Weeks 1 – 3 notes
Chapter 1:

Assessment is the collection of data about a person’s state of health by collecting and
analyzing subjective data and objective data, which will form a database. Clinical
judgment and diagnoses can be made based off of the database.
Diagnostic reasoning is the process of analyzing health data and drawing conclusions to
identify diagnoses. It involves hypothesis forming and deductive reasoning. This has four
major components:
o Attending to initially
available cues (a sign or
symptom or a piece of
laboratory data)
o Formulating diagnostic

Make sure you gather data fully and eliminate any gaps you may have. If you are not sure
of something, ask an expert of the particular subject to validate the data.
Nursing process: assessment, diagnosis, outcome identification, planning,
implementation, evaluation. To function at the expert level of clinical judgment involves
using intuition and critical thinking.
There are various critical thinking skills that nurses can use:
o Identifying assumptions
o Identifying an organized and
comprehensive approach
o Validation
o Distinguishing normal from
o Making inferences
o Clustering related cues
o Distinguishing relevant from
o Recognizing inconsistencies
o Identifying patterns
o Identifying missing

o Gathering data relative to the
tentative hypotheses
o Evaluating each hypothesis
with the new data collected,
thus arriving at a final

o Promoting health
o Diagnosing actual and
potential (risk) problems
o Setting priorities
o Identifying patient-centered
expected outcomes
o Determining specific
o Evaluating and correcting
o Determining a
comprehensive plan

First-level priority problems are those that are emergent, life threatening, and immediate.
Second-level priority problems are those that are next in urgency (those that require
prompt intervention to forestall further deterioration). Third-level priority problems are

There are 4 factors of EBP clinical decision making: o Evidence from research and evidence-based theories o Physical examination and assessment of patient   o Clinical expertise o Patient preferences and values There are four different types of data to collect: o Complete (total health) database: includes a complete health history and a full physical examination. Alaskan natives. Holistic health involves the whole person (the mind. American Indians. o Focused (problem-centered) database: is for a limited or short-term problem. and spirit). and other Pacific Islanders. followed by Asians. and usually only focuses on one problem. Blacks. EBP is “a systematic approach to practice that emphasizes the use of best evidence in combination with the clinician’s experience as well as the patient preferences and values. and describes the current and past health state and forms a baseline against which all future changes can be measured.  Chapter 2:  Hispanics are the largest and fastest growing population in the United States. one cue complex. body. Evidence-based practice (EBP) is considered to be one of the best-practice techniques for treating patients. Nurses work hard with health promotion and disease prevention. to make decisions about care and treatment”. Native Hawaiians. or one body system. Collaborative problems are those in which the approach to treatment involves multiple disciplines. Culture must be included in the holistic model of health care. There are various types of immigrants:  o o o o  Legal Resident Naturalization Non-immigrant Parolee o Permanent Resident Alien o Refugee o Unauthorized Residents There are various new national standards to handle the demographic changes and knowledge: .2  those that are important to the patient’s health but can be addressed after the urgent health problems are addressed. The amount of immigrants to the United States has tripled from 1990s. Diagnosis must be swift and sure. o Emergency database: is often collected rapidly alongside lifesaving measures. o Follow-up database: used to evaluate the status of any identified problems at regular and appropriate intervals.

Culture is learned from birth through the processes of language acquisition and socialization. Religion may be a seen as a shared experience of spirituality or as the values. religion. nature. prayer or meditation. and expressed needs of the patient. Culturally competent implies that the caregivers understand and attend to the total context of the individual’s situation. Cultural care is the provision of health care across cultural boundaries and takes into account the context in which the patient lives as well as the situations in which the patient’s health problems arise. Ethnicity pertains to a social group within the social system that claims to possess variable traits such as a common geographic origin. . and purpose of the universe. and practices that people are either born into or may adopt to meet their personal spiritual needs through communal actions such as religious affiliation. beliefs. and religious practices. shared values. and dynamic and ever changing. Health disparities are the unusual and disproportionate frequency of a given health problem within a population when compared with other populations.3            o Effective Care: results in positive outcomes and satisfaction for the patient. shared by all members of the same cultural group. attitudes. preferences. other social factors. symbols. and cultural similarities and differences. Traditional: living within the norms of the traditional culture. Modern: acculturated to the norms of the dominant society. migratory status. and food preferences. especially belief in or the worship of God or gods. language. Heritage consistency is a concept that describes “the degree to which one’s lifestyle reflects his or her respective American Indian tribal culture”. race. Religion refers to an organized system of beliefs concerning the cause. including awareness of immigration status. o Respectful Care: takes into consideration the values. stress factors. Spirituality is borne out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life. attendance and participation in a religious institution. and policies that come together in a system among professionals that enables work in cross-cultural situations. adapted to specific conditions related to environmental and technical factors and to the availability of natural resources. o Cultural and Linguistic Competence: is a set of congruent behaviors. Culturally appropriate implies that the caregivers apply the underlying background knowledge that must be possessed to provide a given person with the best possible health care. Religion is the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator(s) and ruler(s) of the universe. traditions. Culturally sensitive implies that caregivers possess some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting in which they are participating.

communal. Some questions for heritage assessment can include: o Where were you born? Where did you grow up? o Did your parents encourage you to participate in religious or ethnic activities? What kind of school did you go to? Did you go to a special religious school after regular school hours? o Have you visited the nation(s) or the neighborhoods where your family originated? o Who are the people living in the neighborhood where you now live? o Do you participate in ethnic celebrations from your heritage? o Who lived in your home? Were they related to you? o Do you maintain ties to family? o Was your family name changed when the family   o o o o o o o o came to the United States? Was the name changed to facilitate assimilation? What school did you go to? Was it public or private? Who are your friends. or metaphysical) as a complex. o Acculturation: the process of adapting to and acquiring another culture. . mental. (Education is a form of socialization). and how often do you spend time with them? Do you speak or read the language of your parents or grandparents? Do you identify as an ethnic American or as an American? Do you mostly participate in social activities with members of your family? Do you mostly have friends from a similar cultural background as you? Do you mostly eat the foods of your family’s tradition? Do you mostly participate in the religious traditions of your family? Health is the balance of the person.4   Socialization is the process of being raised within a culture and acquiring the characteristics of that group. that the human body functions more or less mechanically. interrelated phenomenon. both within one’s being (physical. o Assimilation: the process by which a person develops a new cultural identity and becomes like the members of the dominant culture. or spiritual) and in the outside world (natural. o Biculturalism: dual pattern of identification and often of divided loyalty. that all life can be reduced or divided into smaller parts. o Disease can be viewed in three different ways: o Biomedical (scientific) theory: is based on the assumption that all events in life have a cause and effect.

Pain is a universally recognized phenomenon. The patient is in charge during the interview. The yin-yang theory believes that health exists when all aspects of the person are in perfect balance. this rapport facilitates future diagnoses. including the description and chronology of any symptoms of illness. and it is an important aspect of assessment for people of various ages. o Chapter 3:  An interview is the first and the most important part of data collection. The interview contract terms include: o o o o o o o o   Time and place of the interview and succeeding physical examination Introduction of yourself and a brief explanation of your role The purpose of the interview How long it will take Expectation of participation for each person Presence of any other people (family. manifestations.5  o Naturalistic (holistic) theory: a belief that the forces of nature must be kept in natural balance or harmony. o Teach the person about the health state so that the person can participate in identifying problems. o Magicoreligious perspective: the basic premise is that the world is seen as an arena in which supernatural forces dominate. o Build rapport for a continuing therapeutic relationship. other health professionals.  A contract consists of spoken or unspoken rules for behavior. students) Confidentiality and to what extent it may be limited Any costs that the patient must pay All behavior has meaning. Pain is a very private. A successful interview includes: o Gathering complete and accurate data about the person’s health state. o Begin teaching for health promotion and disease prevention. Silent suffering has been identified as the most valued response to pain by health care professionals. Expectations. and management of pain are all embedded in a cultural context. planning. It collects subjective data (what the person says about himself or herself). o Establishes rapport and trust so the person feels accepted and thus free to share all relevant data. subjective experience that is greatly influenced by cultural heritage. The process of communication involves: o Sending information . The fate of the world and those in it depends upon the action of supernatural forces for good or evil. and treatment.

6  o Receiving information o Internal factors  Liking others  Empathy  The ability to listen o External factors  Ensure privacy  Refuse interruptions  Physical environment  Set room temperature at a comfortable level  Provide sufficient lighting  Reduce noise  Remove distracting objects or equipment  Place the distance between you and the patient at 4 – 5 feet.  Arrange equal-status seating. neat hair)  Note-taking (but keep to a minimum)  Tape and video recording  Electronic Heath Recording (EHR) There are various techniques of communication during an interview: o Introduction o The Working Phase  Open-ended questions  Closed or direct questions  Responses (assisting the narrative)         Facilitation Silence Reflection Empathy Clarification There are various traps with interviews:     Confrontation Interpretation Explanation Summary . avoid standing  Arrange a face-to-face position  Dress  The patient should remain in street clothes except in the case of an emergency  Your appearance and clothing should be appropriate to the setting and should meet conventional professional standards (a uniform or lab coat over conservative clothing. a name tag.

race. Older infants have an anxiety to strangers. nonverbal communication is important. Adolescents can have some maturity but in times of stress. or get angry. o Reason for seeking care: record signs and symptoms and talk about what prompted the visit. avoid using “elderspeak”. a sign language interpreter is needed for a complete health history. age. birthplace. gender. In emergencies. Crying is actually a form of relief to the person. If their needs are met. When working with an infant.7 o Providing false assurance or reassurance o Giving unwanted advice o Using authority o Using avoidance language o Engaging in distancing  Nonverbal skills can include: o o o o       o Using professional jargon o Using leading or biased questions o Talking too much o Interrupting o Using “why” questions Physical appearance Posture Gestures Facial expression o Eye contact o Voice o Touch While closing the interview. A preschooler is egocentric but may view things with an animistic sense. o Present health or history of present illness: the final summary should include: . This usually does not have to do with the interviewer. Etiquette refers to the conventional code of good manners that governs behavior and varies cross-culturally. phone number. occupation (hospitals must record language and communication needs). try to interview as much as possible while working to save the person.  Chapter 4:  Health history sequence: o Biographic data: name. it gives a chance to summarize the information you have learned during the interview. and work best if their parent is in view. address. they will be calm. With older adults. you must build rapport with the child and their parent(s). A school-age child can understand more and are more objective and realistic. they may fall back upon childish traits. date of birth. For people who are hearing impaired. When you have a patient that is a child. marital status. You do not have to answer all personal questions. ethnic origin.

4. o Review of systems:             General overall health state Skin Hair Head Eyes Ears Nose and sinuses Mouth and throat Neck Breast Axilla Respiratory system            Cardiovascular Peripheral vascular Gastrointestinal Urinary system Male genital system Female genital system Sexual health Musculoskeletal system Neurologic system Hematologic system Endocrine system o Functional assessment or activities of daily living (ADLs):        Self-esteem. 3. Associated factors 8. Location Character or quality Quality or severity Timing Setting 6. 5. 2. selfconcept Activity/Exercise Sleep/Rest Nutrition/Elimination Interpersonal relationships Resources Spiritual resources       Coping and stress management Personal habits Alcohol Illicit or street drugs Environmental hazards Intimate partner violence .8 1. Aggravating or relieving factors 7. Patient’s perception o Past history:     Childhood illnesses Accidents or injuries Serious or chronic illnesses Hospitalizations       Operations Obstetric history Immunizations Last examination date Allergies Current medications o Family history: a pedigree or genogram is sometimes sent home to gain a more accurate understanding of family conditions.

o Past health:      Prenatal status Labor and delivery Postnatal status Childhood illness Serious accidents or injuries      Serious chronic illnesses Operations or hospitalizations Immunizations Allergies Medications o Developmental history: o o o o  Growth  Milestone  Current development (Children 1 month through preschool)  School-age child Nutritional history Family history Review of systems (same systems as adult) Functional assessment (including ADLs):     Interpersonal relationships Activity and rest Economic status (parent’s jobs) Home environment     Environmental hazards Coping/stress management Habits Health promotion . phone number. or classroom teacher o Present health or history of present illness: note factors such as severity of pain. the health history is altered slightly: o Biographic data: name. body position. eating. and the parent’s intuitive sense of a problem. race. birthplace. nickname.9      Occupational health For children. associated factors such as relation to activity. parent. date of birth. address. age. and can be initiated by the child. social worker. information on other family members at home o Reason for seeking care: can happen spontaneously. parents’ name and work numbers. and the parent’s coping ability and reaction of other family members to child’s symptoms or illness. gender. ethnic origin.

palpation. hospitalizations. . percussion and auscultation. serious or chronic illnesses. operations Last examination Obstetric status Current medications o Family history o Review of systems:      Eyes Ears Mouth Respiratory system Cardiovascular system      Peripheral vascular system Urinary system Sexual health Musculoskeletal system Neurologic system o Functional assessment (including ADLs):      Self-concept. selfesteem Occupation Activity and exercise Sleep and rest Nutrition/Elimination      Interpersonal Relationships Resources Coping and stress management Environmental Hazards  Chapter 8:  Some skills required for a physical examination include: inspection.10  Adolescents tend to follow the HEEADSSS method of interview o o o o  Home Education and employment Eating Activities o o o o Drugs Sexuality Suicide and Depression Safety (Savagery) The health history is also adjusted for the older adult as well: o Reason for seeking care o Past health:      General health Accidents or injuries.

Slow vibrations yield a low-pitched tone o Quality (timbre): a subjective difference due to a sound’s distinctive overtones. temperature. It begins when you first meet the person and develop a “general survey”. the percussion vibrations penetrate about 5 cm deep (a deeper mass would give no change in percussion) o Eliciting a deep tendon reflex using the percussion hammer The sounds that can be heard by percussion include various qualities: o Amplitude (intensity): a loud or soft sound. sharp strokes to assess the underlying structures. o Fingertips: good for fine tactile discrimination. pulsation. fluid. private. The examination room should be warm. and tenderness or pain. Palpation applies the sense of touch to assess texture. comfortable. quiet. crepitation (cracking or rattling sound). and well lit. but then on each individual body system. moisture. swelling. as of skin texture. shape. More rapid vibrations produce a high-pitched tone. organ location and size. Variations within a sound wave produce overtones. rigidity or spasticity. or solid) of a structure by a characteristic note o Detecting an abnormal mass if it is fairly superficial. Loudness depends on the force of the blow and the structure’s ability to vibrate o Pitch (frequency): the number of vibrations per second. It is used for: o Mapping out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbors o Signaling the density (air. determining presence of lumps o A grasping action of the fingers and thumb: to detect the position. presence of lumps or masses. vibration or pulsation. such as the heart and blood vessels and the lungs and abdomen. focusing first on the patient as a whole. and consistency of an organ or mass o The dorsa (backs) of hands and fingers: best for determining temperature because the skin is thinner than on the palms o Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand: best for vibration Percussion is tapping the person’s skin with short. swelling. Overtones allow you to distinguish a C on a piano from a C on a violin o Duration: the length of time the note lingers The types of sounds can include: o Resonant o Hyperresonant o Tympany    o Dull o Flat Auscultation is listening to sounds produced by the body.11      Inspection is concentrated watching. Some equipment used include: .

12 o Platform scale with height attachment o Sphygmomanometer o Thermometer o Pulse oximeter (in hospital setting) o Paper and pencil or pen o Flashlight or penlight o Otoscope/ophthalmoscope o Tuning fork o Nasal speculum o Tongue depressor o Pocket vision screener o Skin-marking pen o Flexible tap measure and ruler marked in centimeters o Reflex hammer o Sharp object (split tongue blade) o Cotton balls o Bivalve vaginal speculum o Clean gloves o Materials for cytologic study o Lubricant o Fecal occult blood test materials .

and as you perform your assessment. the parent should be present. serotonin. The best way to prevent nosocomial infections is to wash your hands before and after every physical patient encounter. nose and throat until last. perception. use the time to check heart. temperature. Talk softly. secretions and excretions. The adolescent is similar to that of an adult. Transduction occurs when there is stimulus in the form of traumatic or chemical injury. lung and abdominal sounds first. which are neurotransmitters. Save the examination of the eye.  Chapter 10:  There are two processes we use to understand pain: nociceptive and/or neuropathic. or tumor. prostaglandins. including substance P. pulse and respirations. Otherwise. perform least distressing steps first.    All equipment should be cleaned to create a clean environment. and metacarpophalangeal joints). Perception indicates the conscious awareness of a painful sensation. If asleep. histamine. ear. The tissue releases chemicals. Nociceptive pain develops when nerve fibers in the periphery and in the central nervous system are functioning and intact. the assessment is altered accordingly.           . Check hands (skin color. The specialized nerve endings are called nociceptors. after contact with blood. leaving underpants on (leave the room). Do not offer the toddler a choice when there is no choice. If needed. and modulation. and bradykinin. The pre-school child is similar to the toddler but the child is more cooperative. BP. Begin the assessment by measuring the person’s height. Pain is highly complex and subjective that originates from the CNS or the PNS (or both). body fluids. Movements should be smooth and deliberate. incision. but should be done without anyone else in the room. burn. weight. nail beds. the parent can help position the child and comfort them during invasive procedures. wash your hands in front of the patient. The school-age children are more interested in learning about the body and are more cooperative. after contact with equipment contaminated with body fluids. explain everything to the patient. and smile. Offer toys as a distraction. The check-up should be 1 – 2 hours after feeding. transmission. Nociception can be divided into four phases: transduction. The aging adult work with the head-to-toe approach best. and after removing gloves. Then ask the patient to change into a gown. Place the infant on a padded examination table (or held against the parent’s chest for some steps). When checking infants. and when you re-enter. The sequence follows that of an adult. Transmission has the pain impulse move from the spinal cord to the brain. make eye contact. The environment should be warm. For an ill person. measure visual acuity using the Snellen eye chart. For a toddler.

Preverbal infants are at high risk for undertreatment of pain because of persistent myths and beliefs that infants do not remember pain. vocalize (moaning). o Cutaneous pain: is derived from skin surface and subcutaneous tissue. With older adults. there can be many acute pain responses and behaviors. For patients with dementia. acute confusion is generally the best indicator of poorly controlled pain. o Referred pain: pain felt at a particular site but originates from another location. and bone. which are most useful for chronic pain. restlessness. the patient may grimace. distention. However. A physical examination can help gather objective data on pain. Pain is more commonplace. the PAINAD is used to help identify pain. If pain is not treated. ischemia. diaphoresis.  Malignant pain: cancer-related  Nonmalignant pain  Breakthrough pain Infants have the same capacity for pain as adults. There are variations such as the Oucher Scale. joints. We have a limited understanding of how to assess pain in infants (chronic pain). or severe contraction. There are overall pain assessment tools. o Deep somatic pain: comes from sources such as the blood vessels. For patients with chronic pain. There are various types of pain: o Acute pain: short-term and self-limiting.  Incident pain happens predictably when certain movements take place. The CRIES score was developed to help find postoperative pain. however. these behaviors can be seen as “comfort” and be left untreated. stillness. For infants and children it is better to use the Faces Pain Scale – Revised (FPS – R). Neuropathic pain is considered to be an abnormal processing of the pain message from an injury to the nerve fibers. There are various pain assessment tools to help gather subjective data. muscles. agitation. or have changes in vital signs. The pain can stem from direct injury to the organ or from stretching of the organ from tumor. tendons. There are various sources of pain: o Visceral pain: originates from the larger interior organs. and dissipates after an injury heals. they may learn to adapt and try to give little indication of pain. There is no evidence to suggest that older adults feel less pain or that sensitivity is diminished. often follows a predictable trajectory. . o Persistent (chronic) pain: is diagnosed when the pain lasts 6 months or longer.           During modulation is how the pain message is inhibited by a built-in system that will eventually slow down and stop the processing of a painful stimulus. There are pain rating scales and a descriptor scale. With acute pain behavior.

or to monitor changes. pregnancy. such as with children. For full-term infants. Optimal nutritional status is achieved when sufficient nutrients are consumed to support day-by-day body needs and any increased metabolic demands due to growth. the nutrition need stabilizes. provide data for designing a nutrition plan of care that will prevent or minimize the development of malnutrition. Food diaries may be used to help come up with plans. Overnutrition is caused by the consumption of nutrients in excess of body needs. There are various nutritional assessment tools. but various factors such as skipping meals and possible drug experimentation must be considered when trying to help them select healthier food choices. For adults. there are many advantages of breastfeeding. to help identify individuals who are malnourished or are at risk for developing malnutrition. current weight Percent of ideal body weight = x 100 ideal weight          Percent of usual body weight =  Body mass index =  Waist-to-hip ration =  current weight usual weight weight (kg) height (meters) 2 or waist circumference hipcircumference x 100 weight(lbs) height (¿) x 703 . A woman may gain more weight during pregnancy because of the fetus’s need for nutrients. such as the MNA. Undernutrition occurs when nutritional reserves are depleted and/or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demands. including: o Fewer food allergies and intolerances o Reduced likelihood of overfeeding o Less cost than commercial infant formulas o Increased mother-infant interaction time Adolescents need more nutritional intake because of their body changes. Chapter 11:  Nutritional status refers to the degree of balance between nutrient intake and nutrient requirement. and establish baseline data for evaluating the efficacy of nutritional care. or illness. Older adults are at higher risk for overnutrition or undernutrition.

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