks, characteristic of
discoid lupus erythematosus (DLE).
Common Pressure Ulcer Sites STAGE 4
 Full-thickness tissue loss with exposed
bone, tendon, or muscle.
 Slough or eschar may be present on
some parts of the wound be
 Ulcers can extend into muscle and/or
supporting structures
 Wound debridement – removing
unhealthy tissue from the body
UNSTAGEABLE
 Full-thickness tissue loss
 base of the ulcer is covered by slough
(yellow, tan, gray, green, or brown)
and/or eschar (tan, brown, or black)
in the wound bed.

1.4 Inspection for lesions

- Observe the skin surface to detect
abnormalities.
Identification of Pressure Ulcer Stage - Note color, shape, and size of lesion.
STAGE 1 - Lesions may indicate local or systemic
 Intact skin with non-blanchable problems.
redness of a localized area usually
over a bony prominence. Primary lesions – arise from normal skin due
to irritation or disease.
 Darkly pigmented skin may not have
Secondary lesions – arise from changes in
visible blanching; its color may differ
primary lesions.
from the surrounding area
 may be painful, firm, soft, warmer, or
PRIMARY SKIN LESIONS
cooler as compared to adjacent
Type and Description Examples
tissue.
Macule, Patch Freckles
STAGE 2
Flat, non-palpable skin Flat moles
 Partial thickness loss of dermis
color change (skin color Petechiae
presenting as a shallow open ulcer may be brown, white, tan Rubella
with a red-pink wound bed, without purple, red) Vitiligo
slough. Macule: < 1 cm, Port wine
 May also present as an intact or circumscribed border stains
open/ruptured serum-filled blister. Patch: > 1 cm, may have Ecchymosis
STAGE 3 irregular border
 Full-thickness tissue loss.
 Subcutaneous fat may be visible but Type and Description Examples
bone, tendon, or muscle is not Papule, Plaque Papules:
exposed. Elevated, palpable, solid Elevated nevi
 may be present but does not obscure mass; circumscribed Warts
border Lichen planus
the depth of tissue loss
Papule: < 0.5 cm Plaques:
 May include undermining and
Plaque: > 0.5 cm Psoriasis
tunneling (may be coalesced Actinic keratosis
papules w/ flat top)
Type and Description Examples
Nodule, Tumor Nodules:
- Elevated, solid, Lipoma
palpable mass Squamous cell
- Extends deeper carcinoma
into dermis than a Poorly absorbed
papule injection
Nodule: 0.5-2 cm; Dermatofibroma
circumscribed Tumors:
Tumor: > 1-2 cm; does Larger lipoma
not always have sharp Carcinoma
borders

Type and Description Examples

Vesicle, Bulla Vesicles:
Circumscribed elevated, Herpes
palpable mass containing simplex/zoster
serous fluid Varicella
Vesicle: < 0.5 cm (chickenpox)
Bulla: > 0.5 cm Poison ivy
Second-
degree burn
Bulla:
Pemphigus
Contact
dermatitis
Large burn
blisters
Poison ivy
Bullous
impetigo

Type and Description Examples

Wheal Freckles
- Elevated mass w/ Flat moles
transient borders Petechiae
- Often irregular Rubella
- Size and color vary Vitiligo
- Caused by Port wine
movement of serous stains
fluid into the dermis Ecchymosis