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Chapter 1:

Assessment is the collection of data about a persons 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

those that are important to the patients health but can be addressed after the urgent health
problems are addressed. Collaborative problems are those in which the approach to
treatment involves multiple disciplines.
Evidence-based practice (EBP) is considered to be one of the best-practice techniques for
treating patients. EBP is a systematic approach to practice that emphasizes the use of
best evidence in combination with the clinicians experience as well as the patient
preferences and values, to make decisions about care and treatment. 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, and describes the current and past health state and forms a
baseline against which all future changes can be measured.
o Focused (problem-centered) database: is for a limited or short-term problem, and
usually only focuses on one problem, one cue complex, or one body system.
o Follow-up database: used to evaluate the status of any identified problems at
regular and appropriate intervals.
o Emergency database: is often collected rapidly alongside lifesaving measures.
Diagnosis must be swift and sure.
Holistic health involves the whole person (the mind, body, and spirit). Nurses work hard
with health promotion and disease prevention. Culture must be included in the holistic
model of health care.

Chapter 2:

Hispanics are the largest and fastest growing population in the United States, followed by
Asians, Blacks, American Indians, Alaskan natives, Native Hawaiians, and other Pacific
Islanders.
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:

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

Socialization is the process of being raised within a culture and acquiring the
characteristics of that group. (Education is a form of socialization).
o Acculturation: the process of adapting to and acquiring another culture.
o Assimilation: the process by which a person develops a new cultural identity and
becomes like the members of the dominant culture.
o Biculturalism: dual pattern of identification and often of divided loyalty.
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

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, 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 familys tradition?
Do you mostly participate in
the religious traditions of
your family?

Health is the balance of the person, both within ones being (physical, mental, or
spiritual) and in the outside world (natural, communal, or metaphysical) as a complex,
interrelated phenomenon.
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, that the human body functions more or less mechanically,
that all life can be reduced or divided into smaller parts.

o Naturalistic (holistic) theory: a belief that the forces of nature must be kept in
natural balance or harmony. The yin-yang theory believes that health exists when
all aspects of the person are in perfect balance.
o Magicoreligious perspective: the basic premise is that the world is seen as an
arena in which supernatural forces dominate. The fate of the world and those in it
depends upon the action of supernatural forces for good or evil.
Pain is a universally recognized phenomenon, and it is an important aspect of assessment
for people of various ages. Pain is a very private, subjective experience that is greatly
influenced by cultural heritage. Expectations, manifestations, and management of pain
are all embedded in a cultural context. Silent suffering has been identified as the most
valued response to pain by health care professionals.
o Chapter 3:

An interview is the first and the most important part of data collection. It collects
subjective data (what the person says about himself or herself). The patient is in charge
during the interview. A successful interview includes:
o Gathering complete and accurate data about the persons health state, 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.
o Teach the person about the health state so that the person can participate in
identifying problems.
o Build rapport for a continuing therapeutic relationship; this rapport facilitates
future diagnoses, planning, and treatment.
o Begin teaching for health promotion and disease prevention.

A contract consists of spoken or unspoken rules for behavior. 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, other health professionals, students)
Confidentiality and to what extent it may be limited
Any costs that the patient must pay

All behavior has meaning.

The process of communication involves:
o Sending information

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 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

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, it gives a chance to summarize the information you have
learned during the interview.
When you have a patient that is a child, you must build rapport with the child and their
parent(s).
When working with an infant, nonverbal communication is important. If their needs are
met, they will be calm. Older infants have an anxiety to strangers, and work best if their
parent is in view. A preschooler is egocentric but may view things with an animistic
sense. A school-age child can understand more and are more objective and realistic.
Adolescents can have some maturity but in times of stress, they may fall back upon
childish traits. With older adults, avoid using elderspeak. For people who are hearing
impaired, a sign language interpreter is needed for a complete health history. In
emergencies, try to interview as much as possible while working to save the person.
You do not have to answer all personal questions.
Crying is actually a form of relief to the person, or get angry. 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.

Chapter 4:

Health history sequence:

o Biographic data: name, address, phone number, age, date of birth, birthplace,
gender, marital status, race, ethnic origin, occupation (hospitals must record
language and communication needs).
o Reason for seeking care: record signs and symptoms and talk about what
prompted the visit.
o Present health or history of present illness: the final summary should include:

1.
2.
3.
4.
5.

Location
Character or quality
Quality or severity
Timing
Setting

6. Aggravating or
relieving factors
7. Associated factors
8. Patients 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 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

Occupational health

For children, the health history is altered slightly:

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

Environmental
hazards
Coping/stress
management
Habits
Health promotion

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, serious or chronic illnesses, 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, 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, percussion
and auscultation.

11

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

All equipment should be cleaned to create a clean environment.

The best way to prevent nosocomial infections is to wash your hands before and after
every physical patient encounter, after contact with blood, body fluids, secretions and
excretions, after contact with equipment contaminated with body fluids, and after
removing gloves.
Begin the assessment by measuring the persons height, weight, BP, temperature, pulse
and respirations. If needed, measure visual acuity using the Snellen eye chart. Then ask
the patient to change into a gown, leaving underpants on (leave the room), and when you
re-enter, wash your hands in front of the patient, and as you perform your assessment,
explain everything to the patient. Check hands (skin color, nail beds, and
metacarpophalangeal joints).
When checking infants, the parent should be present. Place the infant on a padded
examination table (or held against the parents chest for some steps). The check-up
should be 1 2 hours after feeding. The environment should be warm. Talk softly, make
eye contact, and smile. Movements should be smooth and deliberate. Offer toys as a
distraction. If asleep, use the time to check heart, lung and abdominal sounds first.
Otherwise, perform least distressing steps first. Save the examination of the eye, ear, nose
and throat until last.
For a toddler, the parent can help position the child and comfort them during invasive
procedures. Do not offer the toddler a choice when there is no choice.
The pre-school child is similar to the toddler but the child is more cooperative.
The school-age children are more interested in learning about the body and are more
cooperative. The sequence follows that of an adult.
The adolescent is similar to that of an adult, but should be done without anyone else in
the room.
The aging adult work with the head-to-toe approach best.
For an ill person, the assessment is altered accordingly.

Chapter 10:

There are two processes we use to understand pain: nociceptive and/or neuropathic. Pain
is highly complex and subjective that originates from the CNS or the PNS (or both). 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. Nociception can be divided into four phases:
transduction, transmission, perception, and modulation.
Transduction occurs when there is stimulus in the form of traumatic or chemical injury,
burn, incision, or tumor. The tissue releases chemicals, including substance P, histamine,
prostaglandins, serotonin, and bradykinin, which are neurotransmitters.
Transmission has the pain impulse move from the spinal cord to the brain.
Perception indicates the conscious awareness of a painful sensation.

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

Chapter 11:

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

or

waist circumference
hipcircumference

x 100

weight(lbs)
height ()

x 703