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Kingdom of Saudi Arabia Ministry of Higher Education University of Hail College Of Nursing

Guidelines for Review of Body Systems


Use the format below for review of body systems to complete all your assignments. 1. [ [ [ [ 2. GENERAL: ] ] ] ] Recent Weight Changes Fever Body Malaise (Vague feeling of discomfort) Mood Changes

SKIN, HAIR AND NAILS

Rashes [ ] Lesions [ ] Itching [ ] Color Change [ ] Dryness [ ] [ ] Brittle nails [ ] Cracking [ ] Other, specify: ____________________________________________________________ 3. [ [ [ [ [ 4. [ [ [ [ [ [ [ [ [ [ [ [ [ HEAD: ] ] ] ] ] EYES: ] ] ] ] ] ] ] ] ] ] ] ] ] Changes in vision Blindness Cataract Diplopia Redness Pain Photophobia Glasses (last exam date and result) Contact lenses (type) Glaucoma Drainage Infection Other, specify: ____________________________________________________________ Headache Seizure Fainting Head injuries Dizziness

5. [ [ [ [ [ [ 6. [ [ [ [ [ 7. [ [ [ [ [ [ [ [ [ [ [ 8. [ [ [ [ [ [ [ [ 9. [ [ [ [ [ [ [ [ [

EARS: ] ] ] ] ] ] Difficulty in Hearing/Deafness Tinnitus Vertigo Infection Discharge Other, specify: ____________________________________________________________

NOSE AND SINUSES: ] ] ] ] ] Nasal stuffiness Frequent colds Hay fever Nose bleeds Sinusitis

MOUTH, PHARYNX, AND NECK: ] ] ] ] ] ] ] ] ] ] ] Bleeding from gums/teeth Oral infection Dental problems Dentures (last exam, time, and result) Hoarseness Swelling in neck Frequent sore throats Lumps in the neck Dysphagia Stiffness in neck Other, specify: ____________________________________________________________

BREASTS: ] ] ] ] ] ] ] ] Pruritus, pain, or lumps Nipple discharge Dimpling of skin Enlargement (gynecosmastia) Performance of self breast exam Mammograms (date and result) Steroids Other, specify: ____________________________________________________________

LUNGS: ] ] ] ] ] ] ] ] ] Shortness of breath Dyspnea on exertion Orthopnea Pain with respiration Cough Sputum (color, frequency, quantity) Hemopteysis Wheezing Cyanosis 2

[ [ [ [ [ [ [ [ 10. [ [ [ [ [ [ [ [ [ [ [ 11. [ [ [ [ [ [ 12. [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [

] ] ] ] ] ] ] ]

Pneumonia Bronchitis Emphysema Asthma TB test (date and result) TB exposure Chest x-ray (date and result) Other, specify: ____________________________________________________________

HEART: ] ] ] ] ] ] ] ] ] ] ] High blood pressure Heart murmurs Paroxysmal nocturnal dyspnea Chest discomfort/pain Palpitations Syncope (Fainting) Rheumatic fever (date) Coronary Artery disease Heart attack ECG (result and date) Other, specify: ____________________________________________________________

PERIPHERAL VASCULAR: ] ] ] ] ] ] Edema Swelling/pain in calves Pain/ulcerations or discoloration of extremities Muscle Cramps Varicose veins Other, specify: ____________________________________________________________

GASTROINTESTINAL: ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] ] Nausea Vomiting Hematemesis Indigestion/heart burn Abdominal pain Jaundice Hepatitis (type and date) Melena (Black colored stool) Clay colored stools (Dark brown stool) Incontinence of stool Diarrhea Change in bowel habit Constipation Hemorrhoids Excessive gas Hernia Ulcer Gall bladder stone/Colic Pancreatic disease Other, specify: ____________________________________________________________ 3

13. [ [ [ [ [ [ [ [ [ [ 14. [ [ [ [ [ [ [ 15. [ [ [ [ [ [ [ [ 16. [ [ [ [ 17. [ [ [ [ [

URINARY: ] ] ] ] ] ] ] ] ] ] Frequency Urgency Infection Dysuria Nocturia Hematuria Stream, site, and force Hesitancy Incontinence (stress, urge, dribbling) Other, specify: ____________________________________________________________

MALE GENITALIA: ] ] ] ] ] ] ] Penile discharge Genital lesions Testicular pain/mass Syphilis (date and result) Gonorrhea Sexual intercourse problems Other, specify: ____________________________________________________________

FEMALE GENITALIA: ] ] ] ] ] ] ] ] Vaginal discharge Pruritus Genital lesions Painful intercourse Post menstrual bleeding Post coital bleeding Pap smear (date and result) Other, specify: ____________________________________________________________

ENDOCRINE: ] ] ] ] Heat and cold intolerance Thyroid problems Neck surgery (type, date and result of biopsy) Diabetes mellitus (type and date)

HEMATOPOIETIC: ] ] ] ] ] Abnormal bleeding/bruising/petechia Anemia Blood transfusion (date) Leukemia (type and date) Other, specify: ____________________________________________________________

18. [ [ [ [ [ [ [ [ [ 19. [ [ [ [ [ [ [ [ [ 20. [ [ [ [ [ [ [ [ [ [

SPINE AND EXTREMITIES: MUSCOLOSKELETAL ] ] ] ] ] ] ] ] ] Arthritis Joint stiffness Joint swelling Joint pain Muscle weakness Muscle cramps Backache Limited range of motion (ROM) Other, specify: ____________________________________________________________

SPINE AND EXTREMITIES: NEUROLOGICAL ] ] ] ] ] ] ] ] ] Paresthesia/numbness Paralysis (site) Incoordination (Ataxia) Disturbed balance Blackouts Tics Tremors Spasms Other, specify: ____________________________________________________________

PSYCHIATRIC (Problems in the following areas): ] ] ] ] ] ] ] ] ] ] Spouse Family history Insomnia Depression (interfering with ADLs) Anxiety (interfering with ADLs) Mood swings Delusions Hallucinations Eating, sleeping, or memory problems Other, specify: ____________________________________________________________

Kingdom of Saudi Arabia Ministry of Higher Education University of Hail College Of Nursing

Guidelines For Physical Assessments


(Objective Data) Use the following format to conduct and record results of physical examination for all assignments. 1. GENERAL: Statement to include observed state of health, posture, appearance, body odors, manner, affect, signs of distress, speech, and level of awareness. 2. VITAL SIGNS:
a) b) c) d) e) Temperature Pulse Respiration Blood Pressure Pain Score (T) (P) (R) (BP) (PS)

3. NUTRITION:
1) DESCRIBE DIET AND DETERMINE THE FOLLOWING: WEIGHT LOSS, IDEAL BODY WEIGHT (IBW), USUAL BODY WEIGHT (UBW), PRESENT BODY WEIGHT (PBW), ENERGY REQUIREMENTS, AND FLUID REQUIREMENTS. IN ADDITION IDENTIFY RISK FACTORS. DETERMINE IBW AS FOLLOWS: A. Adult Male: Allow 106 pounds for the first 60 inches and add 6 pounds for each additional inch. B. Adult Female: Allow 100 pounds for the first 60 inches and add 5 pounds for each additional inch. Determine weight loss as follows: IBW - PBW UBW - PBW ---------------- X 100 = % IBW or ---------------- X 100% = % of weight loss IBW UBW Weight loss is considered significant if it fallls into the following guidelines: 1-2 % in a week. 5% in 1 month. 7.5% in 3 months. 10% in 6 months.

2) 3)

4) 5)

DETERMINE ENERGY REQUIREMENTS AS FOLLOWS: Body weight in kilogram X 35Kcal. DETERMINE FLUID REQUIREMENTS A FOLLOWS: Body weight in kilograms X 35ml. Note: Increase calories 7% and fluids 125ml for each 1 degree increase in temperature.

6) a)

DETERMINE BODY MASS INDEX (BMI) AS FOLLOWS: Calculate BMI Using the Metric System If you're using the metric system, you can learn how to calculate BMI by using the following formula:

Weight in kilograms divided by height in meters squared (weight (kg) / [height (m)] 2).

Since height is commonly measured in centimeters, divide height in centimeters by 100 to obtain height in meters. An example of calculating BMI using the formula: Height = 165 cm (1.65 m), Weight = 68 kg

b)

BMI Calculation: 68 (1.65)2 = 24.98 Calculate BMI Using the English System With the English system, the BMI formula is: Weight in pounds (lbs) divided by height in inches (in) squared and multiplied by a conversion factor of 703 (weight (lbs) / [height (in)2] x 703). Therefore, to calculate BMI, take the weight (lbs) and divide it by height (in). Take the result of that calculation and divide it by height again. Then, multiply that number by 703. Round to the second decimal place.

An example of calculating body mass index using the BMI formula: Weight = 150 lbs, Height = 5'5" (65 inches) BMI Calculation: [150 (65)2] x 703 = 24.96 c) BMI Categories Underweight Normal weight Overweight Obesity = <18.5 = 18.524.9 = 2529.9 = BMI of 30 or greater

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CONVERSIONS: 1 feet (ft)

= 12 inches

1 inch = 2.54 centimeters (cm) 1 feet = 30.49 centimeters (cm) 1 kilogram (kg) = 2.2 pounds (lbs)

4. MENTAL STATUS: Record a statement about the observation of behavior, mood, thought process, thought content, perceptions, and cognitive functions. 5. SKIN: Note color, temp., texture, moisture, presence of lesions, mobility, turgor, and describe appearance of nails. 6. HEAD: Describe hair, scalp, skull, and results of cranial nerves testing. 7. EYES: Report visual acuity, appearance of eyebrows, eyelids, eyelashes, lacrimal apparatus, sclera, cornea, conjunctiva, corneal light reflection, pupilary light response, extra occular muscle movement, accommodation, peripheral vision. 8. EARS: Record result of inspection, palpation of the outer ear, hearing acuity, whisper test. 9. NOSE AND SINUSES: Report description of the external nose, nasal mucosa, septum, presence of tenderness, transillumination. 10. MOUTH AND PHARYNX: Record description of observations of lips, buccal mucosa, gums, teeth, roof of the mouth, tongue, pharynx, movement of uvula and gage reflex. 11. NECK: Note palpation of lymph nodes, thyroid gland, and position of trachea, presence or absence of masses.

12. PERIPHERAL VASCULAR: Record peripheral pulses, capillary refill, edema, skin temp., and enlarged nodes in lower limbs. 13. THORAX AND LUNGS: Record results of inspection, palpation, and auscultation of lungs. Note diaphragmatic excursion. 14. HEART: Record results of inspection, palpation, and auscultation of the heart, note apical pulse, presence of extra heart sounds, or murmurs. 15. BREAST AND AXILLAE: Record results of inspection and palpation of breast and axillae. 16. ABDOMEN: Record result of inspection, palpation, percussion, and auscultation of abdomen. Note liver size, palpable organs, tenderness, and umbilical reflexes. 8

17. INGUINAL AREA: Record results of inspection and palpation of inguinal area. Note presence or absence of hernias. 18. SPINE AND EXTREMITIES: MUSCULOSKELETAL: Record results of inspection and palpation of all joints. Note test results of ROM and muscle strength of all extremities. Check for scoliosis. 19. SPINE AND EXTREMITIES: NEUROLOGICAL Record results for reflex tests, gait, balance, and coordination. Note sensation to pain, temp. light touch vibration. Note position discrimination.

NURSING PROCESS GUIDELINES:


(Planning Expected Outcomes) I. NURSING PROCESS II. a) b) o o o o c) 1. Is a systematic, patient-centered, goal-oriented method of caring to provide a frame work for nursing practice.

OBJECTIVES OF N P (NURSING PROCESS ) The steps of the nursing process are not separated items, but rather are parts of whole used to: Identify needs of the patient. Establish priorities of care. Maximize strengths. Resolve actual and/or potential patient problem. Apply health promotion to possible for each patient Documenting the nursing process; Is the ability to record communicated nursing skills: Accurately, Concisely , Timely, and Relevant, to provide the member of the caregiver a complete picture of the patients health. Phases: Assessment - Cues and Evidence
(Subjective& Objective Data) Diagnosis (Nursing Diagnosis)

2. 3. 4.
5.

Planning (Goal and Objectives) Implementation (Nursing Interventions) And Evaluation.

1.1 Assessment: A systematic and continuous collection, validation and communication of patient data or data base; includes all patient information, collected by the health care professionals to enables an effective plan of care to be implemented for the patient. 1.1.1 Sources of Data: a) b) c) d) e) f) Patient is the primary source of information. Family & Significant others, friends. Patient record , records from members of health care , provide essential Information related to the patient Medical history, physical examination, & progress notes. Laboratory test &other health professions.

1.1.2 Types of Assessment: a) Initial Assessment - is performed shortly after patient admission to a health agency or hospital b) Focused Assessment - the nurse gathers data about a specific problem that has already been identified c) Emergency Assessment - the nurse performs this type of assessment on a physiological or psychological crisis to identify the life - threatening problems d) Time-lapsed Assessment - this assessment done to compare a patients current status to the base line data obtained earlier 1.1.3 Methods of Assessment: a) Observation b) Interviewing Directive interview Nondirective interview 4 - Physical examination techniques: 1. Inspection 2. Palpation 3. Percussion 4. Auscultation 1.1.4 Assessment Activities: Identify assessment priorities determined by the purpose of the assessment and the patient condition. Organize or cluster the data to ensure systematic collect Establish the data base by: a) nursing history b) nursing examination Review of patient record & nursing literature. Patient consultation and health care personnel Continuously update the database Validate the data. Communicate the data.

2.1

Nursing Diagnosis: Diagnosing (patient problem), the 2nd step in the nursing process. Is a clinical judgment about individual, family or community response to actual or potential health problem. It provides the bases for selection of nursing intervention. 2.1.1 Activities of Nursing Diagnosis: Interpret & analyze patient data Identify patient strength and health problem Formulate and validate nursing diagnosis Develop a prioritized list of nursing diagnosis Detect & refer signs and symptoms that may indicate a problem beyond the nurses experience. 2.1.2 a) Parts of Nursing Diagnosis: Problem the statement that describe the health problem of the patient clearly & concisely. Etiology the reason (etiology) that identifies the physiological, psychological social,spiritual and environmental factors related to the problem. Defining characteristics (signs or symptoms) The subjective and objective data that signal the existence of the proble m. Characteristic Dry Skin, Dryness of the Mouth b) Etiology Diarrhea Problem Deficient fluifd volume

Differentiating Nursing Diagnosis versus Medical Diagnosis: Nursing Diagnosis Focus on unhealthy responses to health Identify diseases and illness. Medical Diagnosis Identify Disease

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Describe problem treated by nurses Within the scope of independent nursing practice. May change from day to day as the patient Response changes.

Describe problems for which the physician Directs the primary treatment. Remains the same foe as long as the disease is present.

c)

Types of Nursing Diagnosis: Types Actual Nursing Diagnosis Definition Represent a problem that has been validated by the presence of its characteristics, e.g.
impaired physical mobility, fatigue, ineffective breathing pattern.

1.

2.

Risk Nursing Diagnosis

Its a clinical judgment that an individual , family , or community is more vulnerable (able) to develop the problem .e.g. Risk for
Deficient fluid Volume.

3. 4.

Possible Nursing Diagnosis Wellness Diagnosis

Are statements describing a suspected Problem .ex chronic low self esteem. Its a clinical judgment about individual , group , or community in transition from Specific level of wellness to a higher level.
e.g. Readiness for enhanced health maintenance or Readiness for enhanced Self-esteem.

5.

Syndrome nursing Diagnosis

a cluster of an actual or risk nursing diagnosis suspected to be present according to certain Events.

3.1

Planning The third step of the nursing process includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the clients plan of care.

3.1.1 Activities of Planning Phase (or step): Establish priorities. Identify expected patient outcome. Select evidence- based nursing intervention. Communicate the plan of care.

3.1.2 Stages of Planning: a) Initial planning; is developed by the nurse, who performs the admission nursing history and the physical assessment. b) Ongoing planning; is carried by the nurse to keep the plan up date , by analyzing data to make plan more accurate . c) Discharge planning ; is best carried out by the nurse ,who has worked most closely with patient and family 3.1.3 The four critical elements of planning include: Establishing priorities Setting goals and developing expected outcomes (outcome identification) Planning nursing interventions (with collaboration and consultation as needed) Documenting 4.1 Implementation: Consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions or nursing orders. 4.1.1 Types of Interventions:

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a) Direct Interventions: Actions performed through interaction with clients. b) Indirect Interventions: Actions performed away from the client, on behalf of a client or group of clients. The nursing care plan consists of three components: 1. 2. 3. Expected outcomes Client problems (nursing Diagnosis ) Interventions Types of Interventions: a) Dependent b) Independent c) Collaborative 5.1 Evaluation: The last phase of the nursing process, follows intervention of the plan of care, its the judgment of the Effectiveness of nursing care to meet client goals based on the clients behavioral responses. 5.1.1 Evaluating: Measure how well the patient has achieved desired outcomes. Final phase of nursing process Occurs whenever nurse interacts with client Determining status of outcomes Systematic and ongoing appraisal

5.1.2. Outcomes: Identify factors contributing to the patient's success or failure. Modify the plan of care, if indicated.

A) Three possible outcomes of evaluation: 1. Outcomes not met continue plan as written 2. Outcomes not met modify the plan 3. Outcomes met terminate the plan B) Factors affecting outcome attainment: Facilitators Barriers C) Evaluating compliance: Performance appraisal Quality assurance

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