CA-1a-csmsmmsmssmsmsmsmsmsmompressed.pdf

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1. Welcome NLE Board Passers &
Topnotchers! Aura Ydda Alyne Toreja Tuiza, MAN, RN
“Have I not commanded you?
Be strong and courageous.
Do not be afraid and dismayed.
For the Lord your God is with
you wherever you go.”
-Joshua 1:9 “We are the light in institutional
darkness, and in this model we get to
return to the light of our humanity.”
— Jean Watson, 2012 CRITERIA OF A PROFESSION
Body of Knowledge
Ongoing Research
Service Orientation
Code of Ethics
Autonomy
Professional Organization

2. F
L
O
R
E
N
C
E
ounder of Modern Nursing
ightingale Training School for Nurses
N tes on Nursing: What It Is and What It Is Not
ady with the LAMP
ich and intellectual family
alled by God to help others…
nvironmental Theory
F rst Scientist - Theorist
CRIMEAN WAR –
SIR SIDNEY HERBERT
Lydia Hall
Hildegard Peplau
Virginia Henderson
Faye Abdellah
Ida Jean OrlandoInterpersonal Relations Theory 14 Basic Needs Theory 21 Nursing Problems The Nursing Process Core, Care, Cure Environmental Theory Human Caring Theory Theory of Bureaucratic Caring
Florence Nightingale
Jean Watson
Marilyn Anne Ray Novice to Expert Theory Theory of Caritative Caring Philosophy of Caring Patricia Benner Katie Eriksson Kari Martinsen
Martha Rogers Unitary Human Beings
Dorothea Orem Self-Care Deficit Theory
Imogene King Goal Attainment Theory
MYRA Levine Conservation Theory
Madeleine Leininger Transcultural Nursing Theory
Humanbecoming Theory
Rosemarie Rizzo ParseBehavioral System Model
Dorothy Johnson

3. STAGE I: NOVICE
STAGE II: ADVANCED BEGINNER
STAGE III: COMPETENT
STAGE IV: PROFICIENT
STAGE V: EXPERT
Benner’s Stages of Nursing Expertise (NAB CPE)
Performance is limited, inflexible, and governed regulations.
Demonstrates marginally acceptable performance.
2 or 3 years of experience. Coordinates multiple complex care
demands.
3 to 5 years of experience. Uses maxims as guides for what
to consider in a situation. Focuses on long-term goals.
Highly skilled intuitive and analytic ability. Takes certain action because “it felt right.”
THE EVOLUTION OF NURSING
INTUITIVE PERIOD
APPRENTICE PERIOD
EDUCATIONAL PERIOD
CONTEMPORARY PERIOD
DARK PERIOD
-Founder of Filipino Nurses Association
(now PNA)
-Graduated at the PGH School of Nursing
Anastacia Giron-Tupas
FILIPINO NURSING LEADERS
Rosario Delgado- 1st President of the PNA
Loreto Tupaz- Florence Nightingale of Iloilo
Julita V. Sotejo
-She tackles on the development of a nursing education
within a University-based College of Nursing.
Vital Signsthoughtful, scientific assessment
The body’s indicators of health.

4. Times to Assess Vital Signs
Admission
Change in health status
Before and after SMN
Surgery
Med admin
Nursing intervention
Body Temperature
BMR — number of calories you burn as your body
performs basic life-sustaining function
Core
Surface
— skin, subcutaneous tissue
— rises and falls in response to the
environment
— deep tissues of the body
— constant
Radiation — transfer of heat without
contact between the two objects
(infrared rays).
Conduction — transfer of heat from one molecule to a
molecule of lower temperature through physical contact.
Convection — dispersion of heat
by air currents.
Evaporation — continuous
vaporization of moisture from the
respiratory tract and mucosa of the
mouth and from the skin.

5. Assessing Body Temperature
Oral
Rectal
Axillary
Tympanic
Temporal Artery
Convenient and Accessible
Reliable
Safe and Non Invasive
Readily Accessible; Very fast
Safe and Non Invasive, Very fast
Assessing Body Temperature
Oral Convenient and Accessible
Thermometers can break if bitten.
Inaccurate (ingested hot or cold food or fluid or smoked [wait for 30 mins]).
Could injure the mouth following oral surgery.
For older children and adults (awake, alert, cooperative)
RectalReliable
Contraindicated:
Rectal sx & diarrhea
Immunosuppressed
Clotting disorder
Hemorrhoids
Assessing Body Temperature
Adults who require very accurate core temperature
Di�icult for client who cannot turn to the side.
Could injure the rectum.
Presence of stool may interfere with placement.
Place the thermometer
• Apply a probe cover
•Lubricate rectal thermometer
AxillarySafe and Non Invasive
The thermometer may
need to be left in place
a long time to obtain
an accurate
measurement.
Assessing Body Temperature
Infants, young children, adults, anyone with altered immune system

6. Tympanic Readily Accessible; Very fast
Can be uncomfortable and involves
risk of injuring the membrane if the
probe is inserted too far.
Presence of cerumen can affect the
reading.
Assessing Body Temperature
All clients except with ear infection or ear pain
Temporal ArterySafe and Non Invasive
Very fast
Electronic equipment that may
be expensive or unavailable.
Variation in technique needed if
the client has perspiration on
the forehead.
Assessing Body Temperature
All clients unless sweating profusely
Intermittent Fever
Relapsing Fever
Remittent Fever
Constant Fever
Fever — Normal — Fever
Fever — Fever — Fever
— alternates at regular intervals
— wide range of temperature
fluctuations (more than 2°C)
— few days febrile periods with periods of
1 or 2 days of normal temperature
— minimal fluctuations
Vital Signs: Temperature
ON and OFF within regular intervals?
ON and OFF within days?
Fever… with wide fluctuations?
Fever… with minimal fluctuations?
Intermittent
Relapsing
Remittent
Constant
C = (Fahrenheit temperature - 32) * 5/9
F = (Celsius temperature * 9/5) + 32

7. Heat exhaustion — 38.3°C to 38.9°C
Paleness
Nausea, Vomiting
Dizziness, Fainting
Heat stroke — 41.1°C or higher (warm flushed skin)
DO NOT sweat
Delirious, unconscious,(+) seizures
Pulse
The pulse is a wave of blood created by
contraction of the left ventricle of the heart.
Central Pulse
Peripheral Pulses
In a healthy individual, the pulse reflects the heartbeat.
Pulse Rate = Ventricular Contractions
Assessing the Pulse
Palpation for Peripheral
Pulses
Moderate pressure using three Middle
fingers.
Auscultation for Apical
Pulse
Assess the rate, rhythm, volume, arterial wall elasticity, and presence
or absence of bilateral equality.
A forceful pulse volume is full; an easily obliterated pulse is weak.
Amplitude can be quantified as follows:
3+ Bounding (requires firm pressure)
2+ Normal (obliterate with moderate pressure)
1+ Weak, diminished (easy to obliterate)
0 Absent

8. Physically active — checking Pulse
Pipteen (wait 10 to 15 minutes) until
the client has rested and the pulse has
slowed to its usual rate.
Apical Pulse Assessment
Position:
Di�iculty hearing the apical pulse?
Disinfect stethoscope?
Warm the diaphragm
Supine or sitting
Roll onto left side or the sitting client to
lean slightly forward.
Use antiseptic wipes
(earpieces, diaphragm)
By holding it in the palm of the hand for a moment.
Apical-Radial Pulse Assessment
An apical pulse rate greater than a radial pulse rate can indicate that the thrust of the
blood from the heart is too weak for the wave to be felt at the peripheral pulse site.
Any discrepancy between the two pulse rates is called a pulse deficit.
Vital Signs: Pulse
Doppler ultrasound stethoscope — detects
movement of red blood cells through a blood
vessel.
Pulses that are difficult to assess?
Apply transmission gel.
Use light pressure and keep the probe in contact with the skin.
Distinguish sounds.
Artery — pulsating and pumping quality
Vein — intermittent and varies with respirations

9. Vital Signs: Respirations
Rhythm
Rate
—short breaths followed by long irregular periods of apnea
—rhythmic waxing and waning of respirations, from very
deep to very shallow breathing and temporary apnea
Biot breathing
Cheyne-Stokes
breathing
—characterized by rapid, deep breathing at a consistent
pace
Kussmaul breathing
Skin and mucous membrane color
Signs lack of oxygen (irritability, restlessness, drowsiness)
Assessing Respirations
P
C
S
Position
Chest movements
Chest pain
Vital Signs: Respirations
Audible Without Amplification
Bubbling
—a shrill, harsh sound heard during inspiration
Stertor
Wheeze
Stridor
—snoring respiration
— musical squeak or whistling sound occurring
on expiration and sometimes on inspiration
—gurgling sounds as air passes moist
secretions in respiratory tract

10. — is a measure of the pressure exerted by the
blood as it flows through the arteries.
Blood Pressure
Arterial blood pressure is the result
of several factors:
Blood volume
Blood viscosity
Pumping action
Peripheral vascular resistance
The American College of Cardiology and the American Heart Association (Cifu & Davis, 2017)
define normal blood pressure as systolic less than 120 mmHg and diastolic less than 80
mmHg
The width should be 40% of
the circumference of the limb
on which it is used.
Vital Signs: Blood Pressure
The length of the bladder
should be su�iciently long
to cover at least two-thirds
of the limb’s circumference.
C U F F
When taking a blood pressure using a stethoscope, the nurse
identifies phases in the series of sounds called Korotkoff sounds.
An auscultatory gap is the
temporary disappearance of
sounds normally heard over
the brachial artery when the
cuff pressure is high followed
by the reappearance of the
sounds at a lower level.
Selected Sources of Error
in Blood Pressure Assessment
Erroneously HIGH
Unsupported arm
Too narrow bladder cuff
Insu�icient rest, assessing immediately after meal
Cuff wrapped too loosely or unevenly
Erroneously LOW
Auscultatory gap
Wide bladder cuff
Arm above level of heart
(-) smoked (-) ingested caffeine within
30 minutes prior to measurement

11. Arteriovenous fistula
Blood pressure is not measured on a particular
client’s limb if:
C
I
S
A
Cast or bulky bandage is on any part of the limb.
Intravenous infusion or blood transfusion or Injury
in that limb.
Surgical removal of breast or axillary (or inguinal)
lymph nodes on that side.
Thigh Blood Pressure
Prone or supine position
with the knee slightly
flexed
Locate the Popliteal artery
Wrap the cuff evenly around the midthigh
Position?
How?
Waiting Time
Thermometer — Thirty mins — hot or cold food or fluid or smoked
wait for 30 mins
Smoked or ingested caffeine — 30 minutes prior to BP
measurement
Exercising client — Rest for a few minutes to permit the
accelerated respiratory rate to return to normal.
T
P
R
BP
Physically active prior to checking Pulse
Pipteen mins — (10 to 15 minutes) until client rested, pulse slowed down
Pulse oximeter — measures blood oxygen saturation
(SpO2) by means of a sensor attached to the client’s finger,
toe, nose, earlobe, or forehead.
Use a nasal sensor or a reflectance sensor on the forehead for patients
with low tissue perfusion (peripheral vascular disease or therapy using
vasoconstrictive medications).
The oxygen saturation value is the percent of all hemoglobin binding
sites that are occupied by oxygen.

12. Remove client’s dark nail polish.
Inspect and change location of:
Minimize motion artifacts by using an adhesive sensor,
changing the sensor location
Co
Co
R
I
M
mpare the pulse rate (oximeter vs radial pulse)
ver the sensor to block light from sunlight or bilirubin lights
Spring-tension sensor — every 2 hours
Adhesives (toe or finger sensor) — every 4 hours Carbon monoxide poisoning
Factors Affecting Oxygen Saturation Readings
Hemoglobin.
Impaired Circulation — poor blood flow to the extremities
Activity — excessive movement of the sensor site. Nursing Process
Data from each phase provide input into the next
phase. Hence, it is a regularly repeated event that
is continuously changing: ___________________
The nurse organizes the plan of care according to
the client problems: _________________
It requires the nurse to communicate directly and
consistently with clients, families and members
of the health care team: _____________________
Cyclic and Dynamic
Client Centered
Interpersonal & Collaborative
Nursing Process

13. A D P I E
Assessment Diagnosing Planning Implementing Evaluating
Collect data
Organize
Validate
Document
Analyze data
Identify health
problems, risks, strengths
Formulate diagnostic
statements
Prioritize problems / diagnoses
Goals / desired outcomes
Select intervention nursing
Write nursing interventions, NCP
Reassess
Assistance?
Implement Nsg Int
Delegated care (supervise)
Document
JUDGE
Collect data and compare with
outcome
Relate nsg action to goals
Draw conclusion
Continue, modify, terminate care plan
Types of Assessment
I
P
E
T
Initial assessment
Problem-focused assessment
Emergency assessment
Time-lapsed reassessment
To establish a complete database for problem identification and future comparison
To determine the status of a specific problem identified in an earlier assessment
During any physiologic or psychologic crisis of the client
To compare the client’s current status to baseline data previously obtained
Status of the Nursing Diagnoses
Actual nursing diagnosis
Health promotion diagnosis
Risk nursing diagnosis
Syndrome diagnosis
— client problem that is present at the time of the nursing
assessment
— clients’ preparedness to implement behaviors to improve
their health condition.
— several similar
nursing diagnoses
— a clinical judgment that a problem does not exist, but the
presence of risk factors indicates that a problem is likely to
develop unless nurses intervene
Willingness to learn about the health
maintenance
Altered respiratory status
Risk for or Potential for impaired breathing
patterns
Impaired respiratory status related to increased secretions and
restricted pulmonary airflow related to a lack of alveoli elasticity.
Fluid replacement related to fever
Alteration in fluid volume related to fever
State in terms of problem, not a need.

14. Altered skin integrity related to improper
positioning
Altered skin integrity related to immobility
Word the statement so that it is legally
advisable
Impaired spirituality related to strict rules
necessitating church attendance
Impaired spirituality related to inability to
attend church services secondary to
immobility
Use non judgmental statements
Altered skin integrity related to
ulceration of sacral area
Potential for altered skin integrity
related to immobility
Make sure that both elements of the
statement do not say the same thing.
Potential for pneumonia
Potential for altered respiratory status
related to accumulation of secretions in
lungs
Use nursing terminology rather than
medical terminology to describe the
client’s response.

15. Types of Planning
Initial Planning
Ongoing Planning
Discharge Planning
Planning begins with the first client contact and continues until the nurse–client relationship ends
The nurse who performs the admission assessment
usually develops the initial comprehensive plan of care.
All nurses who work with the client do ongoing planning.
Effective discharge planning begins at first client contact.
Determine Client Status
Set Priority
Coordinate nurse’s activity
Selecting Nursing Interventions and Activities
Independent
interventions are
those activities that
nurses are licensed to
initiate on the basis of
their knowledge and
skills.
Ex: Physical care, emotional
support and comfort,
teaching, environmental
management, and referrals to
healthcare professionals
Dependent
interventions are
activities carried out
under the orders of a
licensed physician.
Ex: Medications, intravenous
therapy, diagnostic tests,
treatments, diet, and activity.
Collaborative
interventions are
actions the nurse
carries out in
collaboration with
other health team
members (physical
therapists, social
workers, dietitians)
While choosing and writing nursing interventions on the
client’s care plan, determine who should actually
perform the activity.
A licensed nurse has the responsibility to maintain accountability for a client when
care has been delegated to a licensed practical or vocational nurse or to a certified
nursing assistant or medication aid.
P
E
R
A
V
Positioning
Eating
Recording I & O
Ambulating
*Vital Signs, Bathing
NEVER delegate
A licensed nurse has the responsibility to maintain accountability for a client when care
has been delegated to a licensed practical or vocational nurse or to a certified nursing
assistant or medication aid.
U
E
A
T
Unstable clients
Evaluation
Assessment
Teaching
New admission, returning to floor after
procedure, post-operative, unstable VS,
blood sugar, neuro status
Interpreting data
Lab values, Pain, Vital Signs
INITIAL, FIRST, PRIMARY Assessment
INITIAL, FIRST, PRIMARY Education

16. Implementing the Nursing Interventions
A
Adapt activities to the
individual client.
Ex: Beliefs, values, age, health
status, and environment are
factors that can affect the
success of a nursing action
B
Base nursing interventions
on scientific knowledge,
research, & professional
standards of care.
Know scientific rationale,
side effects, complications
C
Clearly understand the
interventions and
question any that are
not understood.
Responsible for
intelligent
implementation of
medical and nursing
plans of care.
Drawing Conclusions About Problem Status
GOAL MET
GOAL PARTIALLY MET
GOAL NOT MET
Actual problem resolved, potential problem prevented and risk factors no longer
exist = DISCONTINUE CARE
Potential problem prevented BUT risk factors are present = KEEP PROBLEM NCP
NCP may need to be revised, since the problem is only partially resolved.
NCP does not need revision, the client needs more time to achieve the
previously established goal(s). Evaluating the Quality
of Nursing Care A Quality Assurance (QA) program is an ongoing, systematic process designed
to evaluate and promote excellence in the healthcare provided to clients.
STRUCTURE
EVALUATION
PROCESS
EVALUATION
OUTCOME
EVALUATION
Setting:
Equipment and
Staffing
Process:
Protocols,
Policies and
Procedures
Outcome:
Safety
Satisfaction
Quality
How many clients undergoing
hip repairs develop Pneumonia?
How the care was given?
What effect does the setting
have on quality of care?
Changes in health status
as a result of nursing care

17. Clinical Alert!
Bad systems—not bad people—lead to most errors.
A sentinel event is an unexpected
occurrence involving death,
permanent harm, or severe temporary
harm and intervention required to
sustain life (The Joint Commission, 2017).
Root cause analysis is a process for
identifying the factors that bring about
deviations in practices that lead to the event.
Nursing Audit
A retrospective audit is the
evaluation of a client’s record
after discharge from an agency.
A concurrent audit is the evaluation
of a client’s healthcare while the
client is still receiving care from
the agency. PHYSICAL
EXAMINATION

18. Comprehensive initial
assessment — upon admission
Focused examination of a body
system — cardiovascular system
Functional assessment — one or
more aspects of client’s abilities (nutrition
and metabolism, elimination)
PHYSICAL EXAMINATION
Shift assessment is focused on immediate needs and problems and includes
evaluating the status of environmental factors such as tubes, devices, and dressings.
I Inspect
PA Palpation
PE Percussion
A Ausculation
PHYSICAL EXAMINATION
Clinical Alert!
Review the agency charting form before beginning your assessment to ensure
that you know which data you will need to collect, have all the equipment you
require, and know how to perform the assessment in a systematic manner.
NAKED EYE
LIGHTED INSTRUMENT
(Otoscope)
OLFACTORY and AUDITORY CUES are noted.
INSPECTION
is the visual examination using the sense of SIGHT
PALPATION
examination of the body using the sense of TOUCH
Use your fingerpads.
To test for skin temperature
dorsum of the hand and fingers
To test for vibration
palmar surface of the hand
Texture, Temperature
Vibration
Masses
Pulsation, Pain
Distention

19. PALPATION
examination of the body using the sense of TOUCH
LIGHT DEEP
— dominant hand’s fingers parallel
to the skin surface
— done with two hands (bimanually) or
one hand
Top hand applies pressure
Lower hand perceives tactile sensations
Finger pads press over
the area to be palpated
PERCUSSION
act of STRIKING the body surface to elicit sound
DIRECT
INDIRECT
Middle Finger — RAPID STRIKES
Movement from WRIST
PLEXOR
PLEXIMETER (Non Dominant Hand)
Angle: 90°
FIRM and RAPID
SOUND LOCATION
“Drum like Sound”
“Hollow Sound”
“Booming Sound”
“Extremely Dull”
“Thud like Sound”
TYMPANY
RESONANCE
HYPERRESONANCE
FLAT
DULL
Stomach filled with air
NORMAL LUNG
Lungs with Emphysema
Muscles and bones
Liver
AUSCULTATION
LISTENING of sounds produced by the body
DIRECT
INDIRECT
“unaided ear”
“Uses a Stethoscope”
Ex: Wheezes
Ex: Bowel Sounds, BP
Tubing
12 to 14 in.
Bell
Diaphragm
The earpieces of the stethoscope should fit
comfortably into the nurse’s ears, facing forward.
If the client has excessive hair —
dampen the hair with a moist cloth

20. Height
Weight
Remove shoes and stand erect with
heels together.
L-shaped sliding arm rests on top of
the client’s head or place a small flat
object (ruler or book) on the client’s
head.
Each morning before breakfast
and after emptying the bladder.
SAME scale
SAME time each day
SIMILAR kind of clothing and
no footwear
SKIN ASSESSMENT
PALLOR
↓ circulating blood = reduced tissue
oxygenation
Brown- skinned —
yellowish brown tinged
Conjunctiva, oral mucous membranes, nail beds, palms, and soles of the feet
Black-skinned —
ashen gray
SKIN ASSESSMENT
CYANOSIS
JAUNDICE
Bluish tinged
Dark-skinned — palpebral
conjunctiva, palms and soles
↑ DEOXYGEANTED hemoglobin
Nail beds, lips, and buccal mucosa
Yellowish tinged
Sclera, mucous membranes, and skin
Nurses should take care not to confuse jaundice
with the normal yellow pigmentation in the
sclera of a dark-skinned client.
PRIMARY SKIN LESIONS
FLAT, UNELEVATED CHANGE IN COLOR
MACULE
PATCH
1 mm to 1cm
freckles, flat moles
Larger than 1 cm
Irregular shape
Portwine birthmark

21. PALPABLE, SOLID ELEVATION
PAPULE
Less than 1 cm
Warts
Elevated molePLAQUE
Larger raised area
Larger than 1 cm
NODULE
Extends deeper
DERMIS
0.5 to 2cm
TUMOR
Larger than 2 cm
PRIMARY SKIN LESIONS
Psoriasis
Lipoma
PRIMARY SKIN LESIONS
Filled with SEROUS FLUID
VESICLE
Less than 0.5 cm
BULLA
Larger than 0.5 cm
PUSTULE
Filled with PUS
Chickenpox
Acne Vulgaris
Large Blisters
2
nd Degree Burn
If agency policy permits and the
client agrees, take a digital or
instant photograph of
significant skin lesions for the
client record.
Include a measuring guide (ruler or tape) in
the picture to demonstrate lesion size.
Clinical Alert!
EDEMA
Assess skin turgor by pinching the skin on
the abdomen (INFANTS).
MOBILITY & TURGOR
Skin Turgor — lifting and pinching the skin on an
extremity or on the sternum (ADULT).
Assess for:
Temperature
Location
Color
Degree to which the skin remains indented or pitted
when pressed by a finger.
Measure circumference with a millimeter tape

22. HAIR
NORMAL HAIR:
RESILIENT
EVENLY DISTRIBUTED
THICK HAIR
KWASHIORKOR:
HAIR COLOR is FADED
COURSE and DRY
Amount of body hair
Evenness of growth, hair thickness, hair texture
Note presence of infections or infestations
Inspect the:
NAILS
C
OLORLESS
ONVEX CURVE = 160°C
KOILONYCHIA
“Spoon Shape”
CLUBBING
180 degrees or greater
Blanch test of capillary refill
Press the nail bed between your thumb and index finger. Prompt
return of pink or usual color (less than 2 seconds)
EYE
Pupils
Equal
Round
Reactive to
Light &
Accomodation
3 to 7 mm in diameter
Shine the light on the pupil again, and
observe the response of the other pupil. It
should also constrict (consensual response)
illuminated pupil = constrict (direct response)
1. Hold Penlight about 4 inches from nose.
Look at penlight and then at a distant object.
2. Look at penlight then move towards the nose.
Pupils converge when near object is moved toward nose.
Cataract
MyDriasis
Miosis
Anisocoria
Amphetamine
Cocaine
Glaucoma
CLOUDY PUPILS
ENLARGED PUPILS
Pain killer (Morphine)
Pilocarpine
CONSTRICTED PUPILS
UNEQUAL PUPILS
CNS disorder

23. NEAR VISION
IF the client wears contact lenses or
glasses it should be WORN during
the test.
CLINICAL ALERT
ROSENBAUM eye chart may be used to test NEAR vision.It
consists of paragraphs of text or characters in different
sizes.
READ MAGAZINE / NEWSPAPER
at a distance of14 inches.
DISTANCE VISION
Take 3 Readings: right, left
and both eyes
STAND or SIT = 20 feet
Cover the eye not being tested.
Record:
Visual acuity 20/40 – 2 cc
cc - with correction
sc - without correction
VISUAL ACUITY
EARS
AURICLES
Aligned with OUTER CANTHUS
EYE = 10°
Color SAME as FACIAL SKIN
TYMPANIC MEMBRANE
Pearly gray color
Abnormal: Redness and discharge,
excessive cerumen obstructing canal

24. TUNING FORK TESTS
weBer’s test
ONE Conduction
NORMAL: sound heard BOTH ears /
localized at center of head
ABNORMAL: SOUND heard better sa EAR
c problem
Bone
Conductive hearing loss
s problem
Sensorineural hearing loss
Rinne’s test
AI
NORMAL:
Air > Bone Conduction
ABNORMAL:
Conductive Hearing Loss
LUNGS
Bronchovesicular
Blowing sound
Between scapula &
sternum
Bronchial (TUBULAR)
Harsh sound
Trachea
Vesicular
Gentle Sighing Sound
Base Lungs
NORMAL BREATH SOUNDS

25. ADVENTITIOUS BREATH SOUNDS
WHEEZE
Crackling Sound
Gurgling, Harsh Sound
Superficial Grating /
Creaking Sound
High pitched, Squeaky
Air passing through fluid or mucus
in any air passage
Rubbing together of inflamed pleural surfaces
Air passing through a constricted bronchus
CRACKLES
(Rales)
GURGLES
(Rhonchi)
FRICTION
RUB
Air passing through narrowed air passages
as a result of secretions & swelling
rolling a lock of hair near the ear
harsh, louder sounds with a moaning or snoring quality
JUGULAR VEINS
POSITION: Semi - Fowler’s
Measure from the sternal angle
to the highest visible distention.
(+) Jugular Distention, assess
Jugular Venous Pressure (JVP)
Locate the highest visible
point of distention of the
internal jugular vein.
Bilateral distention above 3 to 4 cm are
considered elevated.
Unilateral distention - local obstruction
ABDOMEN
PALPATION
INSPECTION
AUSCULATION
PERCUSSION
Ask the client to urinate.
Supine position, arms placed at the sides.
Small pillows beneath the knees and the head to reduce tension in the
abdominal muscles.
ABDOMEN
INSPECTION
Flat, Uniform color
Silver-white striae (stretch marks)
or surgical scars
Tense, glistening skin (Edema)
Purple striae (Cushing’s disease or
rapid weight gain and loss)
If distention is present, measure the abdominal girth by placing a
tape around the abdomen at the level of the umbilicus.
(—) Liver enlargement Evidence of enlargement of liver
Ask the client to take a deep breath
and to hold it.

26. ABDOMEN
AUSCULATION
HYPOACTIVE – soft, infrequent (one per minute)
ABSENT – none in 3 to 5 minutes
HYPERACTIVE (Borborygmus) – high pitched, rushing sound (every 3 sec)
Use the flat-disk diaphragm.
Ask when the client last ate.
Begin in the RLQ and proceed clockwise.
Listen for Active Bowel Sounds occurring about every 5 to 20 seconds.
NORMAL: 5 - 30 per minute
ABDOMEN
PERCUSSION
RLQ —> RUQ —> LUQ —> LLQ
Tympany over the stomach
Dull over the liver, full bladder
Large dull areas (presence
of fluid or tumor)
ABDOMEN
PALPATION
LIGHT PALPATION — to detect tenderness
Explore all four quadrants. Warm the hands.
Depress the abdominal wall lightly (1 cm) with the pads of your fingers.
Move the finger pads in a slight circular motion.
Ticklish begin by pressing your hand on top of the client’s hand while pressing
lightly. Then slide your hand off and onto the abdomen.
Palpate SENSITIVE areas LAST