Health Assessment done so as to make sure that the care offered meets the past health history, family

make sure that the care offered meets the past health history, family history, and lifestyle and health
medical requirements and expectations of the patient. practices as well as objective data gathered during a step-
 plan of care that identifies the specific needs of a person and 4. Implementation: This stage is where the nurse follows by-step physical examination.
how those needs will be addressed by the skilled nursing facility. through with the care plan that was developed in the
 It provides an illustrated approach to the process of holistic previous phase of the process. This includes monitoring the B. On-going or Partial Assessment
assessment, analyzing the data, making judgments about the client for signs of improvement or any new changes in the
effectiveness of nursing interventions, and evaluating client  It consists of data collection that occurs after the
symptoms or condition, offering direct care and comprehensive database is established—a mini-overview of
care outcomes. performing medical tasks, instructing or educating patients the client’s body systems and holistic health patterns as a
Nursing – the protection, promotion, and optimization of health on health management, referring and contacting the follow up on health status.
and abilities, prevention of illness and injury; alleviation of suffering patient for follow-ups if need be.
through the diagnosis and treatment of human responses and 5. Evaluation: To determine whether the goals set in the care C. Focused or Problem-oriented Assessment
advocacy in the care of individuals, families, communities, and plan have been met. It can also be used to identify areas
where the outcome is not desirable and to determine the  It is performed when a comprehensive database exists for a
populations”. American Nurses Association (2010). client who comes to the health care agency with a specific
reason behind this. The patient’s condition can be described
health concern.
Nursing Process - Is a systematic, organized method of planning, and in any of the following three ways:
providing quality and individualized nursing care.  Condition of the patient has improved D. Emergency Assessment
 State of the patient has stabilized
- Synonymous with the PROBLEM-SOLVING APPROACH  Condition of the patient has deteriorated,  Very rapid assessment performed in a life-threatening
that directs the nurse and the client to determine the need for discharged or died. situation to provide prompt treatment.
nursing care, to plan and implement the care and evaluate the  The major and only concern during this type of assessment
result. If the patient has not shown any improvement or the is to determine the status of the client’s life-sustaining
set wellness goals have not been fulfilled the process has to physical functions.
G O S H Approach (Goal-oriented, Organized, Systematic and begin again from step one.
Humanistic care) for efficient and effective provision of Nurse’s Role in Health Assessment
nursing care. Nursing Process” was first used by Lydia Hall, a nursing
theorist, in 1955 wherein she introduced 3 STEPs: 1. Acute Care Nurse – performs a focused assessment, and then
1. Assessment: Usually starts when the patient first arrives at  Observation incorporates assessment findings with a multidisciplinary team to
the facility or when he makes contact with the nurse. It  Administration of care develop a comprehensive plan of care
involves the collection of as much information about the  Validation
• To identify a client’s health status; his Actual/Present and
patient’s medical history as possible. The nurse uses a
Purpose of Nursing Process: potential/possible health problems or needs.
dynamic and systematic approach to collect and analyze
data on the information and can involve simple things such The mind, body, and spirit are considered to be • To establish a plan of care to meet identified needs.
as asking the patients some questions, making observations interdependent factors that affect a person’s level of
and reviewing their medical history. • To provide nursing interventions to meet those needs.
health.
2. Diagnosis: Involves the detailed clinical judgment of a nurse • To provide an individualized, holistic, effective and efficient
on the response of a patient to the actual or potential Types of Health Assessment
nursing care.
health condition.
A. Initial Comprehensive Assessment
3. Planning: A care plan helps the nurse determine what needs 2. Critical care outreach nurses – need enhanced assessment skills to
to be done, how it should be done and when it is to be  It involves collection of subjective data about the client’s safely assess critically ill clients who are outside the structured
perception of his or her health of all body parts or systems, intensive care environment
3. Ambulatory care nurses – asses and screen clients to determine • Acute care nurses in the 1980s employed the “primary care” Preparing for Health Assessment
the need for physician referrals method of delivery of care. Each nurse was autonomous in
1. Knowing the client’s medical record
making comprehensive initial assessments from which
4. Home health nurses – make independent nursing diagnoses and individualized plans of care were established. 2. Knowing the client’s basic biographical data
referrals for collaborative problem as needed 3. Awareness of the client’s and current health status
1990- PRESENT 4. Educate yourself about the client’s medical diagnosis
5. Public health nurses – assess the needs of communities
• Over the last 20 years, the movement of health care from 5. Take a minute to reflect on your own feelings
6. School nurses – monitor the growth and health of children the acute care setting to the community and the 6. Obtain and organize material that you will need
proliferation of baccalaureate and graduate education Subjective Data
7. Hospice nurses - assess the needs of the terminally ill clients and
their families solidified the nurse’s role in holistic assessment.
 Sensations or symptoms (pain, hunger), feelings (happiness,
Evolution of Nurse’s Role in Health Assessment The following factors will continue to promote opportunities sadness), perceptions, desires, preferences, beliefs, ideas, values,
for nurses: and personal information that can be elicited and verified only
Late 1800s-Early 1900s by the client.
 Rising educational costs and increased focus on primary care
• Nurses relied on their natural sense, the client’s face and that affect the numbers and availability of medical students INTERVIEWING - Obtaining a valid nursing health history requires
body would be observed for “changes in color, temperature,  Increasing complexity of acute care professional, interpersonal, and interviewing skills. The nursing
muscle strength, use of limbs, body output, and degrees of  Growing aging population with complex morbidities interview is a communication process that has two focuses.
nutrition, and hydration.  Expanding health care needs of single parents
 Establishing rapport and a trusting relationship with the
 Increasing impact of children and the homeless on client to elicit accurate and meaningful information
• Palpation was used to measure pulse rate and quality and to
communities  Gathering information on the client’s developmental,
locate the fundus of the puerperal woman
 Intensifying mental health issues psychological, physiologic, sociocultural, and spiritual status
1930-1949  Expanding health service networks
 Increasing reimbursement for health promotion and Phases of Interview
• The American Journal of Public Health documents routine
client and home inspection by public health nurses preventive care services 1. Introductory Phase
 Limited number of medical students pursuing practice in 2. Working Phase
• This role of case finding, prevention of communicable primary care setting. 3. Summary and Closing Phase
diseases, and routine use of assessment skills in poor inner-
city areas were performed Steps of Health Assessment A. Introductory Phase
• The nurse introduce himself to the client.
1950-1969 • The nurse explains the purpose of the interview, discusses the
• Nurse were hired to conduct pre-employment health types of questions that will be asked, explains the reason for
taking notes, and assures the client that confidential information
histories and physical examinations for major companies
will remain confidential.
1970-1989 • The nurse also makes sure that the client is comfortable
(physically and emotionally) and has privacy.
• The early 1970s prompted nurses to develop an active role in B. Working Phase
the provision of primary health services and expanded the • The nurse elicits the client’s comments about major biographic
professional nurse role in conducting health histories and data, reasons for seeking care, history of present health concern,
physical and psychological assessment. past health history, family history, review of body systems for
 current health problems, lifestyle and health practices, and  e.g., When did your headache start? B. Cultural Variations in Communication
developmental level. Did it start after you take the medication?  Ethnic/cultural variations in communication and self-disclosure
• The nurse then listens, observes cues, and uses critical thinking 3. Well-placed Phrases styles may significantly affect the information obtained
skills to interpret and validate information received from the  Encourage client verbalization  “a culture broker.”- someone who is thoroughly familiar not only
client.  Encourages client to continue with the client’s language, culture, and related health care
C. Summary and Closing Phase  E.g., ah-huh, yes, I agree practices but also with the health care setting and system of the
• The nurse summarizes information obtained during the working 4. Inferring dominant culture.
phase and validates problems and goals with the client.  the types of questions that involve reading between the lines.  You may have to interview a client who does not speak your
• The nurse also identifies and discusses possible plans to resolve the 5. Providing Information language.
problem with the client.  Another important thing to do throughout the interview is  Possibly the best interpreter would be a culture expert (or
• Finally, the nurse makes sure to ask if anything else concerns the to provide the culture broker).
client and if there are any further questions  client with information as questions and concerns arise  Also keep in mind that communication through use of pictures
6. Laundry List may be helpful when working with some clients
Two Types of Communication  Providing client with list of words to choose from in describing C. Emotional Variations in Communication
symptoms, conditions or feelings Clients’ emotions vary for a number of reasons.
1. Verbal Communication  Helps obtain specific answers and reduces the likelihood of the  They may be scared or anxious about their health or about
1. Open-ended Questions client perceiving or providing expected answer disclosing personal information,
2. Close-ended Questions  e.g., Is the pain severe, dull, sharp, mild, cutting or piercing?  angry that they are sick or about having to have an examination,
3. Well-placed Phrases  Does the pain occur once every year, day, month or hour?  depressed about their health or other life events, or
4. Inferring 7. Rephrasing  they may have an ulterior motive for having an assessment
5. Providing Information  Helps to clarify information the client stated performed.
6. Laundry List  Enables you and the client to reflect on what was said
7. Rephrasing  e.g., Client stated he has been tired and nauseated for 2 months When Interacting with an Anxious Client
and he fears he has a horrible disease. You rephrase: “You are
2. Non- verbal Communication  Provide client simple, organized information in a structural
thinking that you have a serious illness?”
format.
1. Appearance Special Consideration During Interview  Explain who you are and your role and purpose
2. Demeanor  Ask simple, concise questions
3. Facial Expression  Gerontologic Variations in Communication  Avoid becoming anxious like the client.
4. Attitude  Cultural Variations in Communication  Do not hurry and decrease any external stimuli.
5. Silence  Emotional Variations in Communication
6. Listening When Interacting with an Angry Client
A. Gerontologic Variations in Communication  Approach this client in a calm, reassuring, in-control manner.
Verbal Communication  When interviewing an elderly client, you must first assess hearing  Allow him to ventilate feelings. However, if client is out of
1. Open- ended Question acuity. Hearing loss occurs normally with age, and undetected control, do not argue with or touch the client.
 Typically begins with words “how” or “what” hearing loss is often misinterpreted as mental slowness or  Obtain help from other health care professionals as needed.
confusion.  Avoid arguing and facilitate personal space so the client does not
 Requires more than a one-word response from a client,
 If you detect hearing loss: feel threatened or cornered.
therefore encourage description
 e.g., How have you been lately? • speak slowly,
How does this make you feel? • face the client at all times during the interview, and When Interacting with a Depressed Client
2. Close- ended Question • position yourself so that you are speaking on the side of the  Express interest in and understanding of client and respond in a
 Typically begins with words “when” or “did” client that has the ear with better acuity. neutral manner.
 Clients may respond with one or two words • Do not yell at the client.
  Do not try to communicate in an upbeat, encouraging manner. ❎ Reading the questions Medical Instruments
This will not help depressed client.
Complete Health History • Flash light or penlight- To assist
When Interacting with a Manipulative Client viewing of the pharynx and cervix or to
1. Biographical Data - include information that identifies the determine the reactions of the pupils of
 Provide structure and set limits.
client, such as name, address, phone number, gender, and the eye
 Differentiate between manipulation and a reasonable request.
 If you are not sure whether you are being manipulated, obtain an who provided the information – the client or significant
objective opinion from other nursing colleagues. others.
• Laryngeal or dental mirror- to
2. Reasons for seeking health care and Chief Complaint
When Interacting with a Seductive Client observe the pharynx and oral cavity.
 “What are your major health problems or concern
 Set firm limits on overt sexual client behavior and avoid at this time?”
responding to subtle seductive behaviors.  “How do you feel about having to seek health • Nasal Speculum- permit the visualization of the
 Encourage client to use more appropriate methods of coping in
care?” lower and middle turbinates; usually penlight is
relating to others.
3. History of: Present Illness, Past and Family Health History, used for illumination.
When Discussing Sensitive Issues (for example, Sexuality, Dying, Spiritually) Review of System (ROS), Lifestyle, and Developmental Level
and Psychosocial History
 First be aware of your own thoughts and feelings regarding dying,
• Ophthalmoscope- lighted
spiritually, and sexuality; then recognize that these factors may Objective Data instrument to visualize the
affect client’s health and may need to be discusses with someone interior of eye.
 Ask simple questions in non-judgmental manner.  Include information about the client that the nurse directly
 Allow time for ventilation of client’s feelings as needed. observes during interaction with the client and information
• Otoscope- visualize the eardrum and external
 If you don’t feel comfortable or competent discussing personal, elicited through physical assessment techniques. To become
auditory canal (a nasal speculum may be attached
sensitive topics, you may make referrals as appropriate, for proficient with physical assessment skills, the nurse must have to otoscope to inspect nasal cavities)
example, to a pastoral counselor for spiritual concerns or another basic knowledge in three areas:
specialist as needed.
a. Types and operation of equipment needed for the
Communication to Avoid particular examination. • Percussion (Reflex) hammer- with a rubber
head to test reflexes.
A. Nonverbal Communication b. Preparation of the setting, oneself, and the client for the
physical assessment
❎ Excessive or insufficient eye contact
c. Performance of the four assessment techniques: inspection, • Tuning fork- two-pronged metal instrument
❎ Distractions and distance palpation, percussion and auscultation. used to test hearing acuity and vibratory sense

❎ Standing 1. Physical Examination – Prior to the examination, collect the

necessary equipment and place it in area where the examination will • Vaginal speculum (various sizes)- assess the
B. Verbal Communication be performed. cervix and vagina.

❎ Biased or Leading questions

❎ Rushing through the interview

 • Cotton applicators- obtain specimens  Mirror Checking Musculoskeletal Examination
 Metric Ruler
 Magnifying Glass  Measuring tape
 Goniometer (degree of flexion and extension of joints)
• Disposable pads- absorb Checking Head and Neck Examination
liquid Checking Neurologic Examination
 Stethoscope
 Small cup of water  Cotton-tipped applicator and substances to taste and smell
 Penlight
• Gloves (sterile and Checking Eye Examination  Snellen Chart
unsterile)- protect the  Newspaper
nurse.  Penlight  Opaque
 Snellen Chart  Ophthalmoscope
 Newspaper  Cotton ball and paper clip
 Opaque Card  Tongue depressor
• Lubricant- ease insertion of  Ophthalmoscope
instruments  Tuning fork
Checking Mouth, Throat, Nose, and Sinusitis Examination Checking Male Genitals and Rectum Examination
 Penlight  Gloves and lubricant
 4x4 small gauze  Penlight
• Tongue depressors- depress  Tongue Depressor
the tongue.  Specimen card
Checking Thoracic and Lung Examination Checking Female Genitals and Rectum Examination
• Stethoscope- auscultate heart, lung,  Otoscope
abdomen, and cardiovascular sound.  Vaginal speculum and lubricant
 Stethoscope  Bifid spatula, endocervical broom
 Metric ruler and marking pen  Large swabs
Checking Heart and Neck Vessels Examination  Liquid Pap medium
• Thermometer- to check the  Stethoscope
temperature  Metric Ruler
2. Preparation
Checking Vital Signs Checking Vascular Examination
a. Preparing the physical setting
 Sphygmomanometer  Sphygmomanometer and Stethoscope
 Thermometer  Measuring tape b. Preparing oneself
 Watch with second hand  Tuning fork
 Pain Rating Scale c. Approaching and preparing the client
 Doppler ultrasound device
Checking Nutritional Status Examination Checking Abdominal Examination 3. Positioning – different position during physical examination
 Skin-marking pen  Stethoscope  Properly maintaining a patient’s neutral body alignment by
 Platform scale with height attachment  Measuring tape and marking pen preventing hyperextension and extreme lateral rotation to
Checking Skin, Hair, and Nail Examination  Pillows prevent complications of immobility and injury. The ultimate
goal of proper patient positioning is to safeguard the
 Penlight
 patient from injury and physiological complications of 5. Standing Position 4. Techniques – four basic techniques must be mastered before you
immobility. Specifically, patient positioning goals include: can perform a thorough and complete assessment of the client.
 Provide patient comfort and safety.  This position allows the examiner to assess posture, balance,
 Maintaining patient dignity and privacy. and gait. This position is also used for examining the male a. Inspection – involves using the senses of vision, smell, and
 Allows maximum visibility and access. genitalia hearing to observe and detect any normal or abnormal
6. Prone position findings. Note the following characteristics while inspecting
1. Sitting position the client:
 This position is good for evaluating the head, neck, lung, chest,  It is used primarily to assess the hip joint and back. The only  Color
back, breast, axilla, heart, vital signs, and upper extremities. It bed position that allows full extension of the hip and knee  Patterns
is useful because it permits full expansion of the lungs and it joints  Size
allows the examiner to assess symmetry of upper body parts.  Promote drainage from the mouth and is especially used for  Location,
 Semi-fowler’s position – 15 to 45 degrees unconscious client or those clients recovering from surgery.  Consistency
 Clients with cardiac and respiratory problems cannot  Symmetry
 Fowler’s position – 60 to 90 degrees
tolerate this position.  Movement
2. Supine position  Behavior
7. Knee-chest Position  Odors
 This position allows the abdominal muscles to relax and  It is useful for examining the rectum. This position may be  Sounds
provides easy access to peripheral pulse sites. Areas assesses b. Palpation – it consists of using body parts of the hands to
embarrassing and uncomfortable for the client; therefore,
with the client in this position may include head, neck, chest, touch and feel
the client should be kept the position as limited time as
breast, axilla, abdomen, heart, lungs, and all extremities
possible. b.1 light palpation – to perform light palpation,
3. Dorsal recumbent place your dominant hand lightly on the surface of the
8. Lithotomy Position
 This position may be more comfortable than the supine structure. There should be very little or no depression (less
 It is used to examine the female genitalia, reproductive than 1cm). feel the surface structure using a circular
position for clients with pain in the back or the abdomen. The
tract, and the rectum. It is best to keep the client well motion.
abdomen should not be assessing because the abdominal
draped during the examination as quickly as possible.
muscles are contracted in this position. Areas assesses with
b.2 moderate palpation – depress the skin surface 1
the client in this position may include head, neck, chest, breast, 9. Orthopneic position to 2 cm with your dominant hand, and use a circular motion
axilla, heart, lungs, and peripheral pulses
 The client sits either in bed or on the side of the bed with to feel for easily palpable body organs and masses. Note the
4. Sim’s position an overbed table across the lap. This position facilitates size, consistency, and mobility of structures you palpate.
respiration by allowing maximum chest expansion
 This position is useful for assessing the rectal and vaginal b.3 deep palpation – place your dominant hand on
 It is helpful to clients who have problems exhaling, because
areas, hips and joints. May be used for unconscious clients the skin surface and your nondominant hand on top of your
they can press the lower part of the chest against the edge
because it facilitates drainage from the mouth and prevent dominant hand to apply pressure. This allows you to feel
of the overbed table
aspirations of fluids. Used for paralyzed clients because it very deep organs or structure covered with thick muscle
reduces pressure over the sacrum 10. Lateral Position
b.4 bimanual palpation – use two hands, placing one
 Clients with joint problems and elderly clients may have some
difficulty maintaining the position  Also called side-lying position, the client lies on one side of on each side of the body part being palpated (uterus, breast,
the body. This position helps to relieve pressure on the spleen). Use one hand to apply pressure and the other hand
sacrum and heels to feel the structure.
 Parts of Hand to use when Palpating Validation of data h. Record the client’s understanding and perception of problems
Hand Part Sensitive to i. Avoid recording the word “normal” for normal findings. Also,
Finger pads Fine discrimination:  Process of confirming or verifying that the subjective and
the terms good, fair, poor, sometimes, occasional, frequently,
pulses, texture, size, objective data you have collected are reliable and accurate. The recently, or some.
consistency, shape, steps of validation include: j. Record complete information and details for all client
crepitus 1. Deciding whether the data require validation symptoms or experiences
Ulnar or palmar Vibrations, thrills, 2. Determining ways to validate the data k. Include additional assessment content when applicable
surface fremitus 3. Identifying areas for which data are missing l. Support objective data with specific observations obtained
Dorsal (back) surface Temperature during the physical examination
Conditions that require data to be rechecked and validated include:
c. Percussion – involves tapping body parts to produce sound  Discrepancies or gaps between the subjective and objective Mental Status
waves. Uses of percussion includes: eliciting pain, determining data
location, size and shape, determining density, detecting  Client’s level of cognitive functioning (thinking, knowledge,
 Discrepancies or gaps between what the client says at one problem solving) and emotional functioning (feelings, mood,
abnormal masses, eliciting reflexes. time versus another time behaviors, stability).
c.1 Direct percussion – is the direct tapping of a  Findings that are highly abnormal and/or inconsistent with
body with one or two fingertips to elicit possible tenderness other findings Mental Health

c.2 Blunt percussion – used to detect tenderness Methods of Validation  Essential part of one’s total health and is more than just the
over organs (e.g., kidneys) by placing one hand flat on the absence of mental disabilities or disorders.
1. Recheck your own data through a repeat assessment
body surface and using the fist of the other hand to strike  The World Health Organization (WHO, 2014) states: “Health is a
2. Clarify data with the client by asking additional questions
the back of the hand flat on the body surface. 3. Verify the data with another health care professional state of complete physical, mental and social well-being and not
4. Compare your objective findings to uncover discrepancies merely the absence of disease or infirmity.”
c.3 Indirect or mediate percussion – It produces  WHO defines mental health as “A state of well-being in which an
sound or tone that varies with the density of underlying Documentation of Data individual realizes his or her own abilities, can cope with the
structures. As density increases, the sound of tone becomes normal stresses of life, and work productively”.
quieter  Helps identify health problems, formulate nursing diagnoses, and
plan immediate and ongoing interventions by promoting Factors Affecting Mental Health
d. Auscultation – A stethoscope is used because these body effective communication among multidisciplinary health team 1. Economic and social factors, such as rapid changes, stressful
sounds are not audible to the human ear. The sounds members to facilitate safe and efficient client care. work conditions, and isolation
detected are classified according to the: 2. Unhealthy lifestyle choices, such as sedentary lifestyle or
Guidelines for Documentation substance abuse
 Intensity (loud or soft)
a. Keep confidential all documented information in the client 3. Exposure to violence, such as being a victim of child abuse
 Pitch (high or low) record. 4. Personality factors such as poor decision-making skills, low
 Duration (length) b. Document legibly or print neatly in nonerasable ink
 Quality (musical, crackling or raspy) of the sounds. self-concept, poor self-control
c. Use correct grammar and spelling. Use only abbreviations that 5. Spiritual factors
 Type of assessment technique that requires are acceptable and approved by the institution 6. Cultural factors
 The use of stethoscope to listen for heat sounds, d. Avoid wordiness that creates redundancy 7. Changes or impairments in the structure and function of the
 Movements of blood through the cardiovascular e. Use phrases instead of sentences to record data neurologic system: for example, cerebral abnormalities
system, f. Record data findings, not how they were obtained 8. Psychosocial developmental level and issues
 Movement of the vowel, and g. Write entries objectively, without making premature
 Movement of air through the respiratory tract. judgments or diagnoses
Mental Disorders Older Adult Considerations in Assessing Mental Health Glasgow Coma Scale (GCS)
 The Diagnostic and Statistical Manual of Mental Disorders  Check first the hearing and vision  most widely used scoring system for Intensive Care Unit
(DSM) has 5-definition for a mental disorder that has the  Although the older client’s response and ability to process (ICU) comatose patients in assessing their level of
following features (American Psychiatric Association, 2012) information may be slower, he/she is normally alert and consciousness by beginning in the least noxious stimulus:
1. A behavioral or psychological syndrome or pattern oriented verbal, tactile, to painful
that occurs in an individual  Some older adults may wear excess clothing because of
2. That reflects an underlying psychobiologic slowed metabolism and loss of subcutaneous fat resulting in
dysfunction. cold intolerance
3. The consequences of which are clinically significant  In older adult, purposeless movements, wandering,
distress (e.g., a painful symptom) or disability (i.e., aggressiveness, or withdrawal may indicate neurologic
impairment in one or more important areas of deficits
functioning)  Responses may be slowed but speech should be clear and
4. Must not be merely an expectable response to moderately paced
common stressors and losses (e.g., the loss of a
loved one) or a culturally sanctioned response to a
particular event (e.g., trance states in religious SLUMS Dementia/Alzheimer Test Examination
rituals)
5. That is not primarily a result of social deviance or  Or the St. Louis University Mental Status Examination
conflicts with society  Clinician administered examination used to identify persons
who have dementia or mild neurocognitive impairment
Alcohol Use Disorder Identification Test (AUDIT)  Used to test the level of orientation, memory, speech, and Levels of Consciousness
 Simple method for screening for excessive drinking and cognitive functions but not mood, feelings, expressions,
thought processes and perceptions in older adults 1. Full Consciousness – awake and alert
alcohol use disorders that provides a framework for 2. Confusion – Progressive disorientation, forget stuffs,
intervention to help risky drinkers reduce or cease alcohol
difficulty following commands, Restless/Agitated
consumptions and its harmful consequences
SAD PERSON: Suicide Risk Tool 3. Lethargy – alert and oriented (person, place, time) but quite
CAGE: Questionnaire for Detecting Alcoholism sluggish, sleeps frequently but wakens to voice or gentle
shaking
 offers simple methodology for determining if patient have
4. Obtundation – extreme drowsiness, minimally responsive,
an alcohol problem and can provide a quick indication for the
barely follows commands, requires vigorous stimulation to
need for follow-up alcohol assessment
awaken, stays awake for mere minutes
5. Stupor – minimal movement, responds in groans and moans,
awakens briefly only with repeated stimulation
6. Coma – does not respond to verbal stimuli, does not speak,
Decorticate/decerebrate/No response to pain
Cognitive involves the following:
1. Memory
2. Thinking
 3. Reasoning c. Superego – the moral component of morality (conscience), the intrapersonal and interpersonal responses of a person
4. Understanding provides feedback to the person regarding how closely his or her to external events.
5. Judgement behavior conforms to the external value system, it strives for
6. Behavior perfection, disregards reality, usually operates at the unconscious
level, and is an insistent force against the desires of the id. C. Piaget Theory of Cognitive Development
PSYCHOSOCIAL, COGNITIVE and MORAL DEVELOPMENT
Psychosexual Stages of Self-Development
A. Freud theory of Psychosexual Development
Sigmund Freud (1935) 1. Oral Stage – from birth up to first year of life.
 Viennese physician, develop the first formal theory of • Babies derive pleasure from oral activities like sucking
personality. He originated the concept of psychoanalysis or biting. Overindulgence of oral needs may lead to oral
and believed that personality development was based on incorporative personality disorder such as overeating,
understanding the individual life history of a person. smoking, alcoholism while dissatisfaction may lead to
Freud conceived the concept of mental qualities, which oral aggressive personality disorder such as sarcasm
influence behavior and occur at three level of awareness. Dr. Jean Piaget (1970)
and tactlessness.
 Generic epistemologist (one who studies the origin of
a. Consciousness – refers to whatever a person is sensing, 2. Anal Stage – 1 to 3 years old: Anus.
knowledge). His theory is a description and an explanation
thinking about, or experiencing at any given moment. It is limited, • Child derives pleasure from the elimination of wastes. of the growth and development of intellectual structures.
since only a small amount of such thought exists at one time. Anal fixation can lead to anal retentive personality He focused on how a person learns, not what the person
disorder such as having obsession with cleanliness or learns.
b. Precociousness – involves all of a person’s memories and anal expulsion personality disorder such as clumsiness
stored knowledge that can be recalled and brought to the conscious 3. Phallic Stage – 3 to 6 years old: Genitals. Piaget believed that individual cognitive development occurs
level. • Child derives pleasure form examining, touching, as the result of one’s organization and adaptation to the
c. Unconsciousness – the largest and most influential. This level fondling or displaying their genitals. These behaviors are perceived environment. To explain his theory, he applied the
corresponds to socially unacceptable sexual desires, shameful likely motivated by curiosity about differences between concepts of schema (schemata), assimilation,
impulses, and irrational wishes, as well as anxieties and fears. the anatomy of man and woman. accommodation, and equilibration.
4. Latency Stage – 6 to 12 years old: Libido. a) Schemas – “a cohesive, repeatable action sequence
Later, Freud (1949) revised his theory to include three basic • Sexual energy is repressed because children become possessing component actions that are tightly
structures in his anatomy of the personality. He believed occupied with school. interconnected and governed by a core meaning”
that these structures could operate within any of the level 5. Genital Stage – Puberty to Adult: Heterosexual Relationships:
of awareness. • Pleasure is again derived from genital area and –the basic building block of intelligent behavior/ way
individuals seeks to satisfy their sexual derives. Sexual or organizing knowledge – “units” of knowledge
a. Id – the inherited system. Containing the basic motivational
drives for such entities as air, water, warmth, and sex, that seeks problems may result as consequence of inappropriate b) Assimilation – using an existing schema to deal with new
instant gratification and supplies the psychic energy for the ego and sex behaviors.
object or situation
superego. c) Accommodation – when the existing schema (knowledge)
B. Erikson Theory of Psychosocial Development
b. Ego – emerges to act initially as an intermediary between Erik Erikson does not work, and needs to be changed to deal with a new
the id and then external world, or reality. It includes many processes  Psychoanalyst who adapted and expanded Freud’s object or situation
such as learning, perceptions, memory, problem solving, and decision psychosexual theory. Erikson theory has become known as
making. a psychosocial theory, with psychosocial being defined as
d) Equilibration – force which moves development along; Kohlberg’s Three Levels of Moral Development • > 60 bpm = BRADYCARDIA
Cognitive development did not progress at a steady rate but 1. Level 1: Preconventional – child’s sense of morality - Prolonged sitting or standing
rather in leaps and bounds is externally controlled as they accept and believe • Pulse Deficit
the rules of authority figures -Difference between the apical and the radial pulse
Piaget’s 4 Stages of Cognitive Development: Increasing  Stage 1: Obedience-and-Punishment  Respiratory Rate
sophistication of children’s thought Orientation - Normal rate = 12 -20 cpm
1. Sensorimotor Stage: birth to age 2 – main  Stage 2: Instrumental Orientation - Regular and spontaneous rhythm
achievement is Object Permanence (knowing that 2. Level 2: Conventional – sense of morality is tied to - Equal bilateral chest expansion of 1 – 2 inches
an object still exists, even if it is hidden) personal and societal relationships where children
2. Pre-operational Stage: age 2 to age 7 – young believe that it is necessary to ensure positive
Types of Respiration
children can think things symbolically where thinking relationships and societal order
is still egocentric and the infant has difficulty  Stage 3: Good boy, Nice Girl Orientation
taking the viewpoint of others  Stage 4: Law-and-Order Orientation
 Fundamental Egocentrism – never thinks that 3. Level 3: Postconventional – sense of morality is
anything is other than the way the child defined in terms of more abstract principles and
perceived. values
 Centration – tends to focus on one aspect of  Stage 5: Social-Contract Orientation
an object or experience  Stage 6: Universal-Ethical-Principal
 Limited Transformation – not be able to Orientation
comprehend the steps of an object is changed Vital Signs Measurement
from one state to another
3. Concrete operational Stage: age 7 to age 11 –  Normal body temperature by site
major turning point in the child’s cognitive
development, beginning of logical or operational  Blood Pressure
thought
4. Formal operational Stage: age 11 to adulthood –
people develop the ability to think about abstract
concepts, and logically test hypotheses
D. Kohlberg Theory of Moral Development Page  Pulse Rate
Lawrence Kohlberg -Normal rates = 60 – 100 bpm
 Psychologist, expanded Piaget’s thoughts on morality; in -Mean/Average = 80 bpm
doing so, he developed a comprehensive theory of moral -May be as low as 50 bpm in healthy athletes
development. -Regular Rhythm
Kohlberg (1981) proposed, individual morality has been viewed -Equal bilaterally in strength/amplitude
as a dynamic process that extends over one’s lifetime, Deviations from Normal Pulse Rate
• > 100 bpm = TACHYCARDIA
primarily involving the affective and cognitive domains in
-Anxiety, fear, nervousness
determining what is “right” and “wrong.”
  Pain assessment • Increased antidiuretic hormone, epinephrine, Pain Tolerance – maximum amount and duration of pain that an
-Universal Pain Assessment Tool norepinephrine, aldosterone, glucagons; decreased individual is willing to endure that varies greatly among people
insulin, testosterone
Pain Perception – actual feeling of pain
• Hyperglycemia, glucose intolerance, insulin resistance,
protein catabolism Bradykinin – universal stimulus for pain
• Muscle spasm, resulting in impaired muscle function
and immobility, perspiration Hyperalgesia – excessive sensitivity to pain
Theories of Pain Classification of Pain
A. Pattern Theory – pain is perceived whenever the stimulus is A. Classification of pain by cause includes:
intense enough a) Nociceptive: response to noxious insult or injury of
B. Specificity Theory – there are specific nerve receptors for tissues such as skin, muscles, visceral organs, joints,
PAIN ASSESSMENT: 5TH VITAL SIGN particular stimuli tendons, or bones
C. Gate Control Theory – introduced by Wall and Melzack - there is b) Neuropathic: pain initiated or caused by a primary lesion
Pain or disease in the somatosensory nervous system
a gate in the spinal cord called substantia gelatinosa where pain
 sensation of physical or mental hurt or suffering that is transmitted c) Inflammatory: a result of activation and sensitization of
D. Affect Theory – pain is emotional – the intensity of pain the nociceptive pain pathway by a variety of mediators
causes distress or agony – subjective in nature –
perceived depends on the value of the organ affected released at a site of tissue inflammation
protective as it provides warning signal for tissue injury
B. Classification of pain by Duration and etiology
 elicits a stress response in the human body that triggers E. Parallel Processing Model – psychologic or neurologic deciphering
a) Acute pain: usually associated with a recent injury
the sympathetic nervous system, resulting in physiologic of pain sensation and the cognitive emotional properties occur
b) Chronic nonmalignant pain: usually associated with a
responses such as: along the different nerve fibers
specific cause or injury and described as a constant pain
• Anxiety, fear, hopelessness, sleeplessness, thoughts of
Factors Influencing the Pain Experience: that persists for more than 6 months
suicide
c) Cancer pain: often due to the compression of peripheral
• Focus on pain, reports of pain, cries and moans, • Age nerves or meninges or from the damage to these
frowns, and facial grimaces • Sex structures following surgery, chemotherapy, radiation, or
• Decrease in cognitive function, mental confusion, • Childhood tumor growth and infiltration
altered temperament, high somatization, and dilated • Cultural Background d) Intractable pain: defined by its high resistance to pain
pupils • Psychological factors relief
• Increased heart rate; peripheral, systemic, and • Previous experience C. Classification of pain by location
coronary vascular resistance; increased blood pressure • Religious beliefs a) Cutaneous pain (skin or subcutaneous tissue)
• Increased respiratory rate and sputum retention, • Expected response b) Visceral pain (abdominal cavity, thorax, cranium)
resulting in infection and atelectasis • Setting c) Deep somatic pain (ligaments, tendons, bones, blood
• Decreased gastric and intestinal motility • Diagnosis vessels, nerves)
• Decreased urinary output, resulting in urinary • Physical/Mental health
retention, fluid overload, depression of all immune Seven Dimensions of Pain
• Knowledge/Understanding
responses 1. Physical dimension – physiologic effects just described. This
Pain Threshold – amount of pain stimulation a person requires before
dimension includes the patient’s perception of the pain and the
feeling pain that is generally fair uniform among people
body’s reaction to the stimulus.
 2. Sensory dimension – concerns the quality of the pain and how c) Biologic theory (physiologic changes from childhood trauma,  Norms – learned behaviors that are perceived to be appropriate
severe the pain is perceived to be. This dimension includes the head injuries, or through heredity cause violent behavior); or inappropriate
patient’s perception of the pain’s location, intensity, and d) Family systems theory (violence grows through family  Ethnocentrism – perception that one’s worldview is the only
quality. system function, but some criticize this theory as blaming acceptable truth and that one’s belief, values, and sanctioned
3. Behavioral dimension – verbal and nonverbal behaviors that the the victim); and behaviors are superior to all others
patient demonstrates in response to the pain. e) Feminist theory (male/female inequity in patriarchal societies  Ethnicity – person’s ethnic identity that holds commons set of
4. Sociocultural dimension – concerns the influences of the leads to violence). characteristics not shared by others
patient’s social context and cultural background on the Types of Family Violence  Race – socially constructed concept that has a meaning to a
patient’s pain experience. larger group
5. Cognitive dimension – concerns “beliefs, attitudes, intentions, 1. Physical Abuse
and motivations related to the pain and its management” 2. Psychological Abuse Values and beliefs can be divided into 2 categories:
6. Affective dimension – concerns feelings, sentiments, and 3. Economic Abuse  Those that affect the client’s approach to the health care
4. Sexual Abuse system and provider
emotions related to the pain experience. Pain can affect the
emotions and the emotions can affect the perception of pain. Categories of Family Violence  Those that affect the client’s disease, illness, and health
7. Spiritual dimension – meaning and purpose that the person state
“attributes to the pain, self, others, and the divine”. 1. Intimate Partner Violence
2. Child Abuse Purposes and Scope of Assessment
ASSESSING PATIENTS FOR VIOLENCE 3. Elder Mistreatment The main purposes of assessing culture in a health care setting
Domestic violence ASSESSING CULTURE are:
 To learn about the client’s beliefs and usual behaviors
 “a pattern of abusive behavior in any relationship that is Albrecht et al. (2013, p. 2) noted that disease refers to associated with health and illness, including beliefs about
used by one partner to gain or maintain control over “deviations from a biomedical norm”; illness refers to “the disease causes, caregiving, expected treatments
another intimate partner.” lived experience of culturally constructed categories”; and  To compare and contrast the client’s beliefs and
sickness refers to “patients’ roles.” All three of these terms practices to standard Western health care
Family violence
need to be considered when talking with clients about health.  To compare the client’s beliefs and practices with those
 a “violent or threatening behavior, or any other form of of other persons from a similar cultural background (to
Culture
behavior, that coerces or controls a family member or avoid stereotyping)
causes that family member to be fearful.”  shared system of values, beliefs, and learned patterns of  To assess the client’s health relative to diseases
behavior; totality of socially transmitted behavioral prevalent in the specific cultural group
Theories of Family Violence patterns, that guide people’s worldview and decision making
McCue (2008) presents five theories related to domestic violence  Purnell (2013) provides the following useful definition of Cultural beliefs and values to assess include:
for why men batter women: culture: “the totality of socially transmitted behavioral 1. Value orientation (principles of what values and behaviors are
a) Psychopathology theory (batterers suffer personality patterns, arts, beliefs, values, customs, lifeways, and all other considered right or wrong by a group or an individual)
disorders); products of human work and thought characteristic of a 2. Beliefs about human nature
population or people that guide their worldview and decision 3. Beliefs about relationship with nature
b) Social learning theory (violence is a learned behavior from
making” 4. Beliefs about purpose of life
childhood);
5. Beliefs about health, illness, and healing
 Values – learned beliefs about what is held to be good or bad
6. Beliefs about what causes disease
 7. Beliefs about health and mental activities that make up human life” (Carpenter, Vitamin K – blood clotting found in leafy vegetables
8. Beliefs about who serves in the role of healer or what 2016, p.1)
practices bring about healing  Carbohydrates –either simple or complex, depending on their Vitamin C – found in citrus and fruits
9. Beliefs about the meaning of suffering and pain chemical structure. Known as protein sparing because the body Vitamin D – help with calcium metabolism and found in milk
ASSESSING SPIRITUALITY AND RELIGIOUS PRACTICES uses them for energy source and helps to burn fats more  Minerals – essential for promoting growth and maintain health
effectively and completely that can be found in all body fluids and tissues
Spiritual Assessment  Hydration – is another important indicator of the client’s
Healthy diet should consist of 45% - 65%
 Gaining relevant information about the client’s spirituality carbohydrates with 75% complex carbohydrates general health status, may be overlooked or confused with the
helps to identify related nursing diagnoses and needed signs and symptoms of nutritional changes.
interventions, and can improve client care.  Proteins – important in a healthy diet, which is essential for Water – accounts for 50 to 75% of body weight
normal growth and development made up of amino acids and – Average Daily Intake: 2 L – 4 L of water
Spirituality are stored in muscle, skin, bone, blood, cartilage, and lymph
tissue. Genogram
 Multidimensional and unique to each individual. These
characteristics of spirituality can present difficulties in proper  Fiber – helps to promote normal bowel function, reduce  helps to organize and
assessment.  cholesterol levels, control blood sugar levels, and aid in weight illustrate the client’s
management family history
ASSESSING NUTRITIONAL STATUS  Fats – important part of a healthy, well-balanced diet. Fats are
Key symbols used in genogram:
Nutritional Assessment stored in adipose cells and are classified as triglycerides, which
make up 95% of fats in foods, phospholipids, or sterols. • provide a key
 Identifies risk factors for obesity (excessive body fat) and for Ingested fats are saturated, originating from animal sources or • female relatives -
dietary deficits (malnutrition and undernutrition), and is also tropical oils and solid at room temperature; or unsaturated, indicated by a circle
used to guide health promotion and disease prevention originating from plant sources and soft or liquid at room • male relatives - indicated
activities. temperature. by a square.
Functions of fats include: • Relatives with no health
problems – A/W (alive and well)
• Providing concentrated energy
Assessing Hydration Status • deceased relative - is noted by marking an X in the circle or
• Aiding in absorption of fat-soluble vitamins (A, D, E, and
square
 important aspect of the nutritional assessment and an K)
• (list the age at death and the cause of death)
important indicator of the client’s general health. • Supplying essential fatty acids for healthy skin
• horizontal dotted line - indicate the client’s spouse
• Insulating skin and nerve fibers
• vertical dotted line - indicate adoption.
Food Safety • Lubricating skin to slow water loss
• Protecting internal organs
 Essential component of nutritional assessment to determine
 Cholesterol – fat-like substance that the liver produces. It is
how clients store and prepare food in addition to their
also found in animal food sources, such as meats, egg yolks, and
understanding of food contamination and allergies.
dairy products. Necessary component of bile salts that aid in
Nutrition digestion and essential element in all cell membrane
 Vitamins – required energy to be released from carbohydrates,
 “process by which substances in food are transformed into
proteins and fats
body tissues and provide energy for the full range of physical
COLDSPA ASSESSMENT