Wilson: Health Assessment for Nursing Practice, 6th Edition
Chapter 05: Cultural Assessment
Key Points
 Individuals living in the United States have varying cultural and spiritual beliefs and
behaviors representing a mixture of foreign and American influences.
 Nurses are responsible for caring for individuals who may have varying differences in
language, skin color, health practices, beliefs, religious practices, and values. The goal
with cultural diversity is to understand and work with these varying beliefs and values.
 To achieve cultural and spiritual awareness, one must understand the meanings of
culture, ethnicity, race, spirituality, and religion.
 Culture refers to various characteristics of a population that influence an individual’s
perception, behavior, and evaluation of the world. This includes things such as morals,
customs, and ways of life.
 Ethnicity refers to characteristics a group may share within a particular geographic
location. This may include race, language, dialect, and religious practices.
 Race refers to genetics and includes the physical characteristics of skin color, eye color,
and hair color.
 Spirituality and religion may be more difficult to define. Religion usually refers to an
organized system of beliefs in which an individual associates. Spirituality refers to
practices such as prayer, meditation, and listening to music or nature.
 Culturally competent nurses display an ability to respect patients as unique individuals
regardless of their beliefs, values, and preferences. These nurses have an awareness of
their own biases and have gained knowledge about various cultures.
 There are five attributes that convey patient-centered, culturally competent care: (1)
knowledge, (2) consideration, (3) understanding, (4) respect, and (5) tailoring.
 When caring for patients, the nurse should avoid stereotyping based on the skin color or
physical characteristics of a person.
 When performing an assessment, nurses should ask about health beliefs, practices, and
spiritual beliefs that are important to patients and that may have an impact on their health.
 Understanding preferred communication practices and behaviors of a patient will
improve the nurse’s cultural awareness and sensitivity.
 It is important to recognize that each individual is unique and influenced by many
things. The nurse must remain sensitive and ask questions to gain information about the
patient.
Chapter 06: Pain Assessment
Key Points
 Pain is generally assessed and documented as a part of vital signs. It is often referred to
as “the fifth vital sign.”
 Pain is whatever the person experiencing the pain says it is. The perception of pain
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Key Points
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cannot be judged by anyone other than the person perceiving it.
 Pain can reduce mobility, impair sleep, and contribute to a loss of appetite. When a
person is taking narcotics for pain, there may be a change in bowel elimination.
 Response and perception of pain is influenced by cognitive factors, cultural influences,
and a person’s previous experiences with pain. One of the cognitive factors associated
with pain perception is the attention given to the pain. An effective pain relieving strategy
in this instance is distraction.
 While pain may be categorized, it is not always possible to identify all types of pain.
 Acute pain has a recent onset of less than 6 months and is caused by tissue damage. It
usually ends when the tissue heals.
 Persistent pain is also called chronic pain. It may be intermittent or continuous and lasts
longer than 6 months.
 Nociceptive pain is caused by stimulation of somatic structures. Neuropathic pain is
associated with the central or peripheral nervous systems.
 Referred pain is used to describe pain that can be felt in a location other than the area of
injury or disease. Phantom pain is that which is felt by a person who has had an
amputated extremity.
 Standards for pain assessment have been put into place by The Joint Commission.
Nurses of accredited hospitals must follow these standards in assessing and managing
pain.
 The physiology of pain begins with stimuli that cause tissue damage to nociceptors.
From there, sensory peripheral nerves are stimulated and initiate action along the spinal
cord. Pain impulses are carried to the thalamus where perception of pain occurs. Once in
the thalamus, impulses eventually reach the parietal lobe, where the patient feels the pain.
 A person’s pain experience is influenced by his or her tolerance and threshold. Pain
threshold is the level at which pain is perceived. Pain tolerance refers to how much pain a
person can handle before responding outwardly.
 There are several different types of behavior scales used to assess pain in patients who
are unable to communicate. This includes the assessment of pain in infants and young
children.
 The perception of pain in older adults may be slower, but their pain is not different.
Accurate pain assessment may be difficult to obtain because of hearing or visual
impairments.
Chapter 07: Mental Health Assessment
Key Points
 Mental health is an integral part of overall health. A comprehensive assessment of a
patient includes obtaining information about the emotional and mental health of an
individual.
 The limbic system, also known as the emotional brain, controls regulation of memory
and basic emotions.
 Talking with the patient is the best way to obtain information about mental health. If the
nurse believes that there is deviation from expected findings, additional questions will
help clarify the information.
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Key Points
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 Medications used for mental health disorders can cause adverse side effects, which
change mood or behavior.
 Pertinent elements of a psychosocial history include questions to the patient about selfconcept, relationships, stressors, anger, and alcohol and drug use.
 Common problems associated with alterations in mental health are depression, anxiety,
and altered mental status.
 Common problems associated with abusive behavior encompass alcohol abuse, drug
abuse, and interpersonal violence.
 While depression can occur at any age, it is more commonly seen in women between
the ages of 25 and 44 years.
 Alterations in mental status are assessed by asking the patient about orientation,
memory, calculation abilities, communication skills, judgment and reasoning, and
abstract reasoning.
 Patients with disorders related to alcohol or drug abuse are likely to deny or minimize
their use to avoid being judged by others.
 Regarding care of infants and children, drug and alcohol use by the mother should be
assessed.
 Depression in older adults is often misinterpreted as a manifestation of aging.
 Some of the common psychotic disorders that may be encountered are major
depression, bipolar disorder, and schizophrenia. Nonpsychotic disorders include anxiety,
obsessive-compulsive disorder, substance abuse disorders, delirium, and dementia.
Chapter 08: Nutritional Assessment
Key Points
 An integral part of a comprehensive health assessment includes a nutritional
assessment, which consists of detailed information about the patient’s dietary intake and
any perceived nutrition problems.
 Nutrients are classified into three groups: (1) macronutrients, (2) micronutrients, and
(3) water. Nutrients are a basic part of providing the body with calories for energy,
building, and maintaining tissues, and regulating body processes.
 Macronutrients are those that are needed in large quantities. These include
carbohydrates, proteins, and fats.
 Micronutrients are those that are required in smaller quantities. Vitamins and minerals
are the two micronutrients that are needed for growth, development, and metabolic
processes.
 Water is the most critical component of the body, comprising 60% to 70% of the total
body weight.
 A nutritional assessment should consist of the patient’s perceptions of actual or
potential nutritional needs. The nurse should ask the patient about specific food
preferences, likes, dislikes, and intolerances, as well as food allergies.
 Nutritional deficiencies may be a consideration in a patient with multiple bruises or
tissue trauma.
 The nutritional assessment of infants and children includes feeding patterns, the use of a
growth chart, the presence of rooting and swallowing in infants, and the presence of tooth
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decay in older children.
 A nutritional assessment of the older adult includes a focus on the patient’s ability to
obtain and prepare food.
 Common conditions associated with nutrition are obesity, hyperlipidemia, protein
calorie malnutrition, and eating disorders such as anorexia and bulimia nervosa.
 Obesity is one of the most serious health care concerns in the United States. One of the
goals of Healthy People 2020 is to promote health and reduce the risk of chronic disease
through promoting the consumption of healthy diets and through achieving and
maintaining ideal body weight.
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