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

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

that all life can be reduced or divided into smaller parts. or metaphysical) as a complex. that the human body functions more or less mechanically. 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. 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.4   Socialization is the process of being raised within a culture and acquiring the characteristics of that group. both within one’s being (physical. or spiritual) and in the outside world (natural. (Education is a form of socialization). interrelated phenomenon. o Acculturation: the process of adapting to and acquiring another culture. . 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. communal.

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

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. 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.  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 .

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

Aggravating or relieving factors 7.8 1. 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. Location Character or quality Quality or severity Timing Setting 6. 4. 5. 3. 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. 2. Associated factors 8. 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 .

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

serious or chronic illnesses. palpation. 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. . 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.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. hospitalizations.

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

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 .

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

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

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

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