1

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
hypotheses


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
abnormal
o Making inferences
o Clustering related cues
o Distinguishing relevant from
irrelevant
o Recognizing inconsistencies
o Identifying patterns
o Identifying missing
information

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

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

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

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

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

planning. o Magicoreligious perspective: the basic premise is that the world is seen as an arena in which supernatural forces dominate. manifestations. and it is an important aspect of assessment for people of various ages. and treatment. Expectations. The fate of the world and those in it depends upon the action of supernatural forces for good or evil. 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. Pain is a very private. The patient is in charge during the interview. 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. o Establishes rapport and trust so the person feels accepted and thus free to share all relevant data. o Teach the person about the health state so that the person can participate in identifying problems. and management of pain are all embedded in a cultural context. Pain is a universally recognized phenomenon. A successful interview includes: o Gathering complete and accurate data about the person’s health state. o Chapter 3:  An interview is the first and the most important part of data collection. this rapport facilitates future diagnoses.  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. o Build rapport for a continuing therapeutic relationship. Silent suffering has been identified as the most valued response to pain by health care professionals. other health professionals. The process of communication involves: o Sending information . It collects subjective data (what the person says about himself or herself). o Begin teaching for health promotion and disease prevention. The yin-yang theory believes that health exists when all aspects of the person are in perfect balance. including the description and chronology of any symptoms of illness.

a name tag.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. 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 .

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

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

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

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. percussion and auscultation. 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. palpation. hospitalizations. 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.

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

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 .

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

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

Older adults are at higher risk for overnutrition or undernutrition. Overnutrition is caused by the consumption of nutrients in excess of body needs. or illness. such as the MNA. Food diaries may be used to help come up with plans. 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. pregnancy. to help identify individuals who are malnourished or are at risk for developing malnutrition. the nutrition need stabilizes. For full-term infants. 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. Undernutrition occurs when nutritional reserves are depleted and/or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demands. 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 . 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. there are many advantages of breastfeeding. or to monitor changes. such as with children. 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. There are various nutritional assessment tools.

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