CP 100 Prelim

What is this Module about?
It is to understand the roles and functions of midwives in the health

care process, carrying out the ethical and legal responsibilities in the
assessment of patients. Learn the process and procedures of
assessing patients as to collection of relevant data, taking medical
and family history of the patient. Doing appropriate and timely
physical assessment and knowing the implications of the laboratory
examinations and the result to patient‟s individualized care.
What will you learn from this module?
In this module, you will learn more about Health Care Process. More
importantly you will be able to use this basic skill in the care of
individuals.
This module is divided into four lessons. These are:
 Assessment
1. Data Collection
2. History Taking
3. Physical Assessment
4. Laboratory Exams
Let’s see what you already know
Before you start reading this module, answer first the questions that
follow to determine how much you already know the topics to be discussed.
A. Identify the ff. by writing your answers on the lines provided.

1. It is the process of gathering information about the client‟s health
status______.
2. _________ organized sequence of problem solving steps used to identify
and manage the health problems of the client.
3. __________is a systematic data collection method that uses
observational skills to detect health problems.
4. ________refers to temperature, pulse, respiration, blood pressure and
whether he has pain.
5. _______ Balance between the heat produced and heat lost by the body.
6. _______ Assessment of the body movement and nutrition status.
7. _______ a method used by the examiner through striking a particular
area of the body with the finger to listen, to sound and to determine
resistance of the tissue.
8. ________ it involves sense of hearing to interpret sounds with the aid
of a stethoscope.
9. _______ is the force exerted by the blood against the arterial walls with
each ventricular contraction.
10. ________ determining how to prevent, reduce or resolve the identified
priority client problems.
MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 1

Well how was it? Do you think all your answer is correct? Compare your answers
with those in the answer key on last page to find out.
If you got a low score, don‟t feel bad because this will help you to comprehend the
important concepts of roles and responsibilities of a health care provider. If you
read this module carefully, you will learn the answers to all the items in the test
and a lot more! Are you ready?
You may go now to next page to begin your lesson.
HEALTH CARE PROCESS
Organized sequence of problem solving steps used to identify and manage the
health problems of the client. Its purpose is to identify a client‟s health care status,
and actual or potential health problems, to establish plans to meet the identified
needs, and to deliver specific interventions to address those needs.
1. Assessment
2. Planning
3. Intervention
4. Evaluation
1. ASSESSMENT – Process of COLLECTING, ORGANIZING, VALIDATING AND

RECORDING DATA about client health status. To establish a database about
the client‟s response to health concerns or illness and the ability to manage
health care needs.
 This step of the health care process lead to problem identification
 Double checks the data to ensure accuracy and completeness
 The most important step of the health care process
 Gather, organize, analyze data
DATA COLLECTION – the process of gathering information about the client‟s
health status
Complete history and physical
a. OBJECTIVE DATA (OVERT DATA) – detected by an observer

 Vital signs
b. SUBJECTIVE DATA (COVERT DATA) – perceived by patient
 The clients self – report of pain.
 Nursing history is subjective – includes things like biographic data,
the chief complaint, source of the data, history of present illness,
past medical history, immunization history, allergies, habits ,
stressor family history including genogram, patterns of health
care, and a review of the body‟s systems
Sources of Data
= PRIMARY SOURCE – the primary source is the client

= SECONDARY SOURCE – the information provided by other source
 DEMOGRAPHIC DATA

 Patient‟s Name – correct and complete name of the client
 Sex
 Residence
 Birth date and Age
 Place of birth – maybe useful in assessing incidence of a disease
 Nationality
 Marital status
 Occupation
 OBSTETRICAL HISTORY
 OB Score – number of pregnancies including preterm and abortion
 Gravida – all past pregnancies including present pregnancy
 Para – all viable deliveries
 Term – delivery on 37th – 42nd week
 Preterm – delivery before 37th week
 Abortion – number of all miscarriage
 Living – number of all living children
 Type of previous deliveries, date, place and complication if there is.
 Last menstrual period
 Expected date of delivery
o Pregnancy last for approximately 266 days from conception until
the baby is born or 280 days from the first day of the last
menstrual period (see Naegele‟s rule).
o Naegele’s Rule – method to determine expected date of
confinement (EDC)
 Formula for LMP‟s from January to March : +9 & +7
 From April to December: -3 & +7 +1
Example; 3 – 10 – 2020 5 – 10 – 2020
+9 + 7_____ -3 + 7 + 1_____
12 – 17 – 2020 2 – 17 – 2021
 History of family planning used
o Method and duration of used
 MEDICAL HISTORY (PAST & PRESENT)

 An account of the events in the patient‟s life that have relevance to his
or her mental and physical health
 Previous operation/hospitalization
 Previous and present illnesses
 Current medication
 Allergies to foods/drugs
 Drugs/alcohol user, smoker
History of Present Illness

 HPI is a chronological story of what has been happening
– Must get details of the problem, therefore must be systematic
– OLFQQAAT (one system – there are others): onset, location,
frequency, quality, quantity, aggravating factors, alleviating factors,
associated symptoms, treatments tried (include all treatments - Rx,
OTC, herbal, folk)
– Lots of systems – find one that works, and use it

 Use whatever system works for you, but use a system pain
intensity scales, etc
– Pain, quality/quantity, radiation, setting, timing
– Rate pain from 1 to 10
*Pain Scale – learn what the 0 to 10 pain scale really means and how
to use it most effectively so that your pain is taken seriously.
00 – pain free
01 – (Mild) pain is very mild, barely noticeable.
02 – (Minor) pain. Annoying and may have occasional stronger
twinges.
03 – (Uncomfortable) pain is noticeable and distracting, however, you
can get used to it and adapt.
04 – (Moderate) if you are deeply involved in an activity, it can be
ignored for a period of time, but is still distracting.
05 – (Distracting) moderately strong pain. It can‟t be ignored for more
than a few minutes, but with effort you still can manage to work or
participate in some activities.
06 – (Distressing) moderately strong pain that interferes with normal
daily activities.
07- (Severe) pain that dominates your senses and significantly limits
your ability to perform daily activities or maintain social relationships.
It interfere sleep.
08 – (Intense) physical activity is severely limited. Conversing
requires great effort.
09 – (Excruciating) unable to converse. Crying out and/or moaning
uncontrollably.
10 – (Unspeakable) bedridden and possibly delirious. Very few people
will ever experience this level of pain.
Exam Order and Documentation

 Date and identifying data - name, age, sex, race, place of birth (if
pertinent), marital status, occupation, religion
 Source and reliability of history
 Chief complaint = reason for visit
Order & Documentation

 FH - age and health of parents and siblings or cause of death
(genogram); HTN, DM, CVD, Ca, HA, arthritis, addictions
 ROS (subjective head-to-toe review)
– General - recent wt. change, fatigue, fever
– Skin - rashes, lesions, changes, dryness, itching, color change,
hair loss, and change in hair or nails
– Eyes - change in vision, floaters, glasses, HA, pain
Chief Complaint – the main reason for seeking health care or consultation to
clinics.
Taking a history from a patient is a skill necessary for examinations. It tests

both your communication skills as well as your knowledge about what to ask.
Specific questions vary depending on what type of history you are taking but if you

follow the general framework below you should gain good marks in these stations.
This is also a good way to present your history.
In practice you may sometimes need to gather a collateral history from a relative,
fried or carer. This may be with a child or an adult with impaired mental state.
Procedure/ steps
Step 1
Introduce yourself, identify your patient and gain consent to speak with them. Ask
the patients permission to do so.
Step 2 – Presenting Complaint (PC)

This is what the patient tells you is wrong, for example; chest pain.
Step 3 – History of presenting complaint (HPC)

Gain as much information you can about the specific complaint.
Striking with chest pain as an example you should ask:
- Site: where exactly is the pain?

- Onset; when did it start, was it constant/intermittent, gradual/sudden?
- Character: what is the pain like e.g. sharp, burning, and tight?
- Associations: is there anything else associated with the pain, e.g. sweating,
vomiting.
- Radiation: does it radiate/move anywhere?
- Time course: does it follow any time pattern, how long did it last?
- Exacerbating/relieving factors: does anything make it better or worse?
- Severity: how severe is the pain, consider using the 1-10 scale?
The SOCRATES acronym can be used for any type of pain history.
Step 4 – Past medical history (PMH)

Gather information about a patients other medical problems (if any).
Step 5 – Drug history (DH)

Find out what medications the patient is taking, including dosage and how often
they are taking them, for example: once a day (OD), twice a day (BID), etc.
At this point it is a good idea to find out if the patient has any allergies.
STEP 6 – Family history (FH)

Gather some information about the patient‟s family history, e.g. diabetes or cardiac
history. Find out if there are any genetic conditions within the family, for example:
polycystic kidney disease, cancer etc.
Step 7 – Social history (SH)

This is the opportunity to find out a bit more about the patient‟s background.
Remember to ask about smoking and alcohol. Depending on the PC it may also be
pertinent to find out whether the patient drives, e.g. following an MI patient cannot

drive for 1 month. You should ask the patient if they use any illegal substances, for
example: cannabis, cocaine, etc.
Also find out who lives with the patient. You may find that they are the carer for an
elderly parent or a child and your duty would be to ensure that they are not
neglected, should your patient be admitted/remain in hospital.
Step 8 – Review of systems (ROs)

Gather a short amount of information regarding the other systems in the body that
are not covered in your HPC.
The above example involves the CVS so you would focus on the others.
These are the main systems you should cover:
- CVS
- Respiratory
- GI
- Neurology
- Genitourinary/renal
- Psychiatry
Please these are the main areas, however some courses will also teach the addition
of other systems such as ENT/Ophthalmology.
Step 9 – Summary of history

Complete your history by reviewing what the patient has told you. Repeat back the
important points so that the patient can correct you if there are any
misunderstandings or errors.
You should also address what the patient thinks, if what is wrong with them and
what they are expecting/ hoping for from the consultation. A useful acronym for
this is ICE Ideas, Concerns and Expectations.
Step 10 – Patient questions/feedback
During or after taking their history, the patient may have questions that they want
to ask you. It is very important that you don‟t give them any false information. As
such, unless you are absolutely sure of the answer it is best to say that you will
ask your seniors about this or that you will go away and get them more information
(e.g. leaflets) about what they are asking. These questions aren‟t necessarily there
to test your knowledge, just that you won‟t try and „blag it‟.
Step 11
When you are happy that you have all of the information you require, and the
patient has asked any questions that they may have, you must thank them for
their time and say that one of the doctors looking after them will be coming to see
them soon.
PHYSICAL EXAMINATION/ASSESSMENT – a systematic data collection method

that use through observational skills to detect health problems.
Positions used during nursing assessment, medical examinations, and during

diagnostic procedures:
– Dorsal recumbent
– Supine
– Sims
– Prone
– Lithotomy

– Genupectoral
Assessment Technique
INSPECTION
 Assessment of the body movement and nutrition status
 The examiner is looking to the patient with close observation
 critical observation *always first*
1. Take time to “observe” with eyes, ears, nose (all senses)
2. Use good lighting
3. Look at color, shape, symmetry, position
4. Observe for odors from skin, breath, wound
5. Develop and use nursing instincts
6. Inspection is done alone and in combination with other
assessment techniques
Using the senses to observe the client data

Senses Example of client data
Vision Overall appearance (e.g., body size, general weight,
posture, grooming); signs of distress or discomfort;
facial and body gestures; skin color and lesions;
abnormalities of movement; nonverbal demeanor
(e.g., signs of anger or anxiety); religious or cultural
artifacts (e.g., books, icons, candles, beads)
Smell Body or breath odors
Hearing Lung and heart sounds; bowel sounds; ability to
communicate; language spoken; ability to initiate
conversation; ability to respond when spoken to;
orientation to time, person, and place; thoughts and
feelings about self, others and health status
Touch Skin temperature and moisture; muscle strength
(e.g., hand grip); pulse rate, rhythm, and volume;
palpatory lesions (e.g., lumps, masses, nodules)
Example:

PALPATION
 Using the sense of touch, as the examiners feels or presses on the
body of the patient
 If the examiner is moving a part of the body to examined
 light and deep touch
1. Back of hand (dorsal aspect) to assess skin temperature
2. Fingers to assess texture, moisture, areas of tenderness
3. Assess size, shape, and consistency of lesions and organs
4. Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep
Example;
 Abdomen
o Fundic height – distance from symphysis pubis to top of the
fundus.
o Assessment of fundic height – done to estimate AOG
(Bartholomew‟s rule & Mc Donald‟s rule), EDC (Naegele‟s rule)
and fetal growth rate.
Determining the height of the fundus
BARTHOLOMEW’S RULE – use to calculate AOG.
 3 Landmarks – Symphysis pubis, Umbilicus, Xiphoid process

12 wks – level of symphysis pubis
16 wks – halfway between umbilicus and symphysis pubis
20 wks – level of umbilicus
24 wks – place 2 fingers above umbilicus
30 wks – halfway between umbilicus and xiphoid process
34 wks – just below the xiphoid process
36 wks – level of xyphoid process
40 wks – at 34 wks level due to lightening

Bartholomew’s Rule
MC DONALD’S RULE
Example; Gina visit your clinic last September 3, 2020, her last menstrual period
(LMP) is March 20, 2020. Her AOG is?
Solution; March – 11 187 = 26.5

April – 30 7
May – 31
June - 30 Answer; 26 weeks & 5 days
July – 31
Aug. – 31
Sep. – 3__
187
PERCUSSION
 A method used by the examiner is striking a particular area of the
body with the finger to listen to a sound and to determine
resistance of the tissue.
 Tapping a body organ to listen to the sound produced
 sounds produced by striking body surface
1. Produces different notes depending on underlying mass (dull,
resonant, flat, and tympanic)
2. Used to determine size and shape of underlying structures by
establishing their borders and indicates if tissue is air-filled, fluid-
filled, or solid
3. Action is performed in the wrist.
Example;

AUSCULTATION
 Involves sense of hearing to interpret sounds with the aid of a
stethoscope
 Used when the physical examiner does not use any instrument
but only the sense of hearing for interpreting sound in the body
 Cardiac rate, fetal heart beat
 listening to sounds produced by the body
1. Direct auscultation – sounds are audible without stethoscope
2. Indirect auscultation – uses stethoscope
3. Know how to use stethoscope properly [practice skill]
4. Fine-tune your ears to pick up subtle changes [practice skill]
5. Describe sound characteristics (frequency, pitch intensity,
duration, quality) [practice skill]
6. Flat diaphragm picks up high-pitched respiratory sounds best.
7. Bell picks up low pitched sounds such as heart murmurs.
8. Practice using BOTH diaphragms
Example;
Checking the Fetal Heart Tone Checking the Blood Pressure
Head to toe Examination

A. Examination of Skin
1. Inspect: skin color and uniformity of color, moisture, hair pattern, rashes,
lesions, pallor, and edema
2. Palpate: temperature, turgor, lesions, edema, and texture
3. Percussion and auscultation: rarely used on skin
4. Terminology: pallor, cyanosis, edema, ecchymosis, macule, papule, jaundice,
types of edema, vitiligo, hirsutism, alopecia, etc.
5. Pale, cool, moist skin can be indicative of heat stroke, shock or other cardiac
complications.
6. There are abnormal and normal skin findings (such as nevus)
B. Examination of the Head and Neck

Equipment Needed
1. Otoscope
2. Tongue blades
3. Cotton tipped applicators
4. Non-latex exam gloves
General Considerations
The head and neck exam is not a single, fixed sequence. The assessment varies
depending on the examiner and the situation.
Head
1. Look for scars, lumps, rashes, hair loss, or other lesions.
2. Look for facial asymmetry, involuntary movements, or edema.
3. Palpate to identify any areas of tenderness or deformity.
Fontanels in a newborn - toddler:

1. Posterior fontanel – triangle shaped; closes 1-2 months
2. Anterior fontanel – diamond shaped; closes at 9 months – 2 years
Ears - See also notes under Cranial Nerves for other assessments related to ears
and hearing
1. Inspect the auricles and move them around gently. Ask the patient if this is
painful.
2. Palpate the mastoid process for tenderness or deformity.
3. Assess ears using otoscope:
a) Hold the otoscope upside down with your thumb and fingers so that the ulnar
aspect of your hand makes contact with the patient.
b) For adults, pull the ear upwards and backwards to straighten the canal.
c) PEDIATRICS: For children pull the ear down and back.
d) Use the largest speculum that will fit comfortably.
e) Inspect the ear canal and middle ear structures noting any redness, drainage, or
deformity.
f) Insufflate the ear and watch for movement of the tympanic membrane.
g) Repeat for the other ear.
4. Normal color of eardrum: shiny translucent, pearly gray.
5. Abnormal findings:
a) Erythema – suppurative Otitis Media. purulent drainage.
b) Dull, nontransparent gray – serous otitis media with effusion
6. Conductive hearing loss is due to mechanical dysfunction of inner or middle ear.
7. Sensory-neural loss is due to pathological problem of inner ear, CNS or cerebral
cortex.
8. In older adults, there may be some normal high-tone hearing loss.
Nose and sinuses

It is often convenient to examine the nose immediately after the ears using the
same speculum.
1. Tilt the patient's head back slightly. Ask them to hold their breath for the next
few seconds.
2. Insert the otoscope into the nostril, avoiding contact with the septum.
3. Inspect the visible nasal structures and note any swelling, redness, drainage, or
deformity.
4. Repeat for the other side.
5. Turbinates should be pink and moist
6. Frontal sinuses are below eyebrows
7. Maxillary sinuses are below zygomatic arch
Mouth and Throat

It is often convenient to examine the throat using the otoscope with the speculum
removed.
1. Ask the patient to open their mouth.
2. Using a wooden tongue blade and a good light source, inspect the inside of the
patients mouth including the buccal folds and under the tongue. Note any ulcers,
white patches (leukoplakia), or other lesions.
3. If abnormalities are discovered, use a gloved finger to palpate the anterior
structures and floor of the mouth.
4. Inspect the posterior oropharynx by depressing the tongue and asking the
patient to say "Ah." Note any tonsillar enlargement, redness, or discharge.
5. Hard palate is located in the anterior part of the mouth. It is made of bone and is
pale or whitish.
6. Soft plate is located in the posterior part of the mouth. It is softer, more mobile
and pink in color.
Neck
1. Inspect the neck for asymmetry, scars, or other lesions.
2. Palpate the neck to detect areas of tenderness, deformity, or masses.
Lymph Nodes
1. Systematically palpate with the pads of your index and middle fingers for the
various lymph node groups.
2. Preauricular - In front of the ear
3. Postauricular - Behind the ear
4. Occipital - At the base of the skull
5. Tonsillar - At the angle of the jaw
6. Submandibular - Under the jaw on the side
7. Submental - Under the jaw in the midline
8. Superficial (Anterior) Cervical - Over and in front of the sternomastoid muscle
9. Supraclavicular - In the angle of the sternomastoid and the clavicle
10. The deep cervical chain of lymph nodes lies below the sternomastoid and
cannot be palpated without getting underneath the muscle. Inform the patient that
this procedure will cause some discomfort.
11. Hook your fingers under the anterior edge of the sternomastoid muscle.
12. Ask the patient to bend their neck toward the side you are examining.
13. Move the muscle backward and palpate for the deep nodes underneath.
14. Note the size and location of any palpable nodes and whether they were soft or
hard, non-tender or tender, and mobile or fixed

Thyroid Gland
1. Inspect the neck looking for the thyroid gland. Note whether it is visible and
symmetrical. A visibly enlarged thyroid gland is called a goiter.
2. One way to look is to have person swallow sip of water; the thyroid gland will
move upward with a swallow.
3. Move to a position behind the patient. Have the patient tilt head slightly to right.
4. Identify the cricoid cartilage with the fingers of both hands.
5. Move downward two or three tracheal rings while palpating for the isthmus.
6. Move laterally from the midline while palpating for the lobes of the thyroid.
7. Note the size, symmetry, and position of the lobes, as well as the presence of any
nodules. The normal gland is often not palpable.
C. Examination of the Eye - see also Cranial Nerve II, III, IV, V
Equipment Needed
• Snellen Eye Chart or Rosenbaum Pocket Vision Card
• Ophthalmoscope
Visual Acuity
In cases of eye pain, injury, or visual loss, always check visual acuity before
proceeding with the rest of the exam or putting medications in your patients eyes.
1. Allow the patient to use their glasses or contact lens if available. You are
interested in the patient's best corrected vision.
2. Position the patient 20 feet in front of the Snellen eye chart (or hold a
Rosenbaum pocket card at a 14 inch "reading" distance).
3. Have the patient cover one eye at a time with an opaque card.
4. Ask the patient to read progressively smaller letters until they can go no further.
5. Record the smallest line the patient read successfully (20/20, 20/30, etc.)
6. Repeat with the other eye.
Unexpected/unexplained loss of acuity is a sign of serious ocular pathology.

Inspection
1. Observe the patient for ptosis, exophthalmos, lesions, deformities, or asymmetry.
2. Ask the patient to look up and pull down both lower eyelids to inspect the
conjunctiva and sclera.
3. Next spread each eye open with your thumb and index finger. Ask the patient to
look to each side and downward to expose the entire bulbar surface.
4. Note any discoloration, redness, discharge, or lesions. Note any deformity of the
iris or lesion cornea.
5. If you suspect the patient has conjunctivitis, be sure to wash your hands
immediately. Viral conjunctivitis is very contagious, so protect yourself!
Visual Fields - Screen Visual Fields by Confrontation
1. Stand two feet in front of the patient and have them look into your eyes.
2. Hold your hands to the side half way between you and the patient.
3. Wiggle the fingers on one hand.
4. Ask the patient to indicate which side they see your fingers move.
5. Repeat two or three times to test both temporal fields.
6. If an abnormality is suspected, test the four quadrants of each eye while asking
the patient to cover the opposite eye with a card.
Extraocular Muscles
A. Corneal Reflections
1. Shine a light from directly in front of the patient.
2. The corneal reflections should be centered over the pupils.
3. Asymmetry suggests extraocular muscle pathology.
B. Extraocular Movement (EOM)
1. Stand or sit 3 to 6 feet in front of the patient.
2. Ask the patient to follow you r finger with their eyes without moving their head.
3. Check gaze in the six cardinal directions using a cross or "H" pattern.
4. Check convergence by moving your finger toward the bridge of the patient's nose.
5. Pause during upward and lateral gaze to check for nystagmus (involuntary eye
movement which differs in each eye).
6. Tests CN 3, 4, and 6
C. Pupillary Reactions
1. PERRLA is a common abbreviation that stands for "Pupils Equal Round Reactive
to Light and Accommodation." The use of this term is so routine that it is often
used incorrectly. If you did not specifically check the accommodation reaction use
the term PERRL.
2. Look for direct and consensual responses. In a normal response, the eye which
the light is shined has pupillary constriction (direct reflex) AND the other pupil also
constricts (indirect or consensual reflex). An abnormal response (no pupillary
constriction) can help to localize the lesion, particularly when interpreted with the
result of vision testing. While observing the pupillary light response one should also
check that the pupils are the same size.
3. Light
a) Dim the room lights as necessary.
b) Ask the patient to look into the distance.
c) Shine a bright light obliquely into each pupil in turn.
d) Look for both the direct (same eye) and consensual (other eye) reactions.
e) Record pupil size in mm and any asymmetry or irregularity.
4. Accommodation
If the pupillary reactions to light are diminished or absent, check the reaction to
accommodation (near reaction):
a) Hold your finger about 10cm from the patient's nose.
b) Ask them to alternate looking into the distance and at your finger.
c) Observe the pupillary response in each eye.
Notes
1. Visual acuity is reported as a pair of numbers (20/20) where the first number is
how far the patient is from the chart and the second number is the distance from
which the "normal" eye can read a line of letters. For example, 20/40 means that at
20 feet the patient can only read letters a "normal" person can read from twice that
distance.
2. You may, instead of wiggling a finger, raise one or two fingers (unilaterally or
bilaterally) and have the patient state how many fingers (total, both sides) they see.
To test for neglect, on some trials wiggle your right and left fingers simultaneously.
The patient should see movement in both hands.
3. Diopters are used to measure the power of a lens. The ophthalmoscope actually
has a series of small lens of different strengths on a wheel (positive diopters are
labeled in green, negative in red). When you focus on the retina you "dial-in" the

correct number of diopters to compensate for both the patient's and your own
vision.
D. Examination of the Chest and Lungs

Equipment Needed
• Stethoscope
• Peak Flow Meter
1. The patient must be properly undressed and gowned for this examination.
2. Ideally the patient should be sitting on the end of an exam table.
3. The examination room must be quiet to perform adequate percussion and
auscultation.
4. Observe the patient for general signs of respiratory disease (finger clubbing,
cyanosis, air hunger, etc.).
5. Try to visualize the underlying anatomy as you examine the patient.
Inspection
1. Observe the rate, rhythm, depth, and effort of breathing. Note whether the
expiratory phase is prolonged.
2. Listen for obvious abnormal sounds with breathing such as wheezes.
3. Observe for retractions and use of accessory muscles (sternomastoids,
abdominals).
4. Observe the chest for asymmetry, deformity, or increased anterior-posterior (AP)
diameter.
5. Confirm that the trachea is near the midline
6. A-P (anterior-posterior) diameter vs. transverse diameter
a) A-P should be less than Transverse in adults; 1:2 – 5:7
b) Elevated A-P size = barrel chest, may be COPD in adult; normal in children
Palpation
1. Identify any areas of tenderness or deformity by palpating the ribs and sternum.
2. Assess expansion and symmetry of the chest by placing your hands on the
patient's back, thumbs together at the midline, and ask them to breathe deeply.
Percussion
Proper Technique
1. Hyperextend the middle finger of one hand and place the distal interphalangeal
joint firmly against the patient's chest.
2. With the end (not the pad) of the opposite middle finger, use a quick flick of the
wrist to strike first finger.
3. Categorize what you hear as normal, dull, or hyperresonant.
4. Practice your technique until you can consistently produce a "normal"
percussion note on your (presumably normal) partner before you work with
patients.

Posterior Chest Anterior Chest
Anterior Chest
1. Percuss from side to side and top to bottom using the pattern shown in the
illustration.
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the percussion sounds you hear.
Posterior Chest
1. Percuss from side to side and top to bottom using the pattern shown in the
illustration. Omit the areas covered by the scapulae.
3. Note the location and quality of the percussion sounds you hear.
4. Find the level of the diaphragmatic dullness on both sides.
Flat or Dull – Pleural Effusion or Lobar

Pneumonia
Normal – Healthy Lung or Bronchitis
Hyper resonant – Emphysema or
Pneumothorax
Auscultation
Use the diaphragm of the stethoscope to auscultate breath sounds.
Posterior Chest
1. Auscultate from side to side and top to bottom using the pattern shown in the
illustration. Omit the areas covered by the scapulae.
3. Note the location and quality of the sounds you hear.
Anterior Chest
1. Auscultate from side to side and top to bottom using the pattern shown in the
illustration.

3. Note the location and quality of the sounds you hear.
Interpretation
Breath sounds are produced by turbulent air flow. They are categorized by the size
of the airways that transmit them to the chest wall (and your stethoscope). The
general rule is, the larger the airway, the louder and higher pitched the sound.
c) Vesicular breath sounds are low pitched and normally heard over most lung
fields.
d) Tracheal breath sounds are heard over the trachea.
e) Bronchovesicular and bronchial sounds are heard in between. Inspiration is
normally longer than expiration (I > E).
1. Breath sounds are decreased when normal lung is displaced by air (emphysema
or pneumothorax) or fluid (pleural effusion).
2. Breath sounds shift from vesicular to bronchial when there is fluid in the lung
itself (pneumonia).
3. Extra sounds that originate in the lungs and airways are referred to as
"adventitious" and are always abnormal (but not always significant).
Adventitious (Extra) Breath Sounds

Crackles These are high pitched, discontinuous
sounds similar to the sound produced by
rubbing your hair between your fingers.
(Also known as Rales)
Wheezes These are generally high pitched and
"musical" in quality. Stridor is an
inspiratory wheeze associated with upper
airway obstruction (croup).
Rhonchi These often have a "snoring" or "gurgling"
quality. Any extra sound that is not a
crackle or a wheeze is probably rhonchi.
Low pitched.
E. Cardiovascular Examination and Peripheral Vascular System

1. The patient must be properly undressed and in a gown for this examination.
2. The examination room must be quiet to perform adequate auscultation.
3. Observe the patient for general signs of cardiovascular disease (finger clubbing,
cyanosis, edema, etc.).
Pulses – see vital signs for radial pulse standards; Apical and others described
below
1. Check the radial pulses on both sides. If the radial pulse is absent or weak,
check the brachial pulses.
2. Check the posterior tibia and dorsalis pedis pulses on both sides. If these pulses
are absent or weak, check the popliteal and femoral pulses.
3. Location of pulses
a) Carotid – neck
b) Brachial – upper arm
c) Radial – wrist
d) Femoral – groin

e) Popliteal – behind knee
f) Posterior tibial – back of leg near Achilles tendon
g) Dorsalis pedis (pedal) – top of foot. Requires light touch
Grading force of pulse

0 absent
1+ weak, thready
2+ normal
3+ increased, full,
bounding
Blood Pressure – see vital signs (Blood pressure for process and interpretation)
Pulse pressure: difference between the systolic and diastolic blood pressure
reading.
Amplitude and Contour (Carotid)

1. Observe for carotid pulsations.
2. Place your fingers behind the patient's neck and compress the carotid artery on
one side with your thumb at or below the level of the cricoid cartilage. Press firmly
but not to the point of discomfort.
3. Assess the following:
a. The amplitude of the pulse.
b. The contour of the pulse wave.
c. Variations in amplitude from beat to beat or with respiration.
4. Repeat on the opposite side.
Auscultation for Bruits (Carotids)

If the patient is late middle aged or older, you should auscultate for bruits. A bruit
is often, but not always, a sign of arterial narrowing and risk of a stroke.
1. Place the bell of the stethoscope over each carotid artery in turn. You may use
the diaphragm if the patient's neck is highly contoured.
2. Ask the patient to inhale deep breath then exhale and hold momentarily.
3. Listen for a blowing or rushing sound--a bruit. Do not be confused by heart
sounds or murmurs transmitted from the chest.
Jugular Venous Pressure

1. Position the patient supine with the head of the table elevated 30 degrees.
2. Use tangential, side lighting to observe for venous pulsations in the neck.

3. Look for a rapid, double (sometimes triple) wave with each heartbeat. Use light
pressure just above the sternal end of the clavicle to eliminate the pulsations and
rule out a carotid origin.
4. Adjust the angle of table elevation to bring out the venous pulsation.
5. Identify the highest point of pulsation. Using a horizontal line from this point,
measure vertically from the sternal angle.
6. This measurement should be less than 4 cm in a normal healthy adult.
Precordial Movement
1. Position the patient supine with the head of the table slightly elevated.
2. Always examine from the patient's right side.
3. Inspect for precordial movement. Tangential lighting will make movements more
visible.
4. Palpate for precordial activity in general. You may feel "extras" such as thrills or
exaggerated ventricular impulses.
5. Palpate for the point of maximal impulse (PMI or apical pulse). It is normally
located in the 4th or 5th intercostal space just medial to the midclavicular line and
is less than the size of a quarter.
6. Note the location, size, and quality of the impulse.
Capillary Refill
1. Press down firmly on the patient's finger or toe nail so it blanches.
2. Release the pressure and observe how long it takes the nail bed to "pink" up.
3. Capillary refill times greater than 2 to 3 seconds suggest peripheral vascular
disease, arterial blockage, heart failure, or shock.
Auscultation
1. Position the patient supine with the head of the table slightly elevated.
2. Always examine from the patient's right side. A quiet room is essential.
3. Listen with the diaphragm at the right 2nd interspace near the sternum (aortic
area).

4. Listen with the diaphragm at the left 2nd interspace near the sternum (pulmonic
area).
5. Listen with the diaphragm at the left 3rd, 4th, and 5th interspaces near the
sternum (tricuspid area).
6. Listen with the diaphragm at the apex (PMI) (mitral area).
7. Listen with the bell at the apex.
8. Listen with the bell at the left 4th and 5th interspace near the sternum
9. Have the patient roll on their left side. Listen with the bell at the apex. This
position brings out S3, S4 and mitral murmurs.
10. Have the patient sit up, lean forward, and hold their breath in exhalation.
Listen with the diaphragm at the left 3rd and 4th interspace near the sternum.
This position brings out aortic murmurs.
11. Record S1, S2, (S3), (S4), as well as the grade and configuration of any
murmurs ("two over six" or "2/6", "pansystolic" or "crescendo").
Heart sounds
S1: normal: closure AV, start systole, heard all over, loudest apex
S2: normal: closure of semilunar valves, end systole, all over but loudest base,
“dub”
S3: extra heart sounds: vibrations that come from filling ventricles, start diastolic
usually; audible in children, young adults, pregnant women – otherwise may be
indicative of disease
S4: extra heart sounds: end of diastolic, vibrations; usually abnormal to hear – may
be indicative of disease
Murmurs
1. Grade i-ii functional systolic murmurs are common in young children and
resolve with age
2. Auscultate for blowing, swishing sound.
3. Some are „innocent” murmurs, but most are indicative of disease.
4. Murmurs are graded. A grade “2” murmur would be rated ii/vi.
Grade Description
i Barely audible. Heard only if
room silent and then still hard
to hear
ii Clearly audible, but faint
iii Moderately loud, easy to hear
iv Loud, associated with thrill on
chest wall
v Very loud, can hear with edge
of stethoscope off chest
vi Loudest, can hear with entire
stethoscope off chest wall
Edema, Cyanosis, and Clubbing

1. Check for the presence of edema (swelling) of the feet and lower legs.
2. Check for the presence of cyanosis (blue color) of the feet or hands.
3. Check for the presence of clubbing of the fingers.
a) Normal = 160 degrees
b) Curved = 160 degrees or less
c) Early clubbing = 180 degrees

Pitting edema: Level of pitting Indentation Swelling of leg
Scale
1+ Mild Slight Not noticeable
2+ moderate Subsides rapidly
3+ Deep Remains for Leg looks
short time swollen
4+ Very deep Remains for long Grossly swollen
time and misshapen
F. Examination of the Abdomen

Equipment Needed
1. When assessing start in RLQ over ileocecal valve
2. The patient should have an empty bladder.
3. The patient should be lying supine on the exam table and appropriately draped.
4. The examination room must be quiet to perform adequate auscultation and
percussion.
5. Watch the patient's face for signs of discomfort during the examination.
6. Use the appropriate terminology to locate your findings:
a) Right Upper Quadrant (RUQ)
b) Right Lower Quadrant (RLQ)
c) Left Upper Quadrant (LUQ)
d) Left Lower Quadrant (LLQ)
e) Midline: Epigastric
f) Periumbilical
g) Suprapubic
Notes
1. Disorders in the chest will often manifest with abdominal symptoms. It is always
wise to examine the chest when evaluating an abdominal complaint.
2. Consider the inguinal/rectal examination in males.
3. Consider the pelvic/rectal examination in females.
Inspection
1. Look for scars, striae, hernias, vascular changes, lesions, or rashes.
2. Look for movement associated with peristalsis or pulsations.
3. Note the abdominal contour. Is it flat, scaphoid, or protuberant?
4. Contour in newborn is normally protuberant and soft
5. Contour in child is normally symmetric and slightly rounded
Auscultation
1. Place the diaphragm of your stethoscope lightly on the abdomen.
2. Listen for bowel sounds. Are they normal, increased, decreased, or absent?
Borborygmus = “growling”
3. Listen for bruits over the renal arteries, iliac arteries, and aorta.
Percussion
1. Percuss in all four quadrants (clockwise) using proper technique: Inspect –
Auscultation – Percuss – Palpate.

2. Categorize what you hear as tympanic or dull. Tympany is normally present over
most of the abdomen in the supine position. Unusual dullness may be a clue to an
underlying abdominal mass or full bladder.
Palpation
General Palpation
1. Begin with light palpation (1cm deep). At this point you are mostly looking for
areas of tenderness. The most sensitive
indicator of tenderness is the patient's facial expression (so watch the patient's
face, not your hands). Voluntary or involuntary guarding may also be present.
2. Proceed to deep palpation (5-8 cm deep) after surveying the abdomen lightly.
Try to identify abdominal masses or areas of deep tenderness.
G. Musculoskeletal System
1. The patient should be undressed and gowned as needed for this examination.
2. Some portions of the examination may not be appropriate depending on the
clinical situation (performing range of motion on a fractured leg for example).
3. The musculoskeletal exam is all about anatomy. Think of the underlying
anatomy as you obtain the history and examine the patient.
4. When taking a history for an acute problem always inquire about the
mechanism of injury, loss of function, onset of swelling (< 24 hours), and initial
treatment.
5. When taking a history for a chronic problem always inquire about past injuries,
past treatments, effect on function, and current symptoms.
6. The cardinal signs of musculoskeletal disease are pain, redness (erythema),
swelling, increased warmth, deformity, and loss of function.
7. With Musculoskeletal system, Always begin with inspection, palpation and
range of motion, regardless of the region you are examining (except abdomen).
Specialized tests are often omitted unless a specific abnormality is suspected.
8. A complete evaluation will include a focused neurologic exam of the
affected area.
Regional Considerations
1. Remember that the clavicle is part of the shoulder. Be sure to include it in your
examination.
2. The patella is much easier to examine if the leg is extended and relaxed.
3. Be sure to palpate over the spinous process of each vertebrae.
4. It is always helpful to observe the patient standing and walking.
5. Always consider referred pain, from the neck or chest to the shoulder, from the
back or pelvis to the hip, and from the hip to the knee.
6. Pain with, or limitation of, rotation is often the first sign of hip disease.
7. Diagnostic hints based on location of pain:
Back Side Front

Shoulder Pain Muscle Spasm Bursitis or
Rotator Cuff
Glenohumeral
Joint
Hip Pain Sciatica Bursitis
Hip Joint

Inspection
1. Look for scars, rashes, or other lesions.
2. Look for asymmetry, deformity, or atrophy.
3. Always compare with the other side.
Palpation
1. Examine each major joint and muscle group in turn.
2. Identify any areas of tenderness.
3. Identify any areas of deformity.
Range of Motion
1. Start by asking the patient to move through an active range of motion (joints
moved by patient).
2. Proceed to passive range of motion (joints moved by examiner) if active range of
motion is abnormal.
Active Range of Motion
1. Ask the patient to move each joint through a full range of motion.
2. Note the degree and type (pain, weakness, etc.) of any limitations.
3. Note any increased range of motion or instability.
5. Proceed to passive range of motion if abnormalities are found.
Passive Range of Motion

1. Ask the patient to relax and allow you to support the extremity to be examined.
2. Gently move each joint through its full range of motion.
3. Note the degree and type (pain or mechanical) of any limitation.
4. If increased range of motion is detected, perform special tests for instability as
appropriate.
Specific Joints
1. Fingers - flexion/extension; abduction/adduction
2. Thumb - flexion/extension; abduction/adduction; opposition
3. Wrist - flexion/extension; radial/ulnar deviation
4. Forearm - pronation/supination (function of BOTH elbow and wrist)
5. Elbow - flexion/extension
6. Shoulder - flexion/extension; internal/external rotation; abduction/adduction
(2/3 glenohumeral joint, 1/3 scapulo-thoracic)
7. Hip - flexion/extension; abduction/adduction; internal/external rotation
8. Knee - flexion/extension
9. Ankle - flexion (plantar flexion)/extension (dorsiflexion)
10. Foot - inversion/eversion
11. Toes - flexion/extension
12. Spine - flexion/extension; right/left bending; right/left rotation
Notes
1. Scoliosis = lateral curvature of spine with unequal leg length. Minimal with
young children which resolves with change of position. More common as a concern
in adolescents.

2. Kyphosis = “hunchback”; over-curvature of the thoracic vertebrae
3. Flatfoot = pronation of foot in children. Comes from turning of medial side of
foot. Normal for 12-30 months; abnormal otherwise.
4. “Knock knees” – knees together when standing. Normal to age 7years; abnormal
older.
5. “bow legs” – normal to age 3 years; abnormal older.
6. Toe walking – usually stops by 3 months after start of walking.
H. Neurologic Examination
1. Always consider left to right symmetry
2. Consider central vs. peripheral deficits
3. Organize your thinking into seven categories:
a) Mental Status
b) Cranial Nerves
c) Motor
d) Coordination and Gait
e) Reflexes
f) Sensory
g) Special Tests
Mental Status:
1. Assess level of consciousness; facial expression and body language; speech;
cognition and functioning
2. Assess while doing health history
General notes:
1. Cerebral – mental status
2. Cerebellum – gait, coordination, balance, etc.
Cranial Nerves:
1. Sensory, motor, parasympathetic or mixed
Reflexes
Deep Tendon Reflexes
1. The patient must be relaxed and positioned properly before starting.
2. Reflex response depends on the force of your stimulus. Use no more force than
you need to provoke a definite response.
3. Reflexes can be reinforced by having the patient perform isometric contraction of
other muscles (clenched teeth).
4. Exaggerated hyperactive reflexes in a pregnant woman may be related to pre-
eclampsia.
5. Reflexes should be graded on a 0 to 4 "plus" scale:
Tendon Reflex Grading Scale

Grade Description
0 Absent
1+ or + Hypoactive
2+ or ++ "Normal"
3+ or +++ Hyperactive without May indicate disease but
clonus also may be normal

4+ or ++++ Hyperactive with clonus Indicative of disease (see
definition below)
Plantar Response (Babinski)

1. Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer
or key.
2. Note movement of the toes, normally flexion (withdrawal).
3. Extension of the big toe with fanning of the other toes is abnormal in other than
a young child. This is referred to as a positive Babinski
4. Positive Babinski is normal to age 24 months.
Routine pediatric neuro testing:

1. Plantar (Babinski) – described above. Normal to age 24 months.
2. Moro (startle) – normal to about 4 months
3. Rooting – birth to about 3-4 months
4. Palmar grasp – birth, stronger at 1-2 months, gone by 3-4 months
I. Genito-urinary and wellness

Male:
Prostate screening
1. Digital exam – recommended annually. Hemocult any specimen.
2. PSA – lab test. Recommendations vary – every 1-2 years
Female:
Mammogram
1. Follow current recommendations
Breast Self- Exam (BSE):

1. Perform monthly right after menses or day 4-7 of cycle
2. Include raising arms to look for retraction
Pap-smear. – Tests for cervical cancer

1. Specimens taken from (in order) vaginal pool, cervical scrape, endocervical
specimen.
2. Post hysterectomy and cervix removal – scrape from end of vagina and cervical
pool.

2. PLANNING
 Series of steps in which the midwife and the patient set
PRIORITIES, GOALS and OBJECTIVES and select appropriate
interventions to resolve the identified problems of the client
 Determining how to prevent, reduce, or resolve the identified
priority client problems; how to support client strengths; and how
to implement interventions in an organized, individualized, and
goal directed manner.
 Guidelines must be Specific, Measurable, Attainable, Realistic,
Time bounded.
3. INTERVENTION
 Putting the care plan into action
 Institution of measures to solve the problem in the community
 To assist the client to meet desired goals/ outcomes; promote
wellness; prevent illness and disease; restore health; and facilitate
coping with altered functioning
INDEPENDENT: actions that the midwives carry on herself without
the order from other person.
 Performing Benedict‟s test and Acetic acid test, attended

normal deliveries, TSB
DEPENDENT: following orders from a superior
 Following doctor‟s order; giving methylergometrine

4. EVALUATION
 The examination of the outcome of a chosen action in terms of its
success in meeting the objectives
 Measuring the degree to which goals/outcomes have been
achieved
 To determine whether to continue, modify, or terminate the plan of
care
VITAL SIGNS/CARDINAL SIGNS(V/S)
Vital signs are measurement of the body‟s basic functions. Normal vital signs
change with age, sex, weight, exercise tolerance, and overall health. The four main
vital signs that are usually monitored include:
 Body temperature
 Pulse rate (heart rate)
 Respiratory rate
 Blood pressure
TERMINOLOGY
TEMPERATURE BLOOD PULSE RESPIRATION PAIN

PRESSURE (effects on
vital sins)
1. Afebrile 1. Aneroid 1. Apical 1. Apnea 1.Acute
2. Axilla manometer 2. Arrhythmi 2. Bradypne pain
3. Celcius 2. Bell a a 2.Chronic

4. Fahrenheit 3. Diaphragm 3. Bounding 3. Cheyne- pain
5. Febrile 4. Diastolic 4. Brachial strokes 3.Phantom
6. Metabolis 5. Hypertensio 5. Bradycardi 4. Cyanosis pain
m n a 5. Diaphrag 4.Pain
7. Mucosa 6. Hypotensio 6. Carotid m scales
8. Pyrexia n 7. Pulse 6. Dyspnea
9. Tympanic 7. Orthostatic deficit 7. Orthopne
hypotensio 8. Radial a
n 9. Rhythm 8. Stertorous
8. Pulse 10. Thread 9. Tachypne
pressure 11. Tachycardi a
9. Sphygmom a
anometer
10. Stethoscope
11. Systolic
WHAT IS BODY TEMPERATURE?
- The temperature of a person varies depending on recent activity,

consumption of food or fluids, and time of day. Normal temperature can
range from 97.8 to 99.1 degrees fahreheit.
- Balance between the heat produced and heat lost by the body.
- Normal: 96.8 – 100.4F/ 36.5 – 37.5˚C
Rectal – 37.5C
ORAL – 37C
AXILLARY – 36.5 – 37.5C
Esophagus – 36.3
A fever is when the body temperature is higher than normal for an individual. It
can indicate an abnormal process going on in the body such as an infection.
There are many devices, called thermometers that can be used to take a
temperature. Often a probe that will record the temperature is placed under the
tongue, under the arm, or rectally. There are special thermometers that quickly
measure the temperature of the ear drum. There are also thermometers that
measure the temperature of the skin on the forehead.
KINDS:

Core – temperature of body organs and deep tissues (rectum, tympanic, esophagus)
Surface – temperature of skin, subcutaneous tissues ad fats
Hypothalamus – the most important heat regulating center of the body
Euthermia – normal temperature
Pyrexia/fever/Hyperthermia – above normal temperature
Hyperpyrexia – very high fever 41˚C and above
Mechanisms of Heat Loss
Convection – is the flow of heat from the newborn‟s body surface to cooler
surrounding air. The effectiveness of convection depends on the velocity of the flow
(a current of air cools faster than nonmoving air). Eliminating drafts from windows
or air conditioners reduces convection heat loss.
Conduction – is the transfer of body heat to a cooler solid object in contact with a
baby. For example, a baby placed on a cold counter or on the cold base of a
warming unit quickly loses heat to the colder metal surface.
Radiation – the transfer of body heat to a solid cooler object not in contact with the
baby, such as a cold window or air conditioner. Moving an infant as far as from
cold surface can possibly help reduce this type of heat loss.
Evaporation – is loss of heat through conversion of a liquid to a vapor. Newborns
are wet, so they lose a great deal of heat as the amniotic fluid on their skin
evaporates. To this heat loss, dry newborns as soon as possible, especially their
face and hair as the head, a large surface area in a newborn, can be responsible for
a great amount of heat loss. Covering the hair with a cap after drying it further
reduces the possibility of evaporation cooling. Be certain to remove any wet
blankets used to dry the infant immediately and place the infant on a warm, dry
blanket.
Classifications of fever
1. Intermittent – fever wherein the temperature fluctuates between
periods of fever and periods of normal/subnormal temperature.
2. Remittent – fluctuation in temperature without a return to normal
temperature
3. Relapsing – short periods of fever lasting followed by afebrile state
lasting for several days (on and off fever)
4. Constant – fever that fluctuates minimally and remains continuously
above normal
Resolution of fever
LYSIS – When fever returns to normal temperature gradually
CRISIS – When fever returns to normal temperature suddenly
DEFERVESCENCE – The period when the temperature goes down until it reaches
normal.
HEAT STROKE – this condition occurs when the body‟s thermoregulation system is
overwhelmed by excessively elevated environmental temperature (confusion, IHR,
IBP)
HEAT EXHAUSTION – occurs when excessive diaphoresis results in depletion of the
body‟s fluid and electrolytes.

Conversion
Conversion of centigrade to Fahrenheit
 Centigrade = (F/1.8) – 32
Conversion of Fahrenheit to centigrade
 Fahrenheit = (1.8)C + 32
WHAT IS A PULSE RATE?
The pulse rate measures the heart rate, or the number of times the heart beats per
minute. As the heart pushes blood through the arteries, the arteries pulsate with
each beat. Taking a pulse not only measures the heart rate but it can also be felt if
the heart is beating in a steady or an irregular fashion. This is important to note.
The normal pulse for adults ranges from 60 to 80 beats per minute and 120 to 160
per minute in pediatric. The pulse rate can fluctuate and increase with exercise,
sickness, injury, and emotions. Females tend to have faster heart rates than males.
Athletes often have quite slow heart rates and can tolerate a pulse down to 40
beats per minute.
How to check your pulse:

As the heart beats, you can feel the beats by firmly pressing on the arteries which
are located close to the skin‟s surface. The pulse can most easily be found on the
side of the lower neck, on the inside of the elbow, or at the wrist.
To take a pulse:
• Using your first and second fingertips, press on the artery until you feel the pulse
• Count the pulse for 30 seconds and then multiply by 2 to get the pulse which is
always recorded as beats per minute. Counting the pulse for 15 seconds and
multiplying by 4 is also acceptable.
CHECKING PULSE IN ADULT CHECKING PULSE IN PEDIATRIC
PULSE SITES
1. Apical Artery – most accurate, routinely used for infants and children
up to 3 years of age. Used to determine discrepancies with radial
pulse. Used in conjunction with some medications.
2. Radial artery – wrist/thumb side/most accessible, common/children.

3. Carotid artery – along the side of neck/shock/cardiac arrest/cpr.
Used during cardiac arrest/shock in adults. Used to determine
circulation to the brain.
4. Brachial artery – between biceps and triceps/ circulation to lower
arm. Used to measure blood pressure. Used during cardiac arrest for
infants.
5. Temporal artery – above and lateral to eye/pulse in children. Used
when radial pulse is not accessible.
6. Femoral artery – lower rim of pelvis/ circulation to leg. Used in cases
of cardiac arrest/shock. Used to determine circulation to a leg.
7. Dorsalis pedis – dorsum of foot. Used to determine circulation to the
foot.
8. Popliteal artery – below the knee. Used to determine circulation to
the lower leg.
9. Posterior tibial – used to determine circulation to the foot.
RATE
a. Tachycardia – more than 100
b. Bradycardia – less than 60
c. Pulse deficit – difference between apical and radial pulse
d. Pulse rhythm
- Thready – pulsation is not easily felt and slightly pressure causes it to
disappear.
- Weak pulse – it is stronger than thread pulse
- Pulse alternans – it is a regular rhythm but with alternate, strong,
weak volume.
- Bigeminal pulse – it is an irregular in which every other beat comes
early.
- Paradoxial pulse – pulse volume becomes weak during inspiration.
WHAT IS THE RESPIRATION RATE?

- The respiration is the number of breaths a person takes per minute.
The rate is taken by simply counting the number of breaths over one
minute by watching and counting how many times the chest rises.
- Respiration rates can increase with a fever or other illness, or with
some medical conditions such as lung disease.
- Normal rates for an adult at rest range from 16 to 20 breaths per
minute and 40 to 60 breaths per minute in pediatric..
- The respiratory rate of a newborn in the first few minutes of life may
be as high as 80 beats per minute. As a respiratory activity is
established and maintained, this rate settles to an average of 30 – 60
breaths per minute when the newborn is at rest. Respiratory depth,
rate, and rhythm are likely to be irregular and short periods of apnea
(without cyanosis) which last less than 15 seconds, sometimes called
periodic respirations, are normal. Respiratory rate can be observed
most easily by watching the movement of a newborn‟s abdomen,
because breathing primarily involves the use of the diaphragm and
abdominal muscles.
- The act of breathing – medulla oblongata is the primary center
Ventilation – movement of air in and out of the lungs
Inspiration – inhalation lasts 1-1.5s
BREATHING PATTERNS
Rate
 Tachypnea – quick, shallow breaths
 Bradypnea – abnormally slow breathing
 Apnea – cessation of breathing( absence of breathing)
Volume
 Hyperventilation – overexpansion of the lungs characterized by

rapid and deep breaths
 Hypoventilation – under expansion of the lungs, characterized by
shallow respirations.
Rhythm
 Cheyne-strokes breathing – rhythmic waxing and waning of

respirations from very deep to very shallow breathing and
temporary apnea.
Ease or effort
 Dyspnea – difficult and labored breathing during which the

individual has a persistent, unsatisfied need for air and feels
distressed.
 Orthopnea – ability to breath only in upright sitting or standing
positions.
Expiration – exhalation
Hyperventilation – very deep and rapid respiration, signs is tingling sensation of
the hands
Hypoventilation – very shallow respiration

Diffusion – the process by which oxygen and carbon dioxide moves between the
alveoli and Red blood cells.
Tidal Volume – the amount of air inspired by a person which is around 500ml
 Apnea – absence/ cessation of breathing
 Eupnoea – normal breathing
 Bradypnea – slow breathing
 Tachypnea – fast breathing/ above normal respiration
 Dyspnea – difficult or painful breathing
 Orthopnea – ability to breath only in an upright position.
 Air hunger – symptom indicative of insufficient 02 for proper
functioning of tissue cells.
 Vesicular – normal breath sounds
 Cheyne strokes respiration – marked by variation intensity, with
successive cycle of hyperventilation, gradually decreasing until
breathing cease for a short period (apnea-sign of dying patient).
 Biots respiration – type of breathing states that the person is
having repeated sequences of deep gasps and apnea.
 Kussmauls – abnormally deep, regular and increased in rate.
 Stortorous respiration – accompanied by abnormal sound
resembling snores. Noisy breathing common for asthma patients.
Breath sounds
Audible without amplification
 Stridor – a shrill, harsh sound heard during inspiration with

laryngeal obstruction.
 Stertor – snoring or sonorous respiration, usually due to a partial
obstruction of the upper airway.
 Wheeze – continuous, high pitch musical squeak or whistling
sound occurring on expiration and sometimes on inspiration when
air moves through a narrowed or partially obstructed airway.
 Bubbling – gurgling sounds heard as air passes through moist
secretions in the respiratory tract.
Chest movements
 Intercostal retraction – indrawing between the ribs

 Substernal retraction – indrawing beneath the breastbone
 Suprasternal retraction – indrawing above the clavicles.
Secretions and coughing
 Hemoptysis – the presence of blood in the sputum

 Productive cough – a cough accompanied by expectorated
secretions
 Nonproduction cough – a dry, harsh cough without secretions.
BLOOD PRESSURE
- Elevated blood pressure is associated with heart disease, congestive heart

failure, sudden death from heart attacks, strokes, and kidney disease.

Monitoring blood pressure is important and should be done on a regular
basis. For a young, healthy adult blood pressure readings should be taken at
least every two years. For anyone with medical problems such as diabetes, or
on medications such as antipsychotics; measuring the blood pressure
should be done several times each year.
What do blood pressure numbers mean?

120/70
Read as “one twenty over seventy millimeter mercury” (mm Hg)
Systolic
The top number, which is the higher of the two numbers, measures the pressure in
the arteries when the heart beats (the heart muscle squeezes or contracts).
Pressure when heartbeat eject of blood from the contraction of the left ventricle.
Diastolic
The bottom number, which is also the lower of the two numbers, measures the
pressure in the arteries between heart beats (when the heart muscle relaxes).
Pressure when heart is at rest or when the ventricles relax.
Pulse Pressure – difference between systolic and diastolic pressure
Hypertension – BP 140/90
HYPOTENSION – Less than 110mmHg systolic and less than 60 mmHg diastolic
pressure
Anti-hypertensive drugs/hypotensive drugs – drugs that lower the blood
pressure.
Korotkoff sound – the sound heard during BP taking
When Cuff too narrow or to loose – false high reading

When Cuff to wide – false low reading
What are normal blood Systolic Diastolic

pressures? Blood mm Hg mm Hg
Pressure
Category
Normal less than 120 and less than 80
Prehypertension 120 – 139 or 80 – 89
High Blood Pressure 140 – 159 or 90-99
(Hypertension)
Stage 1
High Blood Pressure 160 or higher or 100 or higher
(Hypertension)
Stage 2
Hypertensive Crisis Higher than 180 or Higher than 120
(Emergency Care Needed)
Symptoms of high blood pressure:

High blood pressure usually occurs with no symptoms. Many people believe that
people with high blood pressure will have headaches, nervousness, sweating, or
facial flushing. Those symptoms are actually seldom seen. Studies have actually

shown that people with high blood pressure often have fewer headaches than those
with normal blood pressure.
Nosebleeds were also thought to be an indicator of high blood pressure. Nosebleeds
can be caused by many factors, the most common being dry air. But nosebleeds
are not a reliable indicator of high blood pressure though they can occur with
extremely high blood pressure readings.
A hypertensive crisis, however, can cause many symptoms and emergency medical
treatment is needed. Symptoms that occur with very high blood pressure readings
include severe headaches, severe anxiety, and shortness of breath.
Symptoms of low blood pressure:

Low blood pressure (hypotension) is generally defined as a systolic pressure less
than 90 mm Hg and a diastolic pressure less than 60 mm Hg. However blood
pressure is not considered too low unless the person has symptoms. Many athletes
have blood pressures that are quite low and this is a sign of their fitness.
Symptoms of low blood pressure include:
• Dizziness or lightheadedness
• Fainting
• Nausea
• Blurred vision
• Fatigue
• Depression
Low blood pressures can occur with:
• Prolonged bed rest
• Blood loss such as from a bleed in the gastrointestinal tract
• Medications such as those used for high blood pressure, drugs for Parkinson‟s
disease, and pain medications.
•Heart problems
• Thyroid problems
• Severe infection (such as septic shock)
• Allergic reactions (anaphylaxis)
• Anemia
Taking blood pressures:

• Heart problems
• Thyroid problems
• Severe infection (such as septic shock)
• Allergic reactions (anaphylaxis)
• Anemia
Blood pressure varies throughout the day and night. Blood pressure is affected by
mental and physical activity and stress. Smoking and/or drinking caffeinated
beverages also raise the blood pressure.
Accurate measurement of blood pressures requires paying attention to the size and
placement of the cuff, the position of the person, and the technique used.
• Cuff size: if the cuff is too small, the systolic pressure will read incorrectly high.
• Cuff placement: ideally above the elbow over a bare arm. It can be taken over thin
clothing but not thick clothing. The sleeve should not be rolled up as this causes
pressure around the arm and an incorrect reading.
• Body position: crossing of the legs, or sitting without a back support can cause
the pressure to be higher.

• Body position: the arm should be supported at the level of the heart, not allowed
to hang down as that can cause an incorrectly high reading.
• With automatic blood pressure devices, the cuff is inflated automatically to the
correct amount. With manual blood pressure cuffs, the cuff should be inflated to
about 180 mm Hg and then allowed to deflate slowly. When the pulse is first heard,
that is the systolic pressure reading. As the air escapes the cuff, the sound of the
pulse will disappear. That is the diastolic pressure reading.
• Wrist blood pressures are often taken especially in obese people. With wrist blood
pressure readings, there is often a false elevation of blood pressures.
• Blood pressure measurements in the finger are not recommended as these
readings can be quite inaccurate.
PULSE OXIMETRY:
Often called the “fifth” vital sign, pulse oximetry is a non-invasive way to monitor
oxygen saturations. Prior to the use of pulse oximeters, the amount of oxygen in
the blood could only be measured by drawing blood directly from an artery and
analyzing that.
Pulse oximetry is generally done by using a device placed on the end of a finger or
on the earlobe. Light of two wavelengths passes through the tissue and the oxygen
saturation is measured. The measurement is the percent saturation of oxygen
which is being carried by hemoglobin in the blood. Hemoglobin is the oxygen
carrying pigment in our red blood cells.
A normal reading is 95% to 99%. Readings below 90% often indicate that someone
needs to have supplemental oxygen.
Applications for use:

Pulse oximetry is used extensively in medical offices and hospitals. It is also now
widely used in the home setting to monitor people with heart and lung problems.
Uses include
• Monitoring the level of supplemental oxygen needed for someone with COPD,
CHF, or other diseases.
• Monitoring someone who is ill with a respiratory infection.
• A fall in oxygen can be a warning that the person needs further evaluation
immediately.
• Monitoring oxygen levels during sleep can help diagnose sleep apnea.
False Readings
There are some limitations of this technology and can result in either falsely low or
high oxygen saturation readings:
• Low blood pressure as blood does not circulate well into the hands.

• Hypothermia (very low body temperature) as blood vessels will constrict or
narrow.
• Motion such as shivering or seizures can affect readings.
• Congenital medical conditions of abnormal hemoglobin or severe anemia can
affect readings.
• Poor sugar control in diabetics has been associated with high oxygen saturation
readings due to an increase in oxygen “sticking” to hemoglobin in the blood.
• Nail polish or artificial nails could affect the reading but the probe can be placed
sideways on the finger so that the pulsed light does not go through the nails. Dark
skin pigmentation can also affect readings.
• Intense daylight, fluorescent light and other intense light can cause falsely low
readings.
Temperature Pulse Respiration Blood

Pressure
Normal - Adult:60-100 per Adult: 16-20 per Systolic- 100-
range 99.6˚F minute minute 139
Average: 98.6˚F Pedia: 120 – 160 Pedia: 40 – 60 per Diastolic- 60-
(37˚C) Rectal: per minute minute 89
98.6˚-100.6˚F High:
Axillary: 96.6˚- 140/90 or
98.6˚F above
Tympanic: 97.6˚-
99.6˚F Temporal:
99.4˚-101.4˚F
Factors Raises Raises pulse: Raises Raises Blood
that Temperature: 1. Anemia respiration: Pressure:
affect the 1. Dehydration 2. Excitement 1. Elevated body 1. Digestion
v/s 2. Exercise 3. Exercise temperature 2. Disease of
3. Exposure to 4. Fever and/or blood vessels
external heat 5. Hemorrhage environmental 3. Excitement
4. Infection 6. Pain temperature 4. Exercise
5. Pain 7. Shock 2. Exercise 5. Pain
6. Smoking 8. Strong emotions 3. Infection 6. Standing or
7. Strong 4. Strong emotions sitting
emotions Lowers pulse: 7. Strong
1. Depression Lowers emotions
Lowers 2. Lying down respiration:
Temperature: 3. Rest/sleep 1. Depression Lowers Blood
1. Cold drink or 2. Respiratory Pressure:
food center depression 1. Depression
2. Depression 3. Rest/sleep 2.
3. Exposure to Hemorrhage
cold 3. Lying down
4. Rest/sleep 4. Rest/sleep
5. Shock 5. Shock
6. Starvation
Time of day
(diurnal
changes)
=Temperature
highest in the
P.M. (4-6pm)
= Temperature
lowest in the
A.M. (2-6am)
= Reflects
changes in
cellular activity,
muscle activity,
and food
metabolism.
Charting 1. When written 1. Rate; number of 1. Rate; number of • If taken in a
reminder on chart as part beats/minute respirations/minut place other
s of TPR 2. Rhythm refers to e than the arm,
Temperature is time interval 2. Rhythm; time note the
the first number. between beats interval between location:
98.6- 82-16 3. Strength (force); respirations
2. Note as thready, bounding 3. Depth; shallow, Example:
a. Oral 98.6 Examples: normal, deep 150/90 thigh
b. Rectal 99.6(R) a. Strong and 4. Effort it involves
c. Axillary 97.6 regular: even beats 5. Discomfort it
(AX) with good force causes
b. Weak and 6. Position patient
regular: even beats adopts
with poor force 7. Sounds that
c. Irregular: both accompany it.
strong and weak 8. Cyanosis
beats occur within
a minute Examples:
a. Regular in both
d. Thready: depth and rate
generally means it b. Rapid, shallow
is of weak force c. Very slow or very
and irregular deep
d. Irregular depth
and rhythm
(Cheyne- Stokes)
e. Dyspnea;
labored or difficult
R, usually with
pain
f. Orthopnea;
breathing possible
only when person
sits or stands up.

COMMON DIAGNOSTIC TESTS
1. Heat acetic acid tests

 Detects Albuminuria/proteinuria
 Urine test screens for presence of preeclampsia
 Acetic acid solution – re-agent is used in the examination of
heart acetic test for albumin
Steps;
1. Place urine in test tube and heat, do not boil
2. If it turns cloudy, add acetic acid
3. If cloudiness disappears, the woman is negative for
albumin in urine.
4. If cloudiness persists after adding, the test is positive
2. Benedict’s test
 Detects glycosuria/sugar (diabetes)
 Glycosuria – the presence of sugar in the urine
Steps;
- Collect urine
- Place 5cc benedicts solution in the test tube
- Add 10 drops of urine and note any changes in color. If it turns blue
means negative, if green (+1), yellow green (+2), orange (+3), brick red
(+4).
3. Sputum examination
 Detects Tuberculosis
 most ideal to collect after awakening before breakfast
 Mouth care first then take a deep breath then cough out
sputum into sterile container.
4. Urinalysis
 routine analysis – take initial voiding anytime of the day
 Sterile technique – catheterize patient first then clamp the
catheter for 30 minutes to 1 hour. Remove clamp and collect
sterile specimen from the distal end of the catheter after
cleaning first the sampling port with alcohol.
5. Tourniquet test/ rumpel leads test
 Test for dengue hemorrhagic fever
 Inflate BP cuff midway between systolic and diastolic
pressure and leave for 5 minutes.
 Release cuff and count the number of petechiae on the
imaginary 1 inch square below antecubital fossa.
 The test is positive if there are 20 or more petechiae.

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What is this Module about?

It is to understand the roles and functions of midwives in the health

What will you learn from this module?

This module is divided into four lessons. These are:

Let’s see what you already know

A. Identify the ff. by writing your answers on the lines provided.

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 1

You may go now to next page to begin your lesson.

HEALTH CARE PROCESS

1. ASSESSMENT – Process of COLLECTING, ORGANIZING, VALIDATING AND

Complete history and physical

a. OBJECTIVE DATA (OVERT DATA) – detected by an observer

= PRIMARY SOURCE – the primary source is the client

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 2

 MEDICAL HISTORY (PAST & PRESENT)

History of Present Illness

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 3

Exam Order and Documentation

Order & Documentation

Taking a history from a patient is a skill necessary for examinations. It tests

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 4

Step 2 – Presenting Complaint (PC)

Step 3 – History of presenting complaint (HPC)

- Site: where exactly is the pain?

Step 4 – Past medical history (PMH)

Step 5 – Drug history (DH)

STEP 6 – Family history (FH)

Step 7 – Social history (SH)

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 5

Step 8 – Review of systems (ROs)

Step 9 – Summary of history

Step 10 – Patient questions/feedback

PHYSICAL EXAMINATION/ASSESSMENT – a systematic data collection method

Positions used during nursing assessment, medical examinations, and during

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 6

Using the senses to observe the client data

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 7

Determining the height of the fundus

BARTHOLOMEW’S RULE – use to calculate AOG.

 3 Landmarks – Symphysis pubis, Umbilicus, Xiphoid process

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 8

Solution; March – 11 187 = 26.5

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 9

Checking the Fetal Heart Tone Checking the Blood Pressure

Head to toe Examination

B. Examination of the Head and Neck

Fontanels in a newborn - toddler:

Nose and sinuses

Mouth and Throat

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 12

Unexpected/unexplained loss of acuity is a sign of serious ocular pathology.

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 14

D. Examination of the Chest and Lungs

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 15

Flat or Dull – Pleural Effusion or Lobar

MODULE IN CLINICAL PRACTICUM 100 (CP100) 2021-2022 Page 16

Adventitious (Extra) Breath Sounds

E. Cardiovascular Examination and Peripheral Vascular System