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

followed by Asians. o Follow-up database: used to evaluate the status of any identified problems at regular and appropriate intervals. and spirit). Collaborative problems are those in which the approach to treatment involves multiple disciplines. and usually only focuses on one problem. Evidence-based practice (EBP) is considered to be one of the best-practice techniques for treating patients. o Emergency database: is often collected rapidly alongside lifesaving measures. 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. Native Hawaiians. Alaskan natives. o Focused (problem-centered) database: is for a limited or short-term problem.  Chapter 2:  Hispanics are the largest and fastest growing population in the United States.2  those that are important to the patient’s health but can be addressed after the urgent health problems are addressed. and describes the current and past health state and forms a baseline against which all future changes can be measured. American Indians. The amount of immigrants to the United States has tripled from 1990s. 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: . to make decisions about care and treatment”. Holistic health involves the whole person (the mind. 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. or one body system. body. Culture must be included in the holistic model of health care. and other Pacific Islanders. Nurses work hard with health promotion and disease prevention. Diagnosis must be swift and sure. Blacks. one cue complex.

Heritage consistency is a concept that describes “the degree to which one’s lifestyle reflects his or her respective American Indian tribal culture”. Religion refers to an organized system of beliefs concerning the cause. preferences. especially belief in or the worship of God or gods. symbols. 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. shared by all members of the same cultural group. stress factors. 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. and practices that people are either born into or may adopt to meet their personal spiritual needs through communal actions such as religious affiliation. 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. and purpose of the universe. other social factors. Traditional: living within the norms of the traditional culture. and expressed needs of the patient. religion. o Cultural and Linguistic Competence: is a set of congruent behaviors. Religion may be a seen as a shared experience of spirituality or as the values. language. 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. Health disparities are the unusual and disproportionate frequency of a given health problem within a population when compared with other populations. including awareness of immigration status. and food preferences. Culturally competent implies that the caregivers understand and attend to the total context of the individual’s situation. shared values. Ethnicity pertains to a social group within the social system that claims to possess variable traits such as a common geographic origin. race. migratory status. and dynamic and ever changing. 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. and policies that come together in a system among professionals that enables work in cross-cultural situations. beliefs. Culture is learned from birth through the processes of language acquisition and socialization. prayer or meditation. adapted to specific conditions related to environmental and technical factors and to the availability of natural resources.3            o Effective Care: results in positive outcomes and satisfaction for the patient. Modern: acculturated to the norms of the dominant society. . and religious practices. o Respectful Care: takes into consideration the values. and cultural similarities and differences. attitudes. nature.

(Education is a form of socialization). mental. o Acculturation: the process of adapting to and acquiring another culture. 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. o Assimilation: the process by which a person develops a new cultural identity and becomes like the members of the dominant culture. or metaphysical) as a complex. 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. that the human body functions more or less mechanically.4   Socialization is the process of being raised within a culture and acquiring the characteristics of that group. communal. 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. . interrelated phenomenon. both within one’s being (physical. or spiritual) and in the outside world (natural. o Biculturalism: dual pattern of identification and often of divided loyalty.

students) Confidentiality and to what extent it may be limited Any costs that the patient must pay All behavior has meaning. o Begin teaching for health promotion and disease prevention. o Magicoreligious perspective: the basic premise is that the world is seen as an arena in which supernatural forces dominate. including the description and chronology of any symptoms of illness. o Establishes rapport and trust so the person feels accepted and thus free to share all relevant data. this rapport facilitates future diagnoses. It collects subjective data (what the person says about himself or herself). subjective experience that is greatly influenced by cultural heritage.5  o Naturalistic (holistic) theory: a belief that the forces of nature must be kept in natural balance or harmony. and it is an important aspect of assessment for people of various ages. o Teach the person about the health state so that the person can participate in identifying problems. planning. Pain is a universally recognized phenomenon. Silent suffering has been identified as the most valued response to pain by health care professionals. other health professionals. o Build rapport for a continuing therapeutic relationship. and management of pain are all embedded in a cultural context. o Chapter 3:  An interview is the first and the most important part of data collection. Pain is a very private. 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. 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. 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. and treatment. Expectations.  A contract consists of spoken or unspoken rules for behavior. A successful interview includes: o Gathering complete and accurate data about the person’s health state. manifestations.

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

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. 2. 5. 4. Aggravating or relieving factors 7. Associated factors 8. Location Character or quality Quality or severity Timing Setting 6. 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. 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. 3.

body position. race. or classroom teacher o Present health or history of present illness: note factors such as severity of pain. parent. and the parent’s intuitive sense of a problem. gender. associated factors such as relation to activity. 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 . ethnic origin. birthplace. phone number. the health history is altered slightly: o Biographic data: name. and can be initiated by the child. and the parent’s coping ability and reaction of other family members to child’s symptoms or illness. information on other family members at home o Reason for seeking care: can happen spontaneously. parents’ name and work numbers. date of birth. nickname. age. social worker.9      Occupational health For children. eating. address.

percussion and auscultation. 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. palpation. hospitalizations. 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. serious or chronic illnesses.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. .

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. moisture. Variations within a sound wave produce overtones. It begins when you first meet the person and develop a “general survey”. vibration or pulsation. Loudness depends on the force of the blow and the structure’s ability to vibrate o Pitch (frequency): the number of vibrations per second. 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. or solid) of a structure by a characteristic note o Detecting an abnormal mass if it is fairly superficial. rigidity or spasticity. determining presence of lumps o A grasping action of the fingers and thumb: to detect the position. 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. private. focusing first on the patient as a whole. but then on each individual body system. temperature. Some equipment used include: . sharp strokes to assess the underlying structures. Slow vibrations yield a low-pitched tone o Quality (timbre): a subjective difference due to a sound’s distinctive overtones. More rapid vibrations produce a high-pitched tone. organ location and size.11      Inspection is concentrated watching. presence of lumps or masses. 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. swelling. fluid. and well lit. The examination room should be warm. comfortable. o Fingertips: good for fine tactile discrimination. pulsation. swelling. such as the heart and blood vessels and the lungs and abdomen. Palpation applies the sense of touch to assess texture. quiet. shape. and tenderness or pain. crepitation (cracking or rattling sound). as of skin texture.

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 .

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

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

and establish baseline data for evaluating the efficacy of nutritional care. or illness. provide data for designing a nutrition plan of care that will prevent or minimize the development of malnutrition. A woman may gain more weight during pregnancy because of the fetus’s need for nutrients. the nutrition need stabilizes. For full-term infants. Older adults are at higher risk for overnutrition or undernutrition. For adults. 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. to help identify individuals who are malnourished or are at risk for developing malnutrition. there are many advantages of breastfeeding. or to monitor changes. such as with children. Food diaries may be used to help come up with plans. 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 . pregnancy. but various factors such as skipping meals and possible drug experimentation must be considered when trying to help them select healthier food choices. Overnutrition is caused by the consumption of nutrients in excess of body needs. Undernutrition occurs when nutritional reserves are depleted and/or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demands. Chapter 11:  Nutritional status refers to the degree of balance between nutrient intake and nutrient requirement. There are various nutritional assessment tools. 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. such as the MNA.

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