Chapter 1: Evidence based practice

Assessment:
 Collecting data
o Review of the clinical record
o History history
o Physical exam
o Functional assessment
o Risk assessment
o Review of the literature
 Use evidence based assessment techniques
 Document relevant data
 Subjective data: what the person says about himself or herself during history taking
 Objective data: what you as the health professional observe by inspecting, percussing,
palpating, auscultating

 Diagnostic reasoning: process of analyzing health data and drawing conclusions to identify
diagnoses
o Hypothetico-deductive process
 Attending to initially available cues
 Formulating diagnostic hypotheses
 Gathering data relative to the tentative hypotheses
 Evaluating each hypothesis with the new data collect----final diagnosis
o Cluster data that appear to be causal or associated
o Validate the data you collect to make sure they are accurate

Nursing Process: dynamic, interactive

abras

Critical thinking skills for the nursing process:

 Identify assumption: recognize you could take info for granted or see it as fact when actually
there is no evidence for it

 Identify organized & comprehensive approach

 Validate: checking accuracy and reliability of the data

 Distinguish normal from abnormal

 Make inferences: hypotheses

 Cluster related cues: relationship among the data

 Distinguish relevant from irrelevant

 Recognize inconsistencies

 Identify patterns

 Identify missing info.

 Promote health: identifying risk factors

 Diagnose actual and potential (risk) problems

 Set priorities

o First-level: emergent, life threatening and immediate ABCS PLUS V

o Second-level: next in urgency--those requiring your prompt intervention (mental status,

acute pain)

o Third-level: important to health but can be addressed after more urgent health problems
are addresses

o Collaborative: approach to treatment involves multiple disciplines

 Identify patient-centered outcomes: specific measureable result you expect

 Determine specific interventions: aim to prevent, manage, or resolve health problems

 Evaluate & correct thinking:

 Determine a comprehensive plan

Four types of data:

  Complete (Total Health) database:

o Health history & physical exam

o Screens for pathology

 Focused or problem-centered
 Short-term; “mini”: immediate focus
 Collect data smaller ins cope and more targeted
 Concerns mainly one problem, one cue complex, one body system

 Follow-up
 Appropriate interval
 Status of identified problems should be evaluated
 What change has occurred? Is the problem getting better?

 Emergency: need to stabilize

 Rapid, swift and sure
 Lifesaving measures

Concept of health:

 Holistic: views the mind, body, and spirit as interdependent and functioning as a whole
within the environment

 Culture & values, family and social roles, self-care behaviors, job-related stress,
developmental tasks, failures and frustrations of life

 Health promotion & disease prevention:

Chapter 2: Cultural competence- cultural care

Immigration:
Impact on health care/nursing
o Language barriers
o Blood products
o Food/diet
o Activities
o Dress
o Decision maker: patriarchy/matriarchy
o Health disparities: cultures more at risk for certain conditions/diseases

Health disparities: unusual and disproportionate frequency of a given health problems within a
population when compared to another population
  Occur in a broader social and economic context
 Ex. Diabetes, HTN, certain cancers
 Issues: health care providers, health care managers, health care system, patients/families

Cultural competence & cultural care: professional health care that is culturally sensitive,
appropriate, and competent
 Culturally sensitive: caregivers possess some basic knowledge of and constructive attitudes
toward the diverse cultural populations found in the setting in which they are practicing
 Culturally appropriate: caregivers apply the underlying background knowledge that must be
possessed to provide a given person the best possible health care
 Culturally competent: caregivers understand and attend to the total context of the
individuals situation, including awareness of immigration status, stress factors, other social
factors, and cultural similarities and differences.
 Need to have knowledge:
o Own personal heritage
o Heritage of nursing profession
o Heritage of health care system
o Heritage of patient

Heritage:
 Heritage consistency: degree to which ones lifestyle reflects his/her respective culture
o Determination of persons cultural, ethnic, religious background and socialization
experiences
o Traditional: norms of traditional culture
o Modern: acculturated to norms of dominant society

Culture:
 Learned from birth- language acquisition and socialization
 Shared by all members
 Adapted to specific conditions
 Dynamic and ever-changing
 Subcultural groups: differences within a culture due to ethnicity, religion, education,
occupation, age, and gender

Ethnicity: social group within the social system that claims to possess variable traits such as
geographic origin, migratory status, religion, language, sacred values, traditions, symbols, food
preferences

Religion: belief in divine or overhuman power or powers to be obeyed and worshipped as creator
and ruler of universe
 Can be seen as a shared experience of spirituality or as the values, beliefs, and practices that
people are either born into or may adopt to meet their personal spiritual needs through
communal action such as religious affiliation, attendance, participation in religious
institutions, prayer, meditation, religious practices

 Spirituality: focusing more on the self and includes belief systems other than religion
o Unique life experience, personal effort to find purpose and meaning of life
  ASK WHAT IS YOUR RELIGIOUS PREFERENCE?

 Influences on health practices:

o Religious affiliation and membership benefit health by promoting health behavior and
lifestyles
o Offers social support
o Faith leads to thoughts of hope, optimism, positivity

Socialization: being raised within a culture and acquiring the characteristics of that group
 Acculturation: adapting to and acquiring another culture
 Assimilation: develops a new cultural identity and becomes like members of dominant
culture
 Biculturalism: dual pattern of identification

Heritage assessment tool

Developmental competence:
 Childhood: parental perceptions may be influenced by religious beliefs
 Older adults: achieving integrity; responsibility for life and sense of accomplishment
o May develop own means of coping with illness through self care, assistance from family,
support from social groups
 Culture shock: state of disorientation or inability to respond to the behavior of a different
cultural group because of sudden strangeness, unfamiliarity to new expectations

Traditional causes of illness:

 Biomedical/scientific: cause and effect; body functions mechanically; life can be reduced
into smaller parts; all reality can be observed & measured
 Naturalistic/holistic: forces of nature must be kept in natural balance (yin/yang theory,
hot/cold theory)
o Yin: female, negative forces, emptiness, darkness, and cold

o Yang: male, positive forces, warmth, fullness

o Hot: abscessed tooth, sore throat, rashes, kidney disorders

o Cold: earache, chest cramps, paralysis, gi discomfort. Rheumatism, TB

 Magicoreligious: supernatural forces dominate (voodoo, witchcraft, faith-healing)

Healing & Culture:

  Folk healers: use of traditional healers from patients background
o Hispanics: curandero, espiritualista(spiritualist), yerbo (herbalist). Partera (lay midwife),
savedor (healer who manipulates bones and muscles)
o African americans: hougans (voodoo priest), spiritualist, old lady,

o American indians: shaman

o Asians: herbalists, acupuncturists, bone setters

o Amish: braucher (herbs/tonics)

Transcultural expressions of illness:

 Transcultural expression of pain: private, subjective and influences by cultural heritage
o Variations in pain perception and tolerance

 Culture & treatment

 Self-care and use of complementary interventions

 Culture & disease prevention

 Abnormal biocultural variations may be genetic or acquired

 Poverty

Steps to cultural competency:

 Understand your own heritage based on cultural values, beliefs, attitudes and practices
 Identify the meaning of health to the patient
 Understand the health care delivery system, how it works, what it does, meaning of
procedures, and costs
 Know social backgrounds of patients
 Familiar with language or get help with interpretation

Chapter 4: Health History

Health history:
 Collect subjective data

 Complete picture- past & present health

  Well person- what is the person doing right?
o Exercise, diet, risk reduction, health promotion

 Ill person- chronologic record of problem (time line)

 Documentation: patient states/patient denies

Sequence of health history:

Chapter 3: Interview

Interview:
 Subjective data collection
 Patient perception of health (beliefs, culture, religion, education)
 Nurse-pt relationship: need a good rapport
 Patient generally controls the interview: can shut down, can limit what they want to share
 Patient centered care: they control things, involved in the entire process and individualized

Contract: interview is a contract between patient and examiner

 Time and place: comfortable, distraction less environment, allotting
 Introduction & explanation: how you introduce yourself, explain role and why you are
there, what you will be doing
 Purpose:
 Length
 Expectations
 Presence of others
 Confidentiality
 Costs: insurance, patients may ask/inquire about costs for things

Communication:
 Verbal
 Nonverbal: more indicative of persons true feelings
o Facial expressions
o Gestures
o Posture
 Need to be aware of own biases/perceptions
 Internal factors:
o Language barriers
o Own biases
o Ability to listen
 External factors:
o Ensure privacy
o Refuse interruptions
 o Physical environment: pleasing, comfortable, well lit, warm temp, reduce noise, remove
distractions, distance 4-5 ft
 equal status seating (90 degrees, avoid facing pt across desk/table, avoid
standing
o Dress: professionally, clean, neat
o Note-taking: negative/positive
o Tape & video recording

Note-taking:
 Impedes eye contact
 Attention-shifting
 Interruption of patients narrative flow
 Impedes observations of nonverbal behavior
 Can be threatening

Interviewing approaches:

 Directive: Highly structured to elicit specific information; controlled by the nurse; client has
limited opportunity to respond to or to ask questions; effective when time is short and
information critical
o Alcohol impaired
o Cognitively impaired
o Elderly
o Acute illness
**IMPORTANT WHEN TIME IS LIMITED AND INFO IS CRITICAL
o Closed questions: used in directive

 Non-directive: also called rapport building, nurse allows patient to control the purpose,
subject matter and pacing
o Open ended: invites patients to discover, explore, elaborate, clarify or illustrate a
thought or feeling
 Begin with what or how

 Neutral: non-threatening that patient can answer without directions

o Used in non-directive, open ended

 Leading: are closed questions used in directive interviews

o Directs patients response
o Ex. You are frightened arent you? You don’t smoke, right?

Techniques of communication:

 Facilitation: encourages patients to say more and shows you are interested and will listen
further

 Silent attentiveness
o Gives patient time to think and organize what to say without interruption from you
o Gives you a chance to observe person unobtrusively and note nonverbal cues
  Reflection
o Echoes patient’s words, repeating what person has just said, focuses further attention
on a specific phrase, and helps person continue in his or her own way

 Empathy
o Recognizes a feeling and puts it into words
o Names the feeling and allows expression of it
 Patient feels accepted and can deal with feeling openly

 Clarification
o Use when person’s words are ambiguous or confusing
o Used to summarize person’s words and to simplify them to make them clearer
o You are asking for agreement, and the person can then confirm or deny your
understanding

 Confrontation
o Frame of reference shifts from patient’s perspective to yours
 May focus on discrepancy or inconsistency in person’s narrative
 You have observed a certain action, feeling, or statement and now focus
person’s attention on it
 You give honest feedback about what you see or feel
o NOT ALWAYS NEGATIVE

 Interpretation
o It links events, makes associations, implies cause, ascribes feelings
o Helps person understand his or her own feelings in relation to the verbal message
o If your inference is incorrect, the patient may correct it and thus prompt further
discussion of topic
o Based on your inference or conclusion

 Explanation
o These statements inform the person; you share factual and objective information,
offering reasons for requirements or actions

 Summary
o Final review of what person has said; it condenses facts and presents your view of
health problem
o Is a type of validation that person can agree with or correct; both you and patient
should participate
o Occurring at the end of the interview, it signals that termination of the interview is near
o PULLS ALL THE FACTS TOGETHER AND THIS IS WHAT YOU HAVE SUMMISED FROM IT

Nutritional/metabolic pattern:
  24 hour diet recall

Elimination pattern: describes the patterns of excretory function (bowel, bladder, skin)

Activity/exercise pattern: patterns of activity, leisure, recreation

Sleep-rest pattern: sleep, rest, relaxation

Communication with different ages across the life cycle:

 Parents: Builds rapport with parent and child

o < 6 years, focus on parent
o Explore sensitive issues with parent alone
o Avoid being judgmental
o Don’t ignore child all together

 Infants:
o Most interaction with parents
o Speak softly
o Handle in secure manner
o More cooperative when parent in view

 Preschoolers (3-6)
o Egocentric: think about themselves
o Animistic thinking unfamiliar objects: stuffed animals
o Their communication is direct, concrete, literal, set in the present
o Education/explanations through play

 School aged (7-12)

o More objective/realistic
o Thinking more stable/logical
o Have the verbal ability to add important data
o Interview the caregiver
o Ask child first then caregiver

 Adolescent:
 o Want to be adults but lack cognitive
o May regress with stress
o Value peers
o Respect them
o Communicate honestly
o Use ice breakers
o Short and simple
o Confidentiality

 Older adult:
o Be alert for hopelessness/despair
o Address mr. mrs.
o Long story to tell, may need multiple sessions
o Adjust pace
o Consider physical limits
o Touch may be valuable

Special needs interview:

 Hearing impaired:
o Ask preferred way to communicate
o Interpreter (sign language)
o Talk normally if lip reading
o May use written
o Communication

 Acutely ill
o Cut to the chase
o Direct interview
o Get info quickly

 Alcohol:
o Simple/ direct
o Be aware of poly substance abuse
o Patient safety always key

 Sexually aggressive people

 o Set appropriate verbal boundaries/safety

Personal questions:
 Try to avoid
 Can provide brief if appropriate
 Be sensitive of possible motive
 Redirect convo back on patient

Cross-cultural care:
 Can influence

Gender: be aware
 Maintain privacy and modesty

Sexual orientation
 Maintain neutrality
 Beware of your own bias

Chapter 9: General survey

General survey :
 Whole person
 Overall impression
 First impression
 Concentrate on norms

Physical appearance:
 Age:
 Sex
 LOC
 Skin color
 Facial features

Body structure:
 Stature
 Nutrition
 Symmetry
  Posture
 Exceptions:
o Toddler lordosis: Standing toddler protuberant abdomen
o Kyphosis: stooping aging person

Mobility:
 gait: normally bases is as wide as shoulder width

Behavior:
 Facial expressions: maintains eye contact
 Mood and affects: person comfortable and cooperative
 Speech: clear articulate, understandable
 Dress:
 Personal hygiene:

Chapter 9: Mental Status Assessment

Mental Status: emotional and cognitive functioning(thinking process, how we acquire

information) and is inferred through individuals behaviors
 Organic disorders: have a known cause
o Delirium
o Dementia

 Psychiatric mental illness: no known cause

o Anxiety disorders
o Bipolar

 Behaviors:
o Consciousness: awareness of your feeling, thoughts, environment
o Language: how we communicate
o Mood and affect: general sense of how we feel, how you demonstrate
o Orientation: alertness (time, place, person)
o Attention: ability to concentrate and focus
o Memory: ability to lay down and store
o Abstract reasoning: thinking beyond what's concrete and literal
o Thought process: the way a person thinks
 o Thought content:
o Perceptions: awareness of objects through our sense

 When to perform mental status exam:

o Behavior change: family member becomes concerns
o Brain lesions
o Aphasia: caused by brain damage
o Symptoms of psychiatric mental illness

 Health history contributions:

o Known illness or health problem
o Current meds
o Baseline educational and behavior level: can influence
o Stress, social habits, sleep habits, drugs/alc

 Main component of mental status examination (NEED TO KNOW)

o Appearance

 Posture

 Body movements

 Dress

 Grooming and hygiene

o Behavior

 Level of consciousness

 Facial expression

 Speech

 Mood and affect

o Cognitive functions

 Orientation: time, person, place(present location, city, type of building)

 Attention span: is someone able to concentrate

 Fatigue

 Stress/illness
  Distractions

 Recent memory: when did you arrive,

 Remote memory: describe past job, employment, past health

 New learning—the four unrelated words test

 Judgment: ability to make appropriate decisions

o Thought processes and perceptions

 Thought processes: goal directed

 Thought content

 Perceptions

 Screen for suicidal thoughts: non verbal communication, if they state they feel
unsafe, states feeling sad/ hopeless, despair

o Older adult developmental considerations:

 Cognitive impairment is no longer considered normal or an expected change of

aging (SLOWER THOUGHT PROCESS)

 Cognitive functioning is especially likely to decline during illness or injury

 Nurses assessment is imperative in identifying early changes in physiological

status

o Mini Mental State Exam (MMSE)/ Folstein test

 Screens/ assess cognition
 Screens for dementia
 Functional areas

 Orientation—what is the year, season, date, day, month?

 Registration—name 3 objects, then repeat them

 Attention/calculation—spell “world” backwards, do serial 7s

 Recall—name previous 3 objects

 Language—point and name to a pencil, follow simple instructions,

repetition, writing, drawing

 Abnormal results
 Mid to low 20's: mild impairment
 10-20: moderate impairment
  < 9: severe impairment

 Abnormal LOC:

 Alert: aware of

 Lethargic (somnolent): slow to react, drifts off, can be aroused

 Obtunded: more difficult to arouse, sleeping a lot, confused

 Stupor or semicoma

 Coma: unconscious.

 Acute confusional state (delirium) clouding of consciousness

 Abnormal findings of mood and affects:

 Flat affect: lack of emotional response
 Depression: sad, rejected
 Depersonalization: outside of themselves, estranged
 Elation: joyful
 Anxiety: restless
 Fear:
 Irritation: easily provoked
 Rage:
 Ambivalence: opposing feelings towards
 Lability: rapid shift of emotions
 Inappropriate affect: disconnecting between what your seeing in
someone's speech and doesn’t fit

o Things that may be misinterpreted for dementia

 Hearing loss
 Visual changes

o Clock drawing test:

 Used to screen patients with cognitive impairment and memory loss
 Quick 5-10 min
 Accepted by pts
 Simple to score
 Technique:
 Give blank piece of paper
  Patient is told to draw a clock
 Draw clock face
 Draw the numbers in correct
 Draw clock hands to show time

Chapter 11: Nutritional Assessment

Developmental considerations:

 Newborn & Infancy

o Most rapid period of growth

 Regain birth weight within 7-10 days after birth.

 Double birth weight by 6 months, triple by one year.

  Increase their length by 50% by end of first year.

o Breastfeeding recommended

 Contraindicated in HIV

 Toddlers

o Food jags; stuck on one food

o Food strikes; refusal to eat meals

o Related to autonomy; want sense of control

 Preschool

o Appetite sporadic

o Likes to eat one food at a time

o Usually dislikes strong tasting foods

 School age

o Food practices well established

o Play takes priority

 Adolescence

o Rapid growth: need more cals

o Endocrine and hormonal changes

o Increased protein and calories needed to support growth and muscle development

o Calcium needed for bone growth

o Iron important for female menses

o Needs usually not met with 3 meals, need snacks

o Boys generally grow taller and have less body fat; 12%, girls 25%

o Girls double body weight age 8-14

o Boys double weight age 10-17

 Adulthood

o Growth and nutrients needs stabilize

o Unhealthy habits; smoking, stress, lack of exercise, ETOH, high fat, salt cholesterol,
sugar, low fiber
  Leads to increase risk for chronic illness

 DM, HTN, overwt, arthrosclerosis, cancer, osteoporosis

 Elders

 Prone to under nutrition or over nutrition

 Poor physical or mental health, poor dentition

 Normal physiologic changes: decrease absorption, decrease sense of smell,

 Decrease in energy requirements due to loss of lean body mass and increase in fat

 By age 51-75 energy needs decrease by 200kcal/day, after age 75 decrease by 500kcal
for men and 400kcal for women

 Protein needs are 0.8g/kg/day, same as younger adult

Procedure of nutritional assessment: (NEED TO KNOW)

 Start with screening: quick easy way to identify risk (wt loss recent illness)

 Weight, hx

 Diet info

 Lab data

 Identify risks: hyperthyroidism, lactose intolerance, gluten allergy, chrons, hygeine poor
dentures

 If at risk:

 Diet hx

 Weight

 Food intake (24 hour diet recall)

 Subjective data:

 Eating patterns:

 Usual wt

 Change in appetites, taste, smell, chewing

 Recent surgery, burns,

 Chronic illnesses

 Allergies
  Medications

 Self-care behaviors

 Alcohol

 Exercise

 Fam hx

 Anthropomorphic measures:

 To depict wt change 2 methods used

 1. Percent Usual Body Weight

 % usual body wt = current wt/usual wt X100

 3. Recent Wt change

 Usual wt – current wt/usual wt X100

 BMI ranges

 Waist to hip ratio

 Skin fold thickness

 Arm span or total arm length (wheelchair bound)

 LOOK AT TABLE 11-2 PG 187

 Kwashiorkor (protein malnutrition)

 Diet mainly carbs may be high in calories

 Little or no protein

 Depressed immune system

 Have adequate anthropometric measurements

 Well nourished appearance may be edematous

 Wt > 100% standard for ht

 TSF > 100% standard

 Serum albumin ,3.5 g/dl

 Serum transferrin <150mg/dl

  Lymphocytes <1500mm3

 Marasmus (protein-calorie malnutrition)

 Inadequate intake of protein and calories due to prolonged starvation

 Anorexia, bowel obstruction, cancer, chronic illness among risk factors

 Decreased anthropometric measures, wt loss, subcue fat and muscle wasting

 Starved appearance

 Wt < 80% standard for ht, TSF <90% of standard MAC < 90% standard

 Creatinine ht index ,80% standard

Ch. 6: Substance Abuse Assessment

Alcohol:
 Most abused drug
 4 standard drinks per day or more increased rates of death in men from
 Cirrhosis
 Cancers
 Injuries
 Women: increases risk of breast cancer
 1 drink: increases risk by 4 %
 Chronic heavy use increases risk of alcoholic cardiomyopathy, with an increase in left
ventricular mass, dilation of ventricles, and wall thinning
 Which can lead to CHF
 Hypertension common
 Dependence increases risk of sepsis, septic shock and hospital mortality in ICU
 Increases risk for ICU admission due to trauma
 Illicit drugs
 Marijuana: most commonly used illicit drug
 Heroin
 LSD
 Hallucinogens
 Cocaine: can cause MI
 Questions about illicit drugs:
 Ask about use of illicit substances
 “Do you sometimes take illicit drugs or street drugs, such as marijuana, cocaine,
hallucinogens, narcotics?”
  If yes, ask, “When was last time you used drugs, and how much did you take
that time?”
 Alcohol dependence or alcoholism is a chronic progressive disease that is not curable but
is highly treatable
 Early diagnosis is key

Diagnosing Substance Abuse:

 Gold standard well defined Diagnostic and Statistical Manual of mental Disorders (DSM-V)

Developmental Competence:
 Pregnant women:
 No amt deemed safe
 1st trimester is most important for fetal growth
 Abstinence should be recommended
 Aging adult
 May be more difficult to detect
 No longer driving--- DUI's not detected
 No longer working---wouldn’t be detected via coworkers
 Liver/kidney functioning decreases--- increases bioavailability of alcohol in blood
 Less tissue mass---increases alcohol concentration in blood
 Polypharm--interactions (benzodiazepines)
 Increases risk of falls, depression, and GI problems

Clinical S&S:

 Intoxication – maladaptive behavior (CNS)

 Abuse – daily use needed to function, inability to stop, impaired life functioning, recurrent
use despite physical hazards or legal problems

 Dependence – physiologic dependence

 Tolerance – need more for same result

 Withdrawal – cessation produces syndrome of physiologic symptoms

Assessment: be NON-JUDGEMENTAL

 Promote healthy lifestyle

  Can reduce personal safety

 Can interact with meds

 Alcohol can make some diseases worse

 Questions

 Do you drink any alcoholic beverages?

 How many drinks would you say you consume on a weekly or monthly basis?

Subjective Data:

 Intoxicated: collecting any history may be difficult (ask CLOSED Questions)

 Sober: most people wiling and able to give reliable

 Do you sometimes drink beer, wine, or other alcoholic beverages?
 If answer is “Yes,” then ask screening question about heavy drinking days, such as, “How
many times in past year have you had five or more drinks a day (for men) or four or
more drinks a day (for women)?”
 “On average, how many days a week do you have an alcoholic drink?” and “On a typical
drinking day, how many drinks do you have?”

 Medications:
 Antibiotics
 Antidepressants
 Anticoagulants: increases INR, lead to bleeding
 Benzodiazepines
 Tylenol
 St. Johns wart

 Screening tools: NEED TO KNOW

 Audit:
 A quantitative form that has the advantage of letting the examiner document a
number for a response so it is not open to individual interpretation
 The AUDIT will help detect less severe alcohol problems (hazardous and harmful
drinking) as well as alcohol abuse and dependence disorders
 Current problems
 Used in adolescents/older adults

 CAGE: (Cutdown, Annoyed, Guilty, Eye Opener)

  Works well in primary care setting ( < 1 minute)
 LIFETIME alcohol abuse/dependence
 Less effective with women and minority groups
 2 or more yes, suspect alcohol abuse

 Have you ever felt you ought to Cut down on drinking?

 Have people Annoyed you by criticizing your drinking?

 Have you ever felt bad or Guilty about your drinking?

 Have you ever had a drink first thing in the morning to steady your nerves or get
rid of a hangover? (Eye-opener)

Standard Clinical Diagnostic Criteria:

 “In past 12 months, has your drinking repeatedly caused or contributed to:
 Risk of bodily harm: drinking and driving, operating machinery, swimming?
 Relationship trouble: family or friends?
 Role failure: interference with home, work, or school obligations?
 Run-ins with law: arrests or other legal problems?”

Screening women for alcohol problems:

 The TWEAK questions; combination of items from two questionnaires which help identify
at-risk drinking in women, especially pregnant women
 Tolerance: How many drinks can you hold? Or How many drinks does it take to make
you feel high?
 Worry: Have close friends or relatives complained about your drinking?
 Eye-opener: Do you sometimes take a drink in morning when you first get up?
 Amnesia: Has a friend or family member told you about things you said but could not
remember?
 Kut down: Do you sometimes feel need to cut down?

Screening aging adult:

 Use the SMAST-G questionnaire for older adults who report social or regular drinking of any
amount of alcohol
 Older adults have specific emotional responses and physical reactions to alcohol and the
10 questions with yes/no responses address these factors

 >2 = an alcohol problem and need for more in-depth assessment

Objective data:
  Clinical labs:

 GGT: most commonly biochemcical marker of alcohol drinking

 Chronic alcohol drinking: >4 drinks per da increases GGT

 MCV: Mean Corpuscular Volume: index of red blood cell size

 Can detect earlier drinking after long period of abstinence

 BAC: blood alcohol concentration

 Detects end of exhaled air following a deep inhalation

Ch. 7: Domestic Violence

Intimate Partner Violence:

 Physical or sexual violence, use of physical force or threat of such violence

 Psychological or emotional abuse or coercive tactics after prior physical violence between
person who are spouses or nonmarital partners or former spouses

Domestic Violence:

 An intimate relationship between two adults in which one partner uses a pattern of assault
and intimidating acts to assert power and control over the other partner

 Not limited to physical acts of violence; includes psychological, economic, and sexual abuse
as well as attempts to isolate the partner.

 More same-sex partners and male victims of violence perpetrated by women are reporting
their victimization.

Types of Abuse:

 Physical: pinching, tripping, punching, grabbing, beating, pulling hair, shoving, biting

 Psychological abuse: mental anguish

 Making or carrying out threats to do something to hurt partner emotionally

 Emotional abuse: putting partner down, name calling, playing mind games, controlling,
ordering around, making them feel bad

 Isolation: controlling what partner does (financially, monitoring activities), limiting access to
others
  Sexual Abuse: making partner perform sexual acts against their will

 Economic: preventing partner from getting a job, stealing money, making them ask for

Elder Abuse & Neglect:

 Physical abuse—violent acts that result or could result in injury, pain, impairment, or disease

 Physical neglect—failure of family or caregiver to provide basic goods and services such as
food, shelter, health care, and medications

 Psychological abuse—behaviors that result in mental anguish

 Psychological neglect—failure to provide basic social stimulation

 Financial abuse—intentional misuse of elderly person’s financial and material resources

 Financial neglect—failure to use elderly person’s assets to provide needed services

Individuals at risk of being abused:

 Planning to leave

 Previous abusive relationship

 Poverty

 Physical/mental disability

 Abused as a child

S&S of being abused:

 Physical

 Injury types & patterns: cord marks, belt marks, hand

 Tympanic membrane rupture

 Rectal/genital injury, bruises, cuts

 Neck, abdominal, body, arm scrapes, bruises

 Injury distribution (breasts, body, buttocks, genitals---HIDDEN)

 Psychological

 Abuser over controlling--doesn’t let the victim out of sight, answers questions
  Abused-may be quiet and passive, no eye contact

 Substance Abuse:

 More common in domestic violence

 Characteristic injuries: Rope burns , Cigarette burns, Bruises, Bite marks, Welts with the
outline of a recognizable weapon (such as a belt buckle)

 Injuries inconsistent with the explanation given:

 The injury type or severity does not fit with the reported cause.
The mechanism of injury reported would not produce the signs of injury found
on physical examination.

 injuries in various stages of healing:

 Signs of both recent and old injuries may represent a history of ongoing abuse.
 Delay in seeking medical attention for injuries may indicate either the victim's
reluctance to involve doctors or his or her inability to leave home to seek
needed care.

Cycle of Violence:
 tension building stage; tension in the relationship gradually increases over time
 acute battering stage; tension erupts, resulting in threats or use of violence and abuse
 honeymoon stage; batterer may be apologetic and remorseful and promise not to be
abusive again
 Traumatic bonding: strong emotional connections develop between the victim and the
perpetrator during the abusive relationship
 Approach and avoidance: mix of pros and cons

Role of Healthcare provider:

 80% say they have been in health care setting for some reason
 25-30% battered women say they sought care
 Mandated reporting; elderly, mentally challenged, children
 Report to your supervisor
 Don’t need to prove just need to suspect

Health effects of elder abuse:

 Minor pain and discomfort to life-threatening injuries
 Bleeding can lead to shock/death
 Localized infection----sepsis
 Cardiac problems
 Sexual abuse same as younger--post menopausal have more friable vaginal mucosa
  SELF NEGLECT ALSO REPORTABLE

Screening for partner violence NEED TO KNOW!

 Open with “Because domestic violence is so common in our society, we are asking all of
our female patients the questions that follow”

 Elder abuse: “Because domestic violence has such serious health care consequences, we are
asking women of all ages the following questions.”

Frequency of Screening:

 ALLLLLLL VISITS!!!!!!

Screening tools: NEED TO KNOW!

Elder abuse screen:

 Has anyone:
 Ever touched you inappropriately?
 Made you do things you didn’t want to do?
 Taken things that were yours without asking?
 Physically hurt you?
 Scolded or threatened you?
 Failed to help you take care of yourself?

Physical exam: NEED TO KNOW

  Complete head-to-toe exam checking for:
 Bruise/contusion
 Laceration/avulsion:
 Ecchymosis/purpura
 Petechiae: pin point
 Rug burn/friction abrasion
 Incision/cut
 Cut/sharp injury
 Stab wounds
 Hematoma

Documentation:

 Detailed nonbiased notes (verbatim)

 Use of injury maps

 Photographic documentation

Assessing for risk of homicide:

 Danger Assessment: 19 item test used by nurses

 Map abuse on calendar: identifies patterns

Ch. 8 Assessment Techniques and the Clinical Setting

Skills required for physical examination NEED TO KNOW

 Inspection: concentrated watching

 Close, careful scrutiny

 Look at the whole (general survey)

 Reveals a rich amount of info

 Avoid touching patient

 Use patient as their own control (compare each side of their body)
  Age- Appropriately developed?

 Skin color- oxygenation, injury/rash

 Position- sit comfortably

 Dress- appropriate?

 Mood- upset, anxious, appropriate?

 Palpation: using touch to assess

 Texture, temperature(back of hand), moisture, organ location, organ size.

 Swelling, vibration, pulsation, rigidity/spasticity, crepitation(crackles).

Lumps/masses, tenderness, pain

 Fingertips

 Base of fingers

 Dorsa of hands/fingers

 Light palpation: detect surface characteristics

 Deep palpation: usually used for abdominal assessment

 Bimanual palpation: use of both hands to envelop or capture certain body parts or
organs

 Percussion: tapping to assess underlying structures

 Map out location/size of organ
 Signal density of a structure
 Detect masses(more superficial masses, not deep)
 Elicit tendon reflexes

Characteristics of sound

 Amplitude- intensity/loudness

 Pitch- frequency
 rapid= high pitch, slower= low-pitched
  Quality- timbre
 Distinctive overtones

 Duration- length of time note lingers

2 types of percussion: (not very hard- but hard enough to produce a sound)
 Direct, sometimes called immediate, the striking hand directly contacts body wall
 Indirect, or mediate, using both hands, the striking hand contacts stationary hand
fixed on person’s skin (BETTER--PRODUCES BETTER SOUND)

Percussion technique:

 Hyperextend the middle finger (pleximiter)

 Place distal portion, phalanx and DIP joint firmly on patients skin

 Lift the rest of the stationary hand off the patients skin

 Use middle finger of dominant hand (Plexor)

 Action is all in the wrist- RELAX the wrist

 Spread fingers, extend wrist, flex wrist and bounce middle finger off the stationary
finger

 Aim just behind nail bed or at DIP joint

 Use TIP of plexor, not finger pad

 Percuss two times, then move stationary finger to a new location

 Auscultation : listening

 Many sounds are produced by the body

 Heart, blood vessels, lungs, abdomen

 Use stethoscope to block out environmental sounds, therefore promotes hearing

 Need to learn normal sounds in order to distinguish abnormal/extra sounds

Stethoscope:

 Diaphragm: best for high-pitched sounds

 Lung, normal heart, breath, bowel

  Hold firmly against patients skin-leave a ring

 Bell: best for soft, low pitched sounds

 Murmurs, extra heart sounds

 Hold lightly against skin

 CLEAN YOUR STETHOSCOPE!!!!!!!

Techniques for correct auscultation:

 Room must be quiet- extra noise can produce a “roaring” sound

 Temperature of examination room

 Hair on chest- can cause crackling and be mistaken for adventitious sound

 Never listen through a gown/clothing

 Avoid “artifact”: breathing heavily down your stethoscope can cause vibration

Setting:
 Warm, quiet, private, well lit- 2 sources
 Stool, table, adjustable HOB
 Your approach:
 confidence
 self-assured
 considerate
 unhurried
 organized (head-toe)
 periodic explanations
 informative

Developmental considerations:

 Infants: Parents present, place on exam table, or parents lap, soft facial, warm hands

 Toddlers: sitting in parents lap, ask parents to help

 Preschooler: parent present, verbal communication, explain steps, enhance autonomy

 School-aged child: sitting/lying on table, parents, present, undress themselves, demonstrate

equipment, shy and modest
  Adolescent: sitting, examine alone

 Older adult: minimize position changes, allow rest time, sitting vs. supine, adjust the pace,
use physical touch to aid understanding, don’t mistake vision/hearing changes for confusion

 Acute ill: alter the position, collect a mini database, focused exam (close ended questions)

Ch. 10 Pain Assessment

2 Pain processes:

 Nociceptive: detect painful sensations and transmit them to the CNS.

 Located in the skin, connective tissue, muscle and thoracic, abdominal and pelvic
visceral.

 Stimulated by trauma or from chemical mediators

 A fibers – myelinated, larger, rapid signal transport

 Sharp, immediate pain
 Burn finger
 Cut your finger

 C fibers- smaller, unmyelinated, slower pain transmission

 Aching, longer lasting pain

 Neuropathic pain: Develops when nerve fibers in periphery and CNS are functioning and
intact

 Pain starts outside the nervous system

 4 phases
 Transduction
 Transmission
 Perception
 Modulation


 From an injury to nerve fibers

 Difficult to assess and treat

 Is present long after injury heals

 Can start 2-3 years after initial injury

  Nocioceptive can change into Neuropathic over time

 Due to constant irritation of nerve cells –makes hypersensitive

 Conditions/Neuropathic pain:

 DM

 Herpes zoster

 HIV

 Sciatica

 Trigeminal neuralgia

 Phantom limb pain

 Chemo

 CNS-strike

 Sources of pain:

 Visceral: larger interior organs, stretching of organ or injury

 Deep somatic: from blood vessels, joints, tendons, muscles, and bone--pain from
pressure, trauma, ischemia

 Cutaneous: from skin surface and sc tissues (sharp superficial/burning pain)

 Referred pain-felt at one site, but originates from another

 Classifications of pain:

 Acute: short sudden, self limiting, can anticipate, self protective measures, incident pain

 Surgery

 Certain traumas

 Persistent pain: > 6 months

 Neuropathic

 Can last indefinitely

 Malignant vs. non-malignant

 Breakthrough pain:
  Many are not believed

 Infants and pain:

 Infants have same capacity for pain as adults by 30 weeks gestation

 Inhibitory neurotransmitters are insufficient until birth at full term

 Aging adult/pain:

 Pain is common but not a normal process of aging

 Arthritis, osteoarthritis, osteoporosis, PVD, cancer peripheral neuropathies, angina,

chronic constipation

 People with dementia feel pain

 Subjective data:

 Use multiple words

 ID the onset, duration

 Quality: what is feels like

 Amount/intensity

 Alleviating/aggravating factors

 Degree of impairment

 How do you usually react when you're

 What does pain mean to you?: see how it affects their daily lives

 Pain assessment tools:

When would you use? How? Population?
 Pain Rating Scale(numeric faces, descriptor scale)

 Unidimensional
 Reflect pain intensity
 Baseline, track changes
 Objective data
 Joints: ROM, inflammation. Deformity , comparison
 Muscle/skin: discoloration, bruising, swelling, deformity
 Abdomen: distention, contour, symmetry. Bulging, inflammation
 Have pt point to area of pain
 Nonverbal behaviors:
 Acute: pulling away, grimacing, restlessness, vital signs, sweating
 Chronic: diminished activity, sighing, changes in sleep/eat
 Infant: changes in facial expressions, near body movements