Course Framework
What is Pathophysiology?
Physiology – study of normal healthy bodily functions.
With disruption of this normal process, it enters the realm of
pathophysiology
Pathophysiology – Looks at the specific malfunctioning that comes from, or
causes the disease
The Process
Process is ongoing & cyclical
1. Assessment = collecting subjective and objective data
2. Diagnosis = analyzing subjective and objective data to make a
professional nursing judgement (nursing diagnosis, collaborative
problem, or referral)
3. Planning = determining outcome criteria and developing a plan
4. Interventions = what you are doing as a result of the data
5. Evaluation = assessing whether outcome criteria have been met
and revising the plan if necessary
ADPIE
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STEP 1: Assessment
Holistic nursing assessment: Collects holistic subjective and
objective data to determine a client’s overall level of functioning
in order to make a professional clinical judgment à BODY, MIND,
and SPIRIT
Physical medical assessment: Focuses primarily on the client’s
physiologic development status
ALWAYS the first step of the nursing process
To systematically collect, validate, organize & communicate the
client data
Who is the client? (individual, family) All members in patient’s life
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Methods of Assessment
Observation (senses)
Interviewing
Screening (broad) = asking the patient Q’s
Focusing (targeted)
Physical exam techniques
o Inspection (look w/o touching), palpation (touch),
percussion (sound) & auscultation (listening)
Intuition
o Gut feeling
Types & sources of data
Subjective: Primary source: client statements, complaints “Use
quotation marks” = what the patient tells you
o Secondary source: Peds patients, mentally handicapped
Health records, other HC providers
Objective (see & measure)
VS
Lab results
Diagnostic test results (ex. CT, MRI, Stool sample)
Physical assessment
Assessing data/Recognizing & Analyzing Cues
Look at significance à What Is patient’s baseline?
What is normal/expected?
What is abnormal/unexpected?
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What risk factors are present?
STEP 2: Creating a hypothesis based upon your data/cues
2nd Step in the process : DIAGNOSIS
RN validates, analyzes & integrates assessment information to identify
clients’ needs & problems
*Ex. Patient states no prior surgeries but has a scar on right knee. Patient
confirms he had right knee surgery years ago*
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How to accurately identify client needs/problems
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Start with considering client concern/problem/issue
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Collect valid & pertinent data
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Client relative data
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Differentiate nursing from collaborative data
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Focus on PRIORITY
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Recognize patterns – compare with normal patterns
•What is salient?
Support of diagnostic problem: PES statement
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Problem/Concern/Issue
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Etiology (contributing factors or causes)
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As manifested by or as evidenced by (AED)
*Ex. Sue has been contracting for three weeks. She is 5cm dilated and is
complaining of pain. Can we get her something for pain?*
Nursing Hypothesis
•Actual problem
• Acute pain (R/T surgical incision AEB r/o pain)
•Potential problem
•Risk for infection R/T abdominal surgery
• Wellness
•Potential for enhanced organized infant behavior, (R/T
prematurity and as manifested by response to visual and auditory stimuli)
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STEP 3: Planning/Generating Solutions
Expected outcomes
Set appropriate goals
o Realistic
o Client centered – “Client will”
o Single factor
Measurable – Desirable change in response to nursing care
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Outcome statement include time limits
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Short term: goals < 1 week
Long term: goals (weeks or months)
On going goal: will maintain
STEP 4: Implentation
Nursing Action
Nursing initiated: Independent
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Requires no supervision
o Ex. Assessing client’s level of anxiety
Physician initiated: ex. MD, PA, DO, NP
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Nurses carry out a written order
o Ex. Medicate with pain drugs per order
Collaborative
> Ex. Dietician, OT, consult with social worker
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STEP 5: Evaluate/Reflection
Effectiveness of actions
Comparing client’s response to goal to determine if goal is achieved à
Client states pain is controlled
Health Assessment and the Nurse
Types and Sources of Data
Subjective = what the patient is telling you
Objective = something we can measure
Steps of Health Assessment
STEP 1: Preparing for the assessment
o Review client’s record
o Review client’s status with other health care team
members
o Educate about client’s diagnosis and tests performed
Collection of Subjective Data
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Biographical information
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History of present health concern; physical symptoms related to each
body part or system = why patient is there
o Ex. When did it start? How long?
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Past health history = medical, surgical,
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Family history
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Health and lifestyle practices = breast, sex, smoking, drinking Q’s
Collection of Objective Data
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Physical characteristics
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Body functions = (ex. Different stool w breastfed vs bottle-fed baby)
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Appearance = what does patient look like without disturbance
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Behavior = (ex. Body language, eye contact)
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Measurements = Vs, Bowel Sounds
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Results of laboratory testing
Methods of Data Collection:
1. Interview: understand your own biases
2. Observation: avoid tunnel vision
3. Physical Assessment: Practice! Remain calm
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Assessment Skills:
1. Cognitive Skills
2. Problem-solving Skills
3. Psychomotor Skills: Ex. Hand hygiene
4. Interpersonal Skills: communicate effectively with patient and family
5. Ethical Skills
Dimensions of Nursing Assessments:
Why is each one important and what can each tell you about a patient?
1. Physiological
2. Psychological
3. Psychosocial
4. Cultural
5. Developmental
6. Spiritual
Interviewing
(Collecting Subjective data)
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A communication process with two foci:
1. Establish a trusting relationship/develop rapport
2. Gather information
Provides focus for physical assessment
Identifies problems
INTERVIEWING (PHASES)
1. Pre-Introductory phase: reviewing your chart & gathering
equipment
2. Introductory phase:
3. Working phase
Conclude - you need to:
›Revise plan - not working
›Discontinue plan – problem is resolved
›Continue plan – problem still present; plan is working
4.
Summary & Closing phase
Interviewing Techniques
Phases of the interview: Introductory
o Explains purpose
o Discusses types of questions
o Assurance of confidentiality
o Important to establish trust & rapport
Phases of the interview ▫ Working:
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Nurse obtains data:
Important for nurse to:
o Listen, Observe cues
o Use critical thinking skills to interpret and validate
information ▫Collaborate with client/patient
Interviewing Techniques
Phases of the interview: Summary/Closing/Termination:
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Summarizes information gathered
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Problems and goals are validated with client
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Helpful to let client know when interview will end
Considerations
Age, Developmental, Cognitive, Physical
Individualized
Christian Humanism
Safety
Communicating with Clients
S - sitting
O - open
L – lean in
E – eye contact
R - relaxed
Nonverbal Communication to Avoid
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Excessive or insufficient eye contact
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Distraction and distance
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Standing
Interview
Therapeutic Techniques
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Problem seeking
—Identifies client's potential problem
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Problem solving
—Focuses on gathering in-depth data on specific problems —
Utilization of COLDSPA Mnemonic
C - Character
O - Onset – when did that start?
L - Location
D - Duration
S- Severity -1-10 what is your pain level?
P - Patterns
A – Alleviate/Aggravate
Interview Techniques
Direct Questions
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Ask for specific information
Often will clarify previous information
Offers additional data
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Does not encourage client to ramble
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Useful for gathering biographic information
Open ended questions
o Goal is to elicit more in-depth response
Ex. Describe how you have been feeling?
Subjective Data:
1. Health History
Biographic
Reasons for seeking care
History of present health concern (COLDSPA) Past health
Family health (genogram)
ROS – review of systems
Lifestyle and health practices
Developmental level
2. Review of Body Systems (review all)
Lifestyle and Health Practices
Lifestyle and Health Practices
o Description of typical day
o Nutrition and weight management
o Activity level and exercise
o Sleep and rest
o Medication and substance use
o Self-concept and self-care responsibilities
o Social activities
o Relationships
o Values and belief system
o Education and work
o Stress levels and coping styles
o Environment
Objective Data
o Gather equipment
o Prepare room (comfortable, warm, private, quiet) – free of
interruptions
o Promote safety
o Adequate lighting
o Firm exam table or bed
o Bedside table/tray to hold equipment
Positions
o Sitting
o Supine
o Dorsal Recumbent
o Sims’ (left lateral)
o Standing
o Knee-chest
o Lithotomy
Inspection
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Look and observe before touching
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Good lighting
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Completely expose part being examined
Palpation
Light palpation (0.5 inch)
Deep palpation (1-2 inch)
Bimanual palpation (using two hands)
Percussion
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Sending soundwaves through the body
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Elicit pain
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Determine location, size, and shape
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Determine density
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Detect abnormal masses
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Elicit reflexes
TYPES:
—Direct, blunt, indirect (mediate)
Auscultation
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Eliminate distracting noise
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Expose body part being auscultated
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Diaphragm = high-pitched sounds
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Bell = low-pitched sounds
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Angle down toward nose
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Warm before use
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EXPLAIN
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AVOID listening through clothes
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VALIDATE & DOCUMENT!!!!
Assessing Vital Signs
Skills used in Assessment
1.Inspection
2. Palpation
3. Percussion
4. Auscultation
*SAME order except for abdomen!*
Preparation for Survey of General Health Status
Perform systematic examination, recording general characteristics and
impressions of the client.
o Observe any significant abnormalities*.
Observe Significant Abnormalities
—Skin color
—Dress (Appropriate for weather? Mental status?)
—Hygiene à odors (Do they need assistance?)
—Posture and gait (how you walk)
—Physical development
—Body build
—Apparent age
—Gender (ASK! Biological sex, hormones, etc)
General Survey
—Physical development and body build
—Gender and sexual development
—Apparent age as compared to reported age
—Apparent age as compared to reported age
—Skin condition and color
—Dress and hygiene
—Posture and gait
—Level of consciousness
—Behaviors, body movements, and affect
—Facial expression
—Speech (slurring)
—Vital signs
Interview
—Any survey questions
—HOPHC (History of Present Health Condition)
—PH (Past Health)
—FH (Family Health)
—LHP (Lifestyle & Health practices)
Assessing Vital Signs
Hands-on physical examination begins with vital signs.
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Provide data that reflect body systems status
o Cardiovascular
o Neurologic
o Peripheral vascular
o Respiratory
Order of Vital Signs
1.
2.
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5.
Temperature
Pulse
Respirations
Blood pressure
TPR, B/P (Pain)
Body Temperature
Balance between internal and external environment of the body OR
Balance between the heat produced by the body and the heat lost from the
body.
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Two types of Body temperature
CORE Temperature: most accurate. Typically done w pulmonary
catheter
Temperature of deep tissues of the body
o e.g. cranium, thorax, abdominal cavity and pelvic cavity)
Relatively constant (37 °C/ 98 °F); Range 96.0-99.9°F
Average temp: Infant 99.4, 1yr = 99.7, 3yr = 99, 5yr = 98.6, 10 yr = 98.0
An accurate measurement is usually done using a pulmonary catheter.
SURFACE temperature:
—Temperature of the skin, subcutaneous tissues and fat
—Constantly rises and falls in relation to environment
Regulation of body temperature
Systems that regulate body temperature
o Sensors in skin and core
o Hypothalamus
*Infants cannot shiver. Their RR goes up*
NOTE: skin has more receptors for cold than warmth, it therefore detects
cold more efficiently than warmth
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Factors affecting heat production
BMR-basic metabolic rate
o Rate of energy utilization in body required to maintain
essential activities such as breathing, walking, speaking and
others.
o Metabolic rate decreases with age
Muscle Activity (walking, jogging, etc) à Increases metabolic rate
Thyroxine output (produced by thyroid):à increase in hormone, increases
rate of cellular metabolism
throughout body.
Chemical thermogenesis à the stimulation of heat production in the body
through increased cellular metabolism
Factors affecting Body temperature
Age:
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Infants greatly influenced by the temperature, cannot shiver
Elderly are extremely sensitive to environmental change due to
decreased thermoregulatory control
Diurnal variations (circadian rhythms):
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Body temp fluctuates throughout day, varying as much as 1.0 °C
between early morning and late afternoon
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Point of highest body temperature betw. 8pm -12 midnight.
Lowest point reached during sleep, betw. 4 - 6 am
Strenuous Exercise
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Hormones: women usually experience more hormone fluctuations
than men, progesterone secretion in women raises body temperature.
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Stress: epinephrine and norepinephrine increases metabolic activity
and heat production
Alteration in Body temperature
—Pyrexia, hyperpyrexia, hyperthermia or fever: increased body
temperature
à Febrile = fever
à Afebrile = without fever
à Hypothermia: low temp
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Rise in Temperature cause
Hyperthermia
o Viral or bacterial infections
o Malignancies
o Trauma
o Various blood, endocrine, immune disorders
Sites commonly used in assessing BT (body temp)
Oral – (most common)
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Axilla – (mostly used in infants and children)
Axilla – (mostly used in infants and children)
Rectal
Tympanic membrane
Types of Thermometer
Mercury in glass - rare
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(Oral thermometer shave a long, slender tips)
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(Rectal thermometers have a short, rounded tips)
Electronic/Digital thermometer
Temporal Artery thermometer
Temperature sensitive strip
Infrared thermometer
o Tympanic thermometer
Digital & Electronic Thermometers
-Insert the tip at the sublingual
fossa, position under tongue
-Let stay for up to 1 to 2 minutes,
tell the patient to close the mouth
-Digital thermometer: commonly
used in infants and children
(insert at axillary region)
-Mobile monitoring system,
Tympanic(ear) and Temporal
artery thermometers
*tympanic is inaccurate for children under 1*
Pulse Rate
—Wave of blood created by contraction of left ventricle of the heart
—Generally, pulse wave represents stroke volume output and compliance
Stroke volume output: amount of blood entering arteries with each
ventricular contraction (each beat).
Compliance: Ability of the arteries to contract and expand.
Adult at rest: Heart pumps 4 to 6 liters of blood per minute = cardiac
output
The cardiac output (CO): result of the stroke volume (SV) times the heart
rate (HR) per minute —
CO= SV x HR
*Note: in healthy people, the pulse reflects the heartbeat*
Factors affecting pulse rate
Age
Gender: After puberty male pulse rate is slightly lower than
female
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Exercise: Resting HR typically lower
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Fever: Pulse rate increases when metabolic rate increases
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Medications
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Hemorrhage:
◦loss of blood increases pulse rate
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Stress
Assessing the Pulse
Palpation or auscultation
◦2 middle fingers (for all, except apical)
Stethoscope
◦used in assessing apical pulse and fetal heart tones
Doppler ultrasound
◦Used for pulses that cannot be palpated
Assessing the pulse:
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1 time, assess for 60 seconds
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Next time: assess for 30 seconds (if regular, then x2)
o BUT, if Irregular c̀ ount for full 60 seconds ◦
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Note rate, rhythm and amplitude
o Thready, weak
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o Normal = strong, smooth
o Bounding
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Rate: KNOW THESE NORMS*
*Medulla oblongata and Pons =. Control center in the brain*
1. Chemoreceptors located centrally in medulla and peripherally in carotid
and aortic bodies
NOTE:
-These centers and receptors respond to changes in O2, CO2 and Hydrogen
concentration in arterial blood.
-Increased CO2 concentration in the blood triggers chemoreceptors,
thus stimulates respiration
o Tachycardia - (over 100 beats/ minute)
o Bradycardia – (60 beats/minute or less)
Rhythm: Pattern of beat and interval between beats
o Regular
o Irregular
o Amplitude
o Pulse strength
o Refers to force of blood with each beat.
—e.g. bounding/full; weak/thready; strong
Elasticity of the arterial wall
—Expansibility of arterial wall
—A healthy, normal artery feels straight, smooth, soft and pliable
—Elderly people often have inelastic arteries
◦feels rigid, hard, twisted or tortuous and irregular upon palpation
—Temporal
— Carotid
— Apical
—Brachial
—Radial (thumb)
—Femoral
—Apical pulse
—Popliteal (behind
knee)
—Posterior Tibialis
—Dorsalis pedis
Pulse sites
Posterior tibialis
Dorsalis pedis
Respiration
—The act of breathing
—Intake of oxygen and output of carbon dioxide
Types:
1. External respiration: interchange of O2 and CO2 between alveoli and
pulmonary blood
2. Internal respiration:
—Throughout body
—Interchange of gases between circulating blood and cells of body
tissues
Terms
—Inhalation or inspiration: Act of intake of air into lungs
—Exhalation or expiration: Act of breathing out of gases from lungs to
environment
—Ventilation: movement of air in and out of lungs
—Hyperventilation: —very deep and rapid
—Hypoventilation: very shallow respiration
Control Centers for Respiration
Respiratory Rate
Respiratory rate: Breaths per minute
—Count for 30 seconds
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Types:
o Eupnea- Normal Breathing (12-20)
o Bradypnea- Abnormally slow
o Tachypnea - Abnormally fast
o Apnea- cessation of breathing. Not breathing
Respiratory rhythm/ pattern
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Regularity of expiration and inspiration
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Assess for rate, rhythm and depth
Types:
o Regular
o Irregular
o Dyspnea- difficulty in breathing
o Orthopnea- ability to breathe easier in an upright position
o Eg. Obese patients prefer sitting upright due to weight
on lungs
Assessing Respiration
Normal breathing pattern is assessed when client is in resting mode.
Identify behavior, activities, or medication therapiesà Affects respiration
Identify any health problems
Watch them breathe!!
Respiratory depth
Watch movement of the chest
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Described as normal, deep or shallow
Deep respiration: large volume of air is inhaled and exhaled.
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Shallow respirations: involve the exchange of small volume of air
NOTE: During “normal” inspiration and expiration, an adult takes in about
500ml of air. This volume is called Tidal volume
BLOOD PRESSURE
Heart Sound
First Sound (lub):
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Occurs at beginning of ventricular systole.
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Caused by closure of tricuspid and mitral valves (atrioventricular)
Second Sound (dub):
• Marks beginning of ventricular diastole
• Caused by closure of aortic and pulmonary valves (semilunar)
Arterial Blood Pressure
Measure of pressure exerted by blood as it flows through arteries.
Two blood pressure measurements
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Systolic pressure:
Maximum pressure developed upon ejection of blood
from left into arteries. 1.
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Diastolic Pressure:
o Lowest pressure and is a measure of peripheral
resistance.
Variations in BP cuff
—Bladder is too narrow = BP reading elevated OR Too wide = BP reading
low
Variations in BP by Age
o
Unpleasant sensory and emotional experience which we primarily associate
with tissue damage or describe in terms of damage or both.
Definition: Acute Pain
Usually associated with a recent injury.
Definition: Chronic Nonmalignant
•Usually associated with a specific cause or injury and described as a
constant pain that persists for more than 6 months.
•Pain in 1 or more anatomic regions
•Persists or recurs for longer than 3 months
•Associated with significant emotional distress or significant functional
disability (interference with activities of daily life and participation in social
roles)
(Ex. Chronic back pain)
Definition: Cancer Pain
•Often due to the compression of peripheral nerves or meninges, or from
the damage to these structures following surgery, chemotherapy,
radiation, or tumor growth and infiltration.
Pain Descriptors
Cutaneous pain: skin or subcutaneous
Visceral pain: abdominal cavity
Deep somatic pain: ligaments, tendons, bones, blood vessels, nerves
Phantom pain: perceived in nerves left by a missing, amputated, or
paralyzed body part
Neuropathic pain: causes an abnormal processing of pain messages and
results from past damage to peripheral or central nerves
Intractable pain: high resistance to pain relief
Physiologic Responses to Pain
Seven Dimensions of Pain: Spiritual, Physical, Sensory, Behavioral,
Sociocultural, Cognitive, Affective
Factors affecting Pain:
•Age
•Socio-cultural values/ interpretations
•Emotional: anxiety, psychological, fatigue, depression
•Past experiences with pain
•Source and meaning
Pulse Oximetry
Noninvasive & Indirect method of measuring oxygen saturation in
the blood photodetector.
Pain
—Fifth vital sign
—Observe comfort level
*Pain is whatever your patient says it is*
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Definitions
Question
Is the following statement true or false?
An unpleasant sensory and emotional experience, which we primarily
associate with tissue damage, is termed pain.
True
Question
Which is an appropriate pain assessment tool for pediatric clients?
A. Verbal Descriptor Scale
B. Numeric Rating Scale
C. Visual Analog Scale
D. Faces Pain Scale
Definition: Pain
Psychosocial, Cognitive, and Moral Development
Growth and Development
•No single theory embraces all aspects of why humans behave, think,
or believe the way they do.
•Growth: Addition of new skills or components
•Development: Refinement, expansion, or improvement of existing skills or
components
Psychosocial development:
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Mental and emotional heakth
Role development
Stress
Self-Concept
Coping patterns
Spiritual beliefs
Relationships
Psychosocial development:
Freud
concept of formal operations)
Oral:
Anal:
Phallic: discovering their bodies
Latency: period of waiting before puberty.
Genital: Puberty
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ERICKSON Theory of Psychosocial Development
Involves intrapersonal and interpersonal response to external events
Societal, cultural, historical factors, and biophysical processes and
cognitive function influence personality development
Each stage has central developmental task corresponding to
biophysical maturity and societal expectations.
If individual resolves challenge in favor of more positive viewpoint,
has achieved positive resolution of development task
Erikson Theory of Psychosocial Development
STAGE 1: Infant -Basic trust vs mistrust
Ex.
STAGE 2: Toddler-Autonomy vs. shame and doubt
Ex. A parent allows their child to pick out their own clothes to wear to
preschool-even if clothes are mismatched
STAGE 3: Preschooler Initiative vs guilt (“Am I good or bad?”)
Ex.
STAGE 4: School-age- Industry vs. inferiority
Ex.
STAGE 5: Adolescent Identity vs role confusion
Ex.
STAGE 6: Young Adult Intimacy vs isolation
Ex.
STAGE 7: Middle Adult Generativity vs stagnation
Ex.
STAGE 8: Older Adult Ego integrity vs despair
Ex.
Psychosocial Development
PIAGET
•Genetic epistemologist
•Focused on how person learns, not what person learns
•Acknowledged interrelationships of physical maturity, social interaction,
environmental stimulation, and experience in general
Major concepts:
•Schema
•Assimilation
•Accommodation
•Equilibration
Piaget’s Stages of Cognitive Development
• Sensorimotor
• Substages: 1, 2, 3, 4, 5, 6
• Preoperational
o Substages: preconceptual, intuitive
• Concrete operational
• Formal operational
KOHLBERG’S Theory of Moral Development
Psychosocial development
Preconventional (premoral)
Conventional (maintain external expectations of others)
Postconventional (maintain internal principles of self—Piaget’s
Health Assessment
History of Present Health Concerns
•Current feelings and concerns about health
•Concerns about self image
•Stressors
•Do you have trouble making decisions?
•Tell me about life changes you have needed or will make?
Health Assessment
Personal Health History
o How would you describe yourself?
o What are your strengths and weaknesses?
o How do you learn?
o Have you been treated for a psychological or psychiatric problem
o Tell me about herbs, OTC, or medications you take?
o Alternative treatments
o Describe any changes you have made concerning your health?
o Describe any chronic illness diagnosed and how has your life changed?
Health Assessment
Family History
o Who is family?
o Describe your life growing up?
o Describe your brothers and sisters and your relationship with them?
o Discuss any genetic predisposition or characteristic trait of a disorder
that you may have inherited?
Lifestyle and Health Practices
o General routine screening versus focused specialty assessment
o Do they have access to adequate nutrition?
Health Assessment
Validation and Documentation of Findings
• Is data accurate and reliable
• Describe the client’s response versus labels. JUST PUT WHAT THEY SAY
• Follow health care facility or agency policy
Assessing Development of Older Adults
Eriksonian tasks for older adults
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Embrace realistically reviewing and viewing life
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Recognizing errors and poor choices
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Learning from past experiences what strengths one has
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Acknowledging accomplishments and developing new wisdom
Piaget tasks for older adults
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Described the use of formal operations as helpful in anticipating and
negotiating the declining of physical and possible cognitive abilities
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Older adults suffer multiple losses and must problem-solve about
possible increased dependency, decreased choices, and impending
death
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Death is seen by the formal operational thinker as universal,
inevitable, and irreversible.
Kohlberg tasks for older adults
• Professed that those who had attained his sixth stage of personal
principles make use of self-evaluation, self-motivation, and self- regulation,
meeting expectations of their ego ideal
• Believed that the person operating at the universal principal stage is
aware of their “reason for existence”
Health Assessment
• Analysis of Data
• Identify abnormal finding
• Identify client’s strengths
• Possible Nursing conclusions
• Wellness Diagnoses
• Readiness for self-health management....
• Readiness for enhanced family process
• Readiness for enhanced knowledge
• Risk Diagnoses
• Risk for disturbed personal identity àself-directed violence r/t
depression etc.
• Risk for developmental delay r/t lack of stimulating environment
Health Assessment
• Possible Nursing conclusions
Actual Diagnoses
o Anxiety
o Disturbed body image
o Dysfunctional family processes
o Ineffective coping
o Moral distress
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Collaborative Problems
Medical Problems
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Psychiatric Diagnoses
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Others
Assessing for Violence
Theories of Family Violence #1
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Violence: The use of physical force to harm someone, to damage
property, etc
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Aggression: a forceful action or procedure (as an unprovoked
attack), especially when intended to dominate or master
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Violence and aggression both have positive and negative
connotations:
o Positive: self-defense, war, getting ahead
o Negative: murder, torture, hate, against cultural norm
Forms of abuse: psychological, sexual assault, progressive isolation,
stalking, deprivation, intimidation, reproduction coercion
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Happens to millions of women regardless of age, economic status,
race, religion, ethnicity, sexual orientation, educational background
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Males also victims, often not believed, similar effects, fewer choices for
help
Not limited to heterosexual couples
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Theories of Family Violence #2
Categories of Family Violence #2
1. Domestic violence theories (McCue, 2008)
Psychopathology therapy: personality disorder
Social learning theory: learned behavior
Biologic theory: experienced child trauma
Family systems theory: violence growing through/around family function
Feminist theory: inequality
Child Abuse
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“Any recent act or failure to act on the part of a parent or
caretaker which results in death, serious physical or emotional
harm, sexual abuse or exploitation” or “an act or failure to act
that presents an imminent risk of serious harm”
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May be commission or omission but rarely isolated incident
2. Walker’s Cycle of Violence (1979, 1984)
Predictable pattern
Stage I - Tension Building Phase
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Possessive, jealous, separates victim from others
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Criticism
Stage 2 - Acute Battering
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Victim blames self
Stage 3 - Honeymoon or Hearts and Flowers
Categories: neglect, emotional abuse, sexual abuse, physical abuse
Long-term consequences: physical, psychological, behavioral, societal
3.
4.
Categories of Family Violence #3
CHILD ABUSE
Tension Building/Explosion Model
Cycle of Domestic Violence Model
Types of Family Violence
Physical Abuse
Psychological Abuse
Economic Abuse
Sexual Abuse
Can be misinterpreted as bruising for certain racial groups
Prevalence of Family Violence
Women: 1 out of every 4
Men: 1 out of 7 men experience physical violence
Categories of Family Violence #1
Intimate partner violence (IPV)
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“Physical, sexual, or psychological harm by a current or former partner
or spouse”
Categories of Family Violence #4
Elder mistreatment
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Includes neglect, physical abuse, sexual abuse, financial abuse,
psychological abuse, exploitation, abandonment, prejudicial attitudes that
decrease quality of life and are demeaning
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May be commission but frequently omission
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Consequences involve physical and psychological effects
Assessment challenges: fear, mistrust, difficult to spot
Elder Abuse Suspicion Index (EASI) (Assessment Tool 10-1)
Categories of Family Violence #5
Effect of immigration status on abuse
Various acts that are considered IPV in one culture, may be accepted
as norm in another culture
Stresses experienced in relocating to different country increases
family stresses and can lead to violence
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STEP 2: Assess mental status
STEP 3: Evaluate vital signs
STEP 4: Inspect skin
STEP 5: Inspect the head and neck
Categories of Family Violence #6
Domestic shelters and crisis hotlines
Most U.S. communities have safe houses and crisis hotlines.
The Family Violence Prevention and Services Improvement Act of 2019
Other Types of Violence
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Human trafficking
Complex issue that takes many forms
Sex trafficking
Involuntary servitude, peonage, debt bondage, slavery
Third largest international crime industry worldwide
Recognizing the signs (see Box 10-2)
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War crimes
Some immigrants in the United States may be victims of war crimes.
Complex issue
Client’s showing signs of PTSD may not answer questions.
Referral to appropriate health care provider essential.
Various tools available to assist
Nursing Assessment of Family Violence
Collecting objective data: Physical examination
Preparing the client
Equipment
Physical assessment
Provide privacy
Keep your hands warm
Remain nonjudgmental
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Assessment of Victims
Screen at each visit
Pregnant women more often (HIGHER RISK)
o Monitor for IPV risk factors
Sexual abuse requires special care
SAFE Nurses
Physical Examination to Assess Abuse
STEP 1: Perform a general survey
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Developmental delays in children
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Poor hygiene and soiled clothing may indicate neglect
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Clothing that covers scars, bruises or may dress provocatively
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Hypertension or other signs of stress
Assessing a Safety Plan #1
Ask the client, Do you:
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Have a packed bag ready? Keep it hidden but make it easy to grab
quickly?
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Tell your neighbors about your abuse and ask them to call the police
when they hear a disturbance?
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Have a code word to use with your kids, family, and friends? They will
know to call the police and get you help?
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Know where you are going to go if you ever have to leave?
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Remove weapons from the home?
Assessing a Safety Plan #2
Have the following gathered:
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Cash, Social Security cards/numbers for you and your children, birth
certificates for you and your children
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Driver’s license, rent and utility receipts, bank account numbers
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Insurance policies and numbers, marriage license, jewelry
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Important phone numbers, copy of protection order
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Validating and Documenting Findings
Validate any violence data collected, photos, descriptions
Only use words provided by client
Do not fill in blanks based on what you think happened
Legal documents
Always be objective
Follow health care facility or agency policy
Analysis of Data to Make Clinical Judgments #1
After collecting data, identify abnormal findings and client strengths
Cluster data to reveal any significant patterns or abnormalities
Data use to make clinical judgements about status of family violence
in client’s life
Selected Client Concerns
Opportunity to improve health
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Example: opportunity to improve family safety: requests information
about safety from family violence
Risk for Client Concerns
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List various risks identified from data.
Actual Client Concerns
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Identify concerns the client expressed while collecting data.
QUESTION
Which suggests physical abuse?
A. Threatening to hurt children or pets
B. Using restraints on a victim
C. Preventing the victim from getting a job
D. Using violence during sex
*D is a sexual abuse, not physical abuse*
QUESTION
Is the following statement true or false?
Social learning theory states that violence is an innate characteristic of
humans, based on neurophysiological states.
FALSEQUESTION
Is the following statement true or false?
Abused children may appear younger than stated age.
True
– The relationship of income and obesity has been established, but the
association of obesity and income has been shown by Ogden et al. (2007)
to vary with gender, age, and race or ethnicity. association of obesity and
income has been shown by Ogden et al. (2007) to vary with gender, age,
and race or ethnicity.
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Assessing Nutritional Status
Factors Involved in Nutrition
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Healthy diet = 55%-to-60% carbohydrates w/ 75% of those as complex
carbohydrates
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Diseases, disorders, or lifestyle behaviors
o place clients at risk for undernutrition or malnutrition
o can exacerbate or facilitate disease processes.
– Increased caloric consumption, food high in fat and sugar, & decreased
energy expenditure = near-epidemic obesity.
– Approximately 2/3 of adult population in USA is overweight and nearly
1/3 of this group (35.7% or 78 million people) is obese.
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Risk Factors for Nutrition Disorders and Disease
Lower SES - making nutritious foods unaffordable
Lifestyle - Long work hours and obtaining one or more meals from a
fast-food chain or vending machine
Poor food choices by children, teens, and adults, including fatty or
fried meats, sugary foods, and few fruits and vegetables
Chronic dieting, particularly with fad diets (teens), to meet perceived
societal norms for weight and appearance
Risk Factors for Nutrition Disorders and Disease (Continued)
Chronic diseases (e.g., Crohn’s disease, cirrhosis, or cancer) that
may interfere with absorption or use of nutrients
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Dental and other factors such as difficulty chewing, loss of taste
sensation, depression
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Limited access to sufficient food regardless of socioeconomic status
such as being physically unable to shop, cook, or feed one’s self such
as being physically unable to shop, cook, or feed one’s self
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Disorders whereby food is self-limited or refused (e.g., anorexia
nervosa, bulimia, depression, dementia, or other psychiatric disorders)
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Physical Assessment
Overall appearance
Body build
o Ectomorph (underweight)
o Mesomorph (normal)
o Endomorph (overweight)
Muscle mass
Fat distribution
Physical Assessment: Equipment
– Balance beam scale with height attachment
– Metric measuring tape
– Marking pencil
– Skin calipers (will not use in lab)
Anthropometric Measurements
(can also be found in Lippincott Procedures)
– Height and weight
– Body mass index (BMI)
– Waist circumference
– Mid-arm circumference
– Triceps skin-fold thickness
– Mid-arm muscle circumference
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Importance of Anthropometric Measurements
Body mass index: Estimate total body fat
Waist circumference: Determine extent of abdominal visceral fat in
relation to body fat
Mid-arm circumference: Assess skeletal muscle mass
Triceps skin fold: Evaluate subcutaneous fat stores
Mid-arm muscle circumference: Evaluate muscle reserve
Body Mass Index & Ideal Body Weight *KNOW THIS*
Interview for Nutritional and Hydration History
Nutritional screening tools
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24-hour food recall (p.219)
Collection of subjective data: The nursing health history
– History of present health concern
– Personal health history
– Family history
– Lifestyle and health practices
Cultural Considerations
– As noted, approximately 1/3 of the adult population in the United
States (35.7% or 78 million people) is obese, according to data
from the Centers for Disease Control and Prevention (2012b).
– Healthy People 2020 (2012) reviews studies on prevalence of obesity in
the United States.
– Flegal et al. (2010) report that among U.S. adults, the obesity prevalence
is highest for middle-aged people, and especially for non-Hispanic black
and Mexican American women.
– In addition, approximately 17% (12.5 million) children in the United
States between 2 and 19 years of age are obese.
– The obesity prevalence in children and adolescents is reported
by Ogden et al. (2010), to be highest among older and Mexican
American children and non-Hispanic black girls.
Exam will include weight and height. We calc BMI. Determine if ideal
weight, underweight, malnourished, or overweight.
Height and Weight Changes With Aging
– Wane in fifth decade because the intervertebral discs become
thinner and spinal kyphosis increases.
– Body weight may decrease with aging because of a loss of muscle or lean
body tissues.
Hydration Assessment
– Weight
– Skin turgor
– Pitting edema
– Skin for moisture
– Venous filling
– Neck veins in supine position with head elevated 45 degrees
– Tongue
– Eyeball palpation
– Eye position
– Lung sounds
– Blood pressure
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Factors Affecting Hydration
Exposure to excessively high environmental temperature
Inability to access adequate fluids, especially water
Excess intake alcohol or other diuretic fluids
Taking diuretic medications
Excess intake alcohol or other diuretic fluids
Taking diuretic medications
Impaired thirst mechanisms
High fevers
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Overhydration Signs and Symptoms
Weight gain of 6–10 pounds in a week
Pitting edema
Visible neck veins
Crackling lung sounds
Elevated pulse rate and blood pressure
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Dehydration Signs and Symptoms
Weight loss of 6–10 pounds in one week
Tenting
Flat veins in supine client
Tongue is dry
Sunken eyeballs
Blood pressure decreased with elevated pulse rate
Question
Is the following statement true or false?
Waist circumference is the most common measurement used to determine
the extent of abdominal visceral fat in relation to body fat.
Answer True.
Question
Is the following statement true or false?
Dehydration in a healthy person is usually not a problem because the body
is effective in maintaining a correct fluid balance.
Answer False.
In the case of overhydration in a healthy person, the body is effective in
maintaining a correct fluid balance.
Mental Status Exam
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MENTAL HEALTH AND MENTAL DISORDERS #1
Mental status refers to level of cognitive functioning (thinking,
knowledge, problem solving) and emotional functioning (feelings,
mood, behaviors, stability).
Mental health part of one’s total health ¡World Health Organization
defined
Health is a state of complete physical, mental, and social well- being
and not merely the absence of disease or infirmity.”
Mental health: “A state of well-being in which an individual realizes his
or her own abilities, can cope with the normal stresses of life, can
work productively and is able to make a contribution to his or her
community.”
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MENTAL HEALTH AND MENTAL DISORDER #2
American Psychiatric Association: “Any condition characterized
by cognitive and emotional disturbances, abnormal behaviors,
impaired functioning, or any combination of these.”
Multiple components contribute to disorders: environmental,
psychological, genetic, chemical, social, or other factors.
May also be called: mental illness, psychiatric disorders,
psychiatric illness, psychological disorder
May affect other body systems
FACTORS AFFECTING MENTAL HEALTH
Economic and social factors
Personality factors
Changes or impairments in the structure and function of the
neurologic system
Unhealthy lifestyle choices
Spiritual factors
Psychosocial developmental level and issues
Exposure to violence
Cultural factors
RISK FACTORS FOR MENTAL HEALTH DISORDERS AND SUBSTANCE ABUSE
GOAL OF PREVENTION
Change the balance between risk and protective factors so that
protective factors outweigh risk factors.
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HEALTH ASSESSMENT
Subjective data
Geriatric considerations
Explain purpose of questions
Validate data
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COLLECTING SUBJECTIVE DATA: THE NURSING HEALTH HISTORY #1
Essential assessment areas for mental health:
Appearance
General behavior
Cognitive function
Memory
Thought processes
Use appropriate questionnaires or tests
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PERSONAL HEALTH HISTORY
Past medical history of mental health problem, counseling
Head injury, meningitis, encephalitis, stroke
Headaches
Served in armed services
Trouble breathing or heart palpitations
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LIFESTYLE AND HEALTH PRACTICES
OTC, alcohol, Substance Abuse
Caffeinated beverages
OTC or Prescribed medications?
Do you drink Alcohol?
CAGE (substance abuse screening tool)
AUDIT
o (Alcohol Use Disorders Identification Test)
¡Alcohol consumption, drinking behaviors, and alcohol-related
problems.
What type?, How much?, How often? Last drink? ¡Use of recreational
drugs?
Anxiety?
Depression?
Thoughts of Suicide?
MENTAL STATUS EXAM
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Can be performed with a complete neurological exam ¡Assess
highest level of cerebral integration
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Nurse can do independently
Gain insight into validity of subjective information
Might have to have secondary source
Check vision and hearing first to not interfere with the
assessment!
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COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION #1
Prepare the client
Equipment: Pencil and paper
Tools
o Glasgow Coma Scale
o PHQ-2
o PHQ-9
o Depression Questionnaire
o Self-Report Depression Questionnaire
o Columbia Suicide Severity Rating Scale (C-SSRS)
o Columbia Suicide Severity Rating Scale (C-SSRS)
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COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION #2
SAD PERSONS Suicide Risk Assessment Tool
Primary care posttraumatic stress disorder (PTSD)
St. Louis University Mental Status (SLUMS) Assessment Tool
SBIRT (Screening Brief Intervention and Referral to Treatment)
CAGE questionnaire
The Alcohol Use Disorders Identification Test (AUDIT)
Clinical Institute Withdrawal Assessment Scale
COMPONENTS OF THE MENTAL STATUS EXAM
A .......Appearance
B .......Behavior
C .......Cognition
T .......Thought processes
COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION
Level of consciousness and mental status
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Level of consciousness
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Alert and oriented
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¡x 3 (person, place, time) , or x4 (person, place, time,
situation)
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Posture, gait, body movements
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Behavior and affect
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Dress and grooming
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Hygiene
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Facial expressions
o Eye contact
o Affect: expression of emotion or feelings displayed to
others through facial expressions, hand gestures, voice
tone, and other emotional signs such as laughter or
tears. (flat affect= no expression)
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Speech
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Mood, feelings, and expressions
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Thought processes and perceptions
LEVEL OF CONSCIOUSNESS
TERMS used to describe
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Lethargy - falls back asleep
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Obtunded - slow, confused,
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Stupor - awakes if shaken or painful stimuli
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Coma - remains unresponsive
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Decorticate -hands to chest, legs internally rotated
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Decerebrate - pronated, extended
COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION #4
COGNITION
Orientation (person, place, time, circumstance) H
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̀ our, day , date,
season, place
Attention
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Concentration :Ability to stay focused, Follow directions, stay on
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task
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Memory
o Recent and remote
o Use of memory to learn new things, (remembering
words, your name)
Judgment
o What would you do if?
Visual, Perceptual, and Constructional Ability
¡SLUMS Dementia/Alzheimer test examination
Thought
o Delusions/Hallucinations
o Grandiose/Depression
o Hopelessness
o Obsessions/Compulsions
Speech
o Tone, clarity, pace; Mood, feelings and expressions
o Abstract reasoning
SLUMS (ST. LOUIS UNIVERSITY MENTAL STATUS)
A score of 27 to 30 for clients with a high school education and a
score of 25 to 30 for clients with less than a high school
education is considered normal.
For clients with a high school education, a score of 21 to 26
indicates mild neurocognitive disorder (MNCD); for clients with
less than a high school education, a score of 20 to 24 indicates
MNCD.
For clients with a high school education, a score of 1 to 20
indicates dementia; for clients with less than a high school
education, a score of 1 to 19 indicates dementia.
MINI MENTAL STATUS EXAM SLUMS
=looks at orientation to time and place and ability to follow commands
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GLASGOW COMA SCALE
Eye opening response
Most appropriate verbal response
Most integral motor response (arm)
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DEPRESSION QUESTIONNAIRE
Falling asleep
Sleeping too much
Decreased or increased weight
Sleep during the night
Feeling sad
Waking up too early
Decreased or increased appetite
Concentration/Decision Making
View of Oneself
Thoughts of Death or Suicide
General interest
Energy Level
Feeling slowed down
Feeling restless
*SAD PERSONS SUICIDE RISK TOOL (SUICIDE ASSESSMENT)
=Tool used to assess have you experienced depression? Still rationalizing?
Social support? Do they have a plan?
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Sex
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Age
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Depression
Previous attempt
Ethanol abuse
Rational thinking loss
Social supports lacking
Organized plan
No spouse
Availability of lethal means
Sickness
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CAGE SELF ASSESSMENT TOOL (ALCOHOL)
Have you ever tried to cut back on your use?
Have you ever been annoyed/angered when questioned about
your use?
Have you ever felt guilt about your use?
Have you ever had an eye-opened to get started in the morning?
SCORING: One “yes” suggests a possible alcohol problem. More
than one “yes” means it is highly likely the problem exists.
ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT)
How often do you have a drink containing alcohol?
How many drinks containing alcohol do you have on a typical day
when you are drinking?
How often do you have six or more drinks on one occasion?
How often during the last year have you found that you were not
able to stop drinking once you had started?
CULTURE
How often during the last year have you failed to do what was
normally expected from you because of drinking?
How often during the last year have you needed a first drink in the
morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or
remorse after drinking?
How often during the last year have you been unable to remember
what happened the night before because you had been drinking?
Have you or someone else been injured as a result of your drinking?
Has a relative or friend or a doctor or another health worker been
concerned about your drinking or suggested you cut down?
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WARNING SIGNS OF ALZHEIMER’S DISEASE SEE ASSESSMENT TOOL 6-6
Asking: Asking the same questions over and over again
Repeating: Repeating the same story; word for word, again and again
Forgetting: Forgetting how to cook, or how to make repairs, or how to do
activities previously done with ease
Losing: Losing one’s ability to pay bills or balance one’s checkbook
Getting: Getting lost in familiar surroundings, or misplacing household
objects
Neglecting: Neglecting to bath or wearing the same clothes
Relying: Relying on someone else such as a spouse to make decision or
answer questions
Assessing Culture
CONCEPTS AND TERMS RELATED TO CULTURE #2
Cultural diversity: coexistence of a difference in behavior, traditions,
and customs
Cultural imposition: intrusive application of majority group’s cultural
view upon individuals and families
Cultural relativism: belief that behaviors and practices of people
should be judged only from context of their cultural system
Enculturation: natural conscious and unconscious conditioning
process of learning accepted cultural norms, values, and roles in
society and achieving competence in one’s culture through
socialization
Defined: Purnell and Paulanka:
“the totality of socially transmitted behavioral patterns, arts, beliefs, values,
customs, lifeways, and all other products of human work and thought
characteristic of a population or people that guide their worldview and
decision making.” Beliefs that guide behaviors.
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Many cultural groups are found in the United States.
U.S. Census categories: White, Black or African American; American
Indian or Alaska Native; Asian; Native Hawaiian and other Pacific Islanders;
Other
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CONCEPTUAL FOUNDATIONS #2
Culture affects every aspect of life Acculturative stress:
adaptation to a new cultural environment
Acculturation process affects values, behaviors, beliefs, attitudes, language,
and much more.
CONCEPTS AND TERMS RELATED TO CULTURE #3
Ethnicity: socially, culturally, and politically constructed group that
holds in common a set of characteristics not shared by others with whom
members of the group come into contact
Ethnocentrism: universal tendency of humans to think their ways or
thinking, acting, and believing are the only right, proper, and natural
waysà “my way or the highway”
Stereotyping: oversimplified conception, opinion, or belief about an aspect
of an individual or group
Subculture: group of people with a culture that differentiates them from
the larger culture of which they are a part
Worldview: way individuals or groups look at universe to form basic
assumptions and values
CONCEPTUAL FOUNDATIONS #3
Why nurses need to know about culture:
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Interact with many different clients every day
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Each have their own beliefs about illness and health, when and from
whom to seek care, who makes decisions concerning health care
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Never assume someone shares the same beliefs as you
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Long history of health care disparity toward certain groups
CONCEPTS AND TERMS RELATED TO CULTURE #1
Culture is learned, shared, associated with adaptation to environment,
universal
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Values: learned beliefs about what is held to be good or bad
Norms: learned behaviors that are perceived to be appropriate or
inappropriate
Acculturation: the circumstance when person gives up the traits of
their culture of origin as a result of context with another culture, to
variable degrees
Assimilation: gradual adoption and incorporation of characteristics of
the prevailing culture
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CULTURAL COMPETENCE
Nurses must know what is normal and abnormal to provide highlevel health care.
Cultural assessment part of health assessment
Cultural competence process:
Cultural awareness
Cultural skill
Cultural knowledge
Cultural encounters
Cultural desire
CULTURAL COMPETENCE #3
Contexts for assessment:
Family structure and function
2.
3.
4.
5.
Spirituality and religion and community
Serves as context for growth and development
Health and illness
Health care delivery
NATIONAL STANDARDS FOR CARE #1
Standard 1: “Provide effective, equitable, understandable and
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respectful quality care and services that are responsive to diverse cultural
health beliefs and practices, preferred languages, health literacy and other
communication needs.”
Standards 2, 3, and 4 refer to governance, leadership, and workforce.
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Standards 5 through 8 refer to communication and language
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assistance.
Standards 9 through 14 refer to engagement, continuous
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improvement, and accountability.
Standard 15 concerns the organization’s progress in implementing and
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sustaining the other standards.
o Application of standards is recommended, and voluntary
acceptance by health care organizations is strongly urged.
o Federal funds distribution depends on adherence to
standards. Level of voluntary acceptance is more a mandate.
o Individuals who work within health care systems are
expected to follow these standards as well.
NATIONAL STANDARDS FOR CULTURALLY AND LINGUISTICALLY
APPROPRIATE SERVICES IN HEALTH CARE
Standard 1: Ensure that
patients/consumers receive from all
staff members effective,
understandable, and respectful care
that is provided in a manner
compatible with their cultural
health beliefs and practices and
preferred language.
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Standard 7: Make available easily
understood patient-related materials and
post signage in the languages of the
commonly encountered groups and/or
groups represented in the service area.
Standard 8: Develop, implement, and
promote a written strategic plan that
outlines clear goals, policies, operational
plans, and management
accountability/oversight mechanisms to
provide culturally and linguistically
appropriate services.
Standard 13: Ensure that conflict and
grievance resolution processes are
culturally and linguistically sensitive
and capable of identifying,
preventing, and resolving crosscultural conflicts or complaints by
patients/consumers.
Standard 14: Regularly make
available to the public information
about their progress and successful
innovations in implementing the CLAS
standards and provide public notice in
their communities about the
availability of this information.
Compare & Contrast client’s beliefs and practices to standard Western
health care
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Assess client’s health relative to diseases prevalent in the specific
cultural group.
Standard 2: Implement strategies to
recruit, retain, and promote, at all
levels of the organization, a diverse
staff and leadership that are
representative of the demographic
characteristics of the service area.
Standard 6: Assure the competence of
language assistance provided to limited
English-proficient patients/consumers by
interpreters and bilingual staff. Family and
friends should not be used to provide
interpretation services (except on request
by the patient/consumer).
Standard 12: Develop participatory,
collaborative partnerships with
communities and utilize a variety of
formal and informal mechanisms to
facilitate community and
patient/consumer involvement in
designing and implementing CLASrelated activities.
PURPOSES FOR ASSESSING CULTURE
Learn: about client’s belieds and usual behaviors associated with health
and illness, including disease causes, caregiving, expected treatments (both
Western medicine and folk practice) daily hygiene, food preferences and
rituals, religious beliefs relative to health care
FACTORS AFFECTING APPROACH TO PROVIDERS
Standard 3: Ensure that staff at all levels and across all disciplines
receive ongoing education and training in culturally and linguistically
appropriate service delivery.
Standard 4: Offer and provide language assistance services, including
bilingual staff and interpreter services, at no cost to each
patient/consumer with limited English proficiency at all points of
contact, in a timely manner during all hours of operation. =
interpreter, iPad, NO children if possible
Standard 5: Provide to
patients/consumers in their preferred
language both verbal offers and written
notices informing them of their right to
receive language assistance services.
Standard 11: Maintain a current
demographic, cultural, and
epidemiologic profile of the
community, as well as, a needs
assessment to accurately plan for and
implement services that respond to
the cultural and linguistic
characteristics of the service area.
Ethnicity
Generational status
Education
Religion
Previous health care
experiences
Occupation and
income level
Beliefs about time
and space
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Communication
needs/preferences
FACTORS THAT AFFECT DISEASE, ILLNESS, AND HEALTH STATE
Biomedical Variations
Family roles and organization, pattenrs
High-risk behaviors
Nutrition/dietary habits
Workforce issues
Pregnancy and childbirth practices
Death rituals
Religious and spiritual beliefs and practices
Health care practitioners
Environment
FACTORS AFFECTING DISEASE, ILLNESS, HEALTH STATE #3
Standard 9: Conduct initial and ongoing
organizational self-assessments of CLASrelated activities and integrate cultural and
linguistic competence-related measures into
internal audits, performance improvement
programs, patient satisfaction assessments,
and outcomes-based evaluations.
Standard 10: Ensure that data on the
individual patient’s/consumer’s race,
ethnicity, and spoken and written language
are collected in health records, integrated
into the organization’s management
information systems, and periodically
updated.
Culture-bound syndromes
• Conditions perceived to exist in various
cultures and occur as combination of
psychiatric or psychological and physical
symptoms
• See Table 11-2
Culture-based treatments
• Often misinterpreted in Western health
care settings
• Examples: cupping, coining,
moxibustion, imbalance of hot/cold,
yin/yang
• Some cultures see some standard
Western treatments as unacceptable.
MODIFICATIONS TO BE CONSIDERED FOR A CULTURALLY COMPETENT
INTERVIEW (SAME AS NU205)
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Communication
o Time
o Space
o Eye contact and face positioning
o Body language and hand gestures
o Silence
o Touch
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CULTURAL HEALTH ASSESSMENT
Skin, hair, nails
Head and neck
Eyes
Ears
Mouth, nose, sinuses
Thorax and lungs
Breasts and lymphatic system
Heart and neck vessels
Peripheral vascular system
Abdomen
Peripheral vascular system Abdomen
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Genitalia, anus, rectum, prostate Musculoskeletal system
Nervous system
VALIDATING AND DOCUMENTING FINDINGS
QUESTION
What is the verbal and behavioral system of culture, when it is transmitted
from one generation to the other?
a. Culture is learned
b. Culture is shared
c. Culture is adapted
d. Culture is universal
QUESTION
Is the following statement true or false?
Conscious incompetence: Aware that one lacks knowledge about another
culture; aware that cultural differences exist but not knowing what they are
or how to communicate effectively with clients from different cultures
Answer: True
Assessing Spirituality and Religious Practices
CONCEPTUAL FOUNDATIONS #1
Spirituality and religion important factors in health
Influence health decisions, lifestyle practices, dietary practices, end-oflife decisions, and many other elements of health care
Need to have an understanding of both
CONCEPTUAL FOUNDATIONS #2
Recent polls suggest decline in religious practice and belief in God or higher spirit in the United States.
SPIRITUALITY
• Definition: A search for meaning and purpose in life
• Seeks to understand life’s ultimate questions in relation to the sacred
• Defining Characteristics
o Informal
o Nonorganized
o Self-reflection
•May involve spiritual experiences •Subjective (difficult to consistently
measure)
SPIRITUAL ASSESSMENT
Active and ongoing conversation that assesses the spiritual needs of
the client
Pew Research Center (2018): 9 of 10 Americans believe in higher power.
Only slightly more than half believe in God described in Bible.
More than 55% say pray on daily basis.
Substantial portion of unaffiliated say believe in God or universal spirit, 42% neither religious or spiritual,
18% are religious, 37% said spiritual but not religious (Pew Research Center, 2012).
DEFINITION OF RELIGION
Rituals, practices, and experiences involving a search for
the sacred
Shared within a group
Some faiths, this idea of religion encompasses the concept
of spirituality and is a natural outflow of that idea
Others may view spirituality as a separate concept,
possibly disconnected from any religious institution
RELIGION
• Defining characteristics:
o Formal
o Organized
o Group-oriented
o Ritualistic
o Objective (church attendance)
SPIRITUAL ASSESSMENT: CHARACTERISTICS
Formal or informal
Respectful
Nonbiased
SPIRITUAL CARE
Addressing the spiritual needs of the client as they unfold through spiritual
assessment
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SPIRITUAL CARE: CHARACTERISTICS
Individualistic
Client oriented
Collaborative
IMPACT OF RELIGION AND SPIRITUALITY ON HEALTH
•Use of spiritual resources during times of high stress
•Relate to client’s well-being during chronic disease management and
ability to adhere to medical regimens
•Powerful coping mechanisms
•Spiritual practices have potential to encourage greater mental and
physical health.
•Religious beliefs can express wide variety of values and practices or
negatively affect health (see Table 12-1).
•Notify supervising staff member or ethics committee if religious or
spiritual views have potential to compromise adequate nursing care.
INCORPORATING RELIGION AND SPIRITUALITY INTO CARE
•Modern nursing theorists have used spirituality as major determinant
in grand theories that guide nursing practice.
•Provide time of silence
•Collaboration and referral to pastoral chaplains or clergy •Community
resources of different faiths
•Some needs may be outside scope of nursing practice and require
someone with more experience and knowledge about a particular faith.
•Nurse should always be respectful, open, and willing to discuss spiritual
issues; avoid conveying judgmental attitude.
SPIRITUAL ASSESSMENT: TOOLS
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FICA
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F: Faith and Belief
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I: Importance
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C: Community
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A: Address in care
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Self-Assessment: Brief Religious Coping Questionnaire (RCOPE)
SPIRITUAL ASSESSMENT: PROCEDURE
TECHNIQUES OF SPIRITUAL ASSESSMENT •Non-formal technique
• S – Spiritual belief system
• P – Personal spirituality
• I – Integration with a spiritual community
• R – Ritualized practices and restrictions •I – Implications for medical care
• T – Terminal events planning
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SPIRITUAL ASSESSMENT TOOL
Explore: Explore the clients religious and spiritual background
Observe: Observe nonverbal and verbal communication patterns in
the presence of others
Focus: Daily spiritual experience
Brief religious coping questionnaire
SPIRITUAL BELIEFS
• In whatever form spirituality is incorporated into client care, the nurse
Steps of Validation
should be respectful, open, and willing to discuss spiritual issues if seen as
appropriate.
• Avoid conveying a judgmental attitude toward client’s spiritual beliefs
and religious practices.
• Useful to define the concepts of religion and spirituality as
interconnected but separate ideas.
•Religion is defined as the rituals, practices, and experiences shared within
a group that involve a search for the sacred.
•Spirituality is defined as a search for meaning and purpose in life; it seeks
to understand life’s ultimate questions in relation to the sacred.
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ANALYSIS OF DATA TO MAKE CLINICAL JUDGMENTS
Selected client concerns
Selected collaborative problems
Medical problems
VALIDATING AND DOCUMENTING FINDINGS
Health promotion diagnoses
Risk diagnoses
Actual diagnoses
Collaborative problems
Medical problems
QUESTION
Which characteristic defines religion?
A. Informal
B. Ritualistic
C. Non-organized
D. Subjective
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Health care agencies developed assessment documentation policies
and procedures.
Categories of information within EHR designed to ensure nurse
gathers pertinent information
Categories of information within EHR designed to ensure nurse
gathers pertinent information
*Remember, if it’s not documented, it didn’t happen!*
Data Requiring Validation
When to validate?
• Discrepancies or gaps between subjective & objective
• Discrepancies in what the clients says at one time versus another
time
• Abnormal and/or inconsistent findings
• Missing data
o Once established an initial database, can identify areas
which need more data
o Possibly overlooked certain questions
o As you examine data in group, realize additional information
needed
Methods of Validation
• Recheck your data through Repeat assessment
• Clarify data with client (ask more questions)
• Verify with another health care professional
• Compare objective findings with subjective findings to uncover
discrepancies
Documenting Data
• Documentation required by various state nurse practice acts,
accreditation and/or reimbursement agencies (The TJC, Medicare,
Medicaid), professional organizations, institutional agencies
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Purposes for Documentation #1
Promote effective communication among multidisciplinary health
team members to facilitate safe and efficient client care •
Provides a chronologic source of client assessment data and a
progressive record of assessment findings that outline the client’s
course of care.
Ensures that information about the client and family is easily
accessible to members of the health care team; provides a vehicle for
communication; and prevents fragmentation, repetition, and delays
in carrying out the plan of care.
Establishes a basis for screening or validating proposed diagnoses
Acts as a source of information to help diagnose new problems
Offers a basis for determining the educational needs of the client,
family and significant others
Provides a basis for determining eligibility for care and
reimbursement. Careful recording of data can support financial
reimbursement or gain additional reimbursement for transition or
skilled care needed by the client.
Forms a component of client acuity system or client classification
systems. Numeric values may be assigned to various levels of care to
help determining the staffing mix for the unit
Provides access to significant epidemiologic data for future
investigations and research and educational endeavors
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Promotes compliance with legal, accreditation, reimbursement, and
profession standard requirements.
Guidelines for Documenting Data
Keep confidential all documented information in the client record
Document legibly or print neatly in nonerasable ink
Use correct grammar and spelling
Avoid wordiness that created redundancy
Use phrases instead of sentences to record data
Record complete information and details for all client symotoms
Include additional measurement content when applicable
Support objective data with specific observation obtained during the
physical examination
Verbal Communication of Findings (Using SBAR)
Use
• Use a standardized method of data communication such as SBAR (Situation, Background,
Assessment, Recommendation).
Communicate
• Communicate face to face with good eye contact.
Allow
• Allow time for the receiver to ask questions.
Provide
• Provide documentation of the data you are sharing.
Validate
• Validate what the receiver has heard by questioning or asking the receiver to summarize your
report.
Ask
• When reporting over a telephone, ask the receiver to read back what the receiver heard you
report and document the phone call with time, receiver, sender, and information shared.
S: Situation
B: Background
A: Assessment
R: Recommendation
Question #1
Which guideline should the nurse follow for documentation?
A. Write “normal” for normal findings
B. Use phrases instead of sentences
C. Exclude client’s understanding
D. Describe how data were obtained
Rationale: When documenting, the nurse should remember to use phrases
instead of sentences, avoid using the word “normal” for normal findings,
include the client’s understanding, and record data findings, not how they
were obtained.