Health Assessment Lec - 1st Lesson -Not only relying on what the patient

is telling you as a nurse as a nurse

must assess the patient so you will
Introduction to the have your own data that can further
Nursing Process support the claims of your patient of
abdominal pain
What is Health
-Client 2 : Admitted due to head
Assessment? injury
-Nurse does what type of
Health Assessment assessment?
-Plan of care that identifies needs of * Assess the level of consciousness
clients. (GCS)
-How these need will be addressed >Talk to the patient to check for
by the health care organization, or consciousness (so this is done to
skilled nursing facility. assess if the patient is alive, alert,
enthusiastic )
Notes: >To assess if patient oriented?
-So that to know what is the need of Drowsy?
the client you need to be able to * Assess pupillary reaction to light
know how to assess or to identify the and accommodation
need of your client and on what to do >Our Brian is situated in our brain so
with these needs of your client we can assess as well for our eye
reaction to light accommodation
Examples of Nursing PERLA (Pupil Equally Reactive to
Assessments Light and Accommodation)
-Client 1 : Complains of abdominal >What is the significance of this?
pain 1. Because if there is an unequal
-Nurse does what type of size of our pupils or if it is sluggish or
assessment? fixed then it would tell you the status
*Inspect, percuss, palpate, and of your patient as well
auscultate the abdomen. *Take and monitor the vital signs
*Take and monitor the vital signs >Always take the patient’s vital signs
so as to assess how is the head
Note: injury.(applicable to all accidents or
-From there you inspect the disease)
abdomen of the patient, find out the
findings and find what does that Note:
entail -check if the patient is Alive, Alert,
-You can come up of why the patient and enthusiastic from the GCS test.
is feeling abdominal pain
-From the vital signs data such as -Client 3 : Prescribed a cardiotonic
heart rate, respiratory rate, blood drug (it can affect the heart)
pressure, temperature, etc. can be - Nurse does what type of
recorded or taken assessment?
>Ex. When patient is in pain * Assess the apical pulse and
patient’s blood pressure elevates compare with baseline data
>Another type of assessment to (meaning before and after the drug
correlate intake) (what is the affect of the drug
to our patient)
-Example 4 : Cast applied on lower
leg
-Nurse does what type
assessment?
* Assess peripheral perfusion of toes
>If patient is cast it can be that the
patient can have compartment
syndrome because of how the cast
is applied so be careful do it right.
* Do capillary blanch test
>basically one of the things to do on
our peripheral perfusion assessment
*Bipedal Pulse (If applicable)
*Take and monitor vital signs
-Client 5 : Has minimal fluid intake
-Nurse does what type of
assessment?
* Assess tissue/skin turgor (you
would know if the patient is
dehydrated or not) (can point out if
patient is drinking water or not)
* Monitor intake and output (you
would know how much the patient is
taking in and excreting out)
>From here it would tell you if the
patient is positive or negative
balance
>Negative balance, means the
patient has lesser intake and higher
output.
>Positive Balance, means the
patient has more intake and less
intake (meaning patient has water
retention.)
* Take and monitor vital signs
>Always done since vital signs are
one of our datas that can support as
well the problems or we can identify
as well problems from our patient.
Evolution of the Nurse’s
Role in Health
Assessment
The Nurse in the 1930s
Weber and kelly
-Routine client and home inspection
by public health nurses
-Case finding, prevention of
communicable diseases, routine
of assessment skills in poor inner - city
areas (Frontier Nursing Service, and
Red Cross)
Note:
-so the pubic health nurses would
just go into the homes of the client
just to see if there are any problems
or findings that can be change if
there are any communicable
diseases, or anything that they could
do to improve the quality of life of the
patient.
Dillon
- Observation note only. Role is a
skilled observer
- “Patient admitted to ward in a
wheelchair. Stated that he is unable
to walk due to pinched nerves of
right foot. Patient is crying, says he
is homesick. Condition of skin good.
Made as comfortable as possible
Note:
-So nurse during the 1930s, what the
nurse can only observe (visually)
from their patient is the only thing
being assess.
-All these notes of your patient, the
Nurses’ assessment, these
assessments are all based on what
the nurse observed
-So the nurse did not palpate,
auscultate, interview the patient,
-So there is limited assessment
during the 1930s
The Nurse in the 1950s
Weber and Kelly
-Pre-employment health and
physical examinations for major
companies (Occupational health
nursing)
>Before you can be employed in a
company you have to first be
examined on your health and are
physically capable of doing your
work.
Dillon
-Nurse’s notes trace the past and
present history of an illness as well
as observations.
>Not only the observation the nurse
also starts to ask questions, and
does interview
-The nurse role has expanded to
include interviewing skills that
assess past and current health
statues
-”25-year old female admitted
ambulatory. Past history of ulcerative
colitis. Now in because of abdominal
cramps and vomiting X 4 days. Is 8
month pregnant. TPR 99.4, 80 (heart
rate), 20 (respiration rate). Ht 5’4”.
Wt 116 1/4. Urine to lab”
>Data is much more complete due to
the interview part.
The Nurse in the 1970s
Weber and Kelly
-Primary health services and
conducting health histories with
physical and psychological
assessments
>Not only that the client would
undergo physical assessment but
psychological assessment is also
included
>Aside from the physical health
mental health of patient this also
included
-Autonomous in making
comprehensive initial assessments
which become the bases for plans of
care
>Nurses’ assessments are now
given weight or is considered
important now.
Dillon
-Records intravenous and blood
therapy. Includes observation and
information on past illness and diet.
Nurse role now includes observation,
interview, performing procedure
(Venipuncture), and monitoring.
>According to DIllon not only the
physical and mental status of your
patient, laboratory findings are also
included, even the procedures as
well are included in the assessment
already.
-”12-year old white female admitted
to room 203 via stretcher from E.R.
with leukemia. Parents don’t seem to
know diagnosis. TPR 102.8, 120,
24.. Ht 62 1/4/ Wt 100 lbs. No known
allergies. Has not been eating much
for the last few days. Appears
extremely pale. BP 150/70. No urine
obtained. I.V. started. Blood started.
Vital signs relatively stable. T 103
when blood started.”
The Nurse in the 1990s - Present
Weber and Kelly
-Expanded from acute care setting
and the community, into
baccalaureate and graduate
education (Holistic assessment)
>There is already an extension, or it
is already an extensive assessment
because it entails a holistic
assessment.
>So client as a whole, not only the
biophysical, psychosocial, spiritual,
but even the cultural is being
assessed, even the beliefs.
>we have to take these one into
consideration and part of the
assessment of our patient
>Settings is also expanded, not only
can we do assessment for our
patient in the hospital, we can also
do these at the community, in our
own homes, etc.
-Because of budget cuts, nurse’s
documentation of health care
providers were used to justify health
care services
>So now because of the rising cause
of health needs. Now if what the
nurse document and what is the
nurses’ observations. It then
becomes a reason or justification
why does health care services were
done to the patient.
>That is why documentation of your
assessment to the patient is very
important.
>In a assessment even if you
assessed it and you have found no
problem and found some problems,
etc. But if it was not documented
it was never done! Or Discovered.
-Creation of critical pathways or
protocols in the care of patients
>Now the current trend is that
according to what is observed form
the patient new pathways are being
used or being created in the care of
the patient
-Advanced practice nurses as
clinical nurse specialists and nurse
practitioners in the hospital and
community setting respectively
-Rise of health maintenance
organization (HMOs) and preffered
provider organizations (PPOs).
Note:
-Nurses role is more supportive in
the past (1930s-1950s), but now
there are nurse specialist and nurse
practitioner that can give out orders
in the care of the patients since they
are licensed to do so.
-Because of the HMOs there are
more or a lot of specialized care for
the patient, that can be done to our
patients, and with each of these
specialized care the nurse will
always be present.
Dillon
-Nurse notes observation and
assessment of the patient as well as
the biophysical, psychosocial, and
cultural factors that influence the
patient’s health problem. The nurse’s
role has grown to include holistic
health assessment.
Note:
-So when you assess the patient,
you look at the patient as a whole.
-Your first look at the patient is your
physical assessment of your patient,
what you see, hear, smell, and
observe from your patient that is
your physical assessment,
laboratory findings is also part of
this.
-When you say psychosocial
assessment, how is the patient
behaving, once the patient arrived
was the patient withdrawn?
Talkative, Was the patient shy? Or
afraid in terms of abuse? Or if the
patient is combative? So these are
behaviors that you can observe as
well and that can be add to the
holistic assessment of your patient.
- Cultural Factors, Examples are
Religion, religious beliefs. Like not
allowed to do blood transfusion due
to their religious beliefs
-Young, Obese Caucasian female
states she came here to ‘get the
sugar out of her blood.’ States she
found out about her sugar 3 months
ago by glucose tolerance test results
(in jan.. 1990 miscarried 2-month
pregnancy and GTT was part of
workup); states she has seen her
husband test his blood (fingerstick
method) and give himself some
insulin but has don neither herself;
has tried to prepare both 1,800 and
2,200 calorie American Diabetic
Association diets as ordered for
husband but ‘he doesn’t stick to it’;
has noted increased hunger,
increased thirst, increased urination
for several months and occasional
blurred vision.
In Comparison
Weber and Kelly

Time Period Weber and Kelly Dillon

Late 1800s o Early Focused natural senses
1900s on observable changes.
1930s PHNs (public health Skilled observer
nurses) do home
inspections, case
finding, prevention of
communicable disease
in inner city areas thru
FNS and RC (nurses
are skilled observers)
1950s Pre-employment Traced past and current
examination (OHN) history as an interviewer
(nurses are now
interviewer)
1970s Primary health service, Begins performing
assessments (Physical procedures
and psychological), (venipuncture) and
formulate plans of care. monitoring vital signs.
(Aside from being an
observer and
interviewer they can
also now do
procedures.)
1990s to Present Baccalaureate and Holistic health
graduate programs. assessment. Includes
Rise of advanced biophysical,
nursing practice. Rise of psychosocial, and
HMOs and PPOs.(there cultural aspects. (and
is already a holistic even the spiritual or
health assessment) religous aspect of our
patient)

Rapid Expansion in the Nurse Rapid Expansion in the Nurse

Role
-More prevalent today than in
previous decades
-New fields are emerging
necessitating the development of
their own related nursing diagnoses
>Because of the expansion of the
available services that we have now
the nurses role as well is expanded
Role
-Home Health Nursing
*Independent nursing diagnosis,
referrals. And collaborative care as
needed
>You as a nurse will go to the home
health nursing, houses of patient,
and there you assess the patient in
the comfort of their ow home
>Then from there you would be able
to identify what are the needs of your
pateint and if the patient would need
to be refer, if you need to add
collaborative care (Physical
therapist, speech therapist, etc.)
*Median Salary $ 78,983 dollars ($
34-$ 41/hours in dollars)
-Public Health Nursing
*Needs of communities and monitor
growth and health of children
*Present in health care center, they
are the one who gives vaccinations,
who gives health teachings to
mothers when giving vaccination to
her or her children.
>Are the public nurses
*Median Salary $ 56,111 ($ 24-$
29/hour)
-School Nursing
*Needs of communities and monitor
growth and health of children
*School nurses
*They are the ones that do yearly
check up on students
*Median Salary $ 49,168 ($21 - $
25 /hour )
-Hospice Nursing
*Assess the needs of terminally ill
clients and their families
*Median salary $ 71,654 ($ 31-$
37/hour)
Note:
-Not that common in the Philippines
but more common abroad
-They do not call their patients
“Patient” but they refer to them as
residents because they are already
living there.
-Nurses would be the one to take
care of these residents until the time
they would expire (Die)
-Acute Care Nursing
*Extensive focused assessments
*Median Salary 73,500 $ (31 $-38
$/hour)
>Hospital based
>Entails the different areas in the
hospital, like the Emergency
Department, OR, DR, ICU, Dialysis
unit, NICU, Pediatric ward
>So the acute care entails for a
much more extensive assessment.
>So there are specialized areas so
there is a more extensive focused
assessment, because in the special
areas there is an acute setting or
acute care happens in the special
area
>Higher salary since these are more
specialized
-Forensic Nursing
*Extensive focused assessments
(reversed process)
-median Salary $81,800 ($ 35-$
42/hour)
Note:
-They are checking where the bruise
came from, how it was develop, and
deduce what object caused the
bruise it it man made? Or done by
an animate object?
>So this is a specialized area of
nursing so it is more higher payed
since you would need further studies
to become a forensic nurse.
-Critical care outreach nursing
*Enhance assessment skills to safely
assess clients outside the structured
intensive care environment
*Median Salary $ 62,822 ($ 27-$
32/hour)
Note:
-Patients who are in step down care
-Our step down patients
-Ward nurses
-It would also include our ward
nurses
-Ambulatory care Nursing
*Assess and screen clients to
determine the need for referrals
*Median Salary $ 78,983 ($ 34-$
41/hour)
Note:
-Termed as travel nurse in the US
Across All fields of Nursing
-Nurses nowadays increasingly
document and retrieve assessment
data through computerized
information systems.
>So due to the advancement of
technology, the trend today is
paperless documentation, no use of
pen and paper.
-Warrants why courses with
informatics content are becoming
the norm in baccalaureate programs
>knowing the IOS operating system
of the hospital
>Students are aware .of the
operating system in the hospital,
how to do charting using the
program, how to check doctor’s
order, how to pull up the laboratory
result
>So that when student nurses
graduate they would already know
how to use the operating system of
the hospital
Future Trend as Predicted
-Continuing increased
specialization and diversity of
assessment skills of nurses
>There are already an abundant
amount of specialization, different
fields of nursing, because of this
assessment skills of nurses are also
now much more diverse.
>So for you to be able to cope and
be in trend on what is being done
these days you would have to step
yup your assessment skill
-Rise of integrated clinical practice
for surgical care.
*Nurse follows a client’s care from
preoperative care, to a >Because of changing times
multidisciplinary outpatient clinic,
and into the home through remote
technology.
>It is very much evident now due to
the pandemic
>We now have Telemedicine, so
there is a remote follow up to our
patient care, we have follow up
assessment that we can do to your
patient through technology.
“There is tremendous growth of the
nursing tole in the managed care
environment. The most marketable
nurses will continue to be those
with strong assessment and client
teaching abilities as well as those
who are technologically savvy.”
>So you need to keep up with times,
now we are in the technological
stage, so you need to also be
terminologically savvy, hospitals are
also upgrading their equipments and
you as a nurse must know how to
use and operate these equipements.
>You would not be able to render
proper care to your patient if you
don’t know how to assess your
patient.
>So if you do not know how to
asses, you do not know how to
identify the needs of your patient,
and in turn you won’t be able to help
your patient in terms of giving them
what they need
-So not all needs of our patient can
be instantly seen some of them
needs to be verbalized by out
patient, that is why assessment is a
skill, we need to earn these and elicit
these information from our patient
and or client so that we can help
them.
Reasons for this Trend
-Rising education costs and focus
on primary care (affects number of
medical students)
>Even if you are already in the
hospital, taking care of our patients
are now more complex due to a lot
of innovations and gadgets are
available for the care of the patient,
especially in acute settings
-Increasing complexity of acute care
-Expanding health care needs of
single parents]
>Because of the changing times
what was the problem before about
50 years ago is not the same
problem we have now
>So we have a lot of health
problems, health care needs now
that we discover not only to single
parents but to all everyone is
included
>Ex. Using gadgets was not a trend
in the past, But now because of the
excessive use of gadgets a lot of
behavioral problems are observed
with our younger children
>So that is a new health care need
that was not seen or present 2 to 3
years ago.
-Increasing impact of children and
the homeless in communities
>Because of the pandemic a lot of
people are struggling, and because
of this as well it will also impact the
health of these people
-Intensifying mental health issues
>Now mental health problems has
been more prevalant
-Expanding health service
networks
>Also because of the rise of our
HMOs, BPOs we now have more
health care services and health care
networks, we expanded
>Because of the Expansion there is
also expansion in the role of our
nurses
-Increasing reimbursement for
health promotion and preventive
care services.
>So it would depend on how much
you pay you would be able to avail
promotions and preventive care, so
we have services or the nurses as
well can cater as well health
promotion and preventive care
services to our patient.
What is the Significance of Health
Assessment?
Significance
-Allows the nurse to formulate the
Nursing Diagnosis that require:
* Nursing care
* Identification of Collaborative
problems (interdisciplinary care)
* Identification of problems requiring
immediate referral
Note:
-Before you can assess the problem
of your patient, of course
assessment
-That is why assessment precedes
all phases in the nursing process.
-It is the first on done in the nursing
process (assessment)
-So if you are able to do your
assessment and you were able to
formulate, you were able to identify
all the cues or the datas, you were
able to collect all the needed datas
-From that data you have collected
then you can deduce what is the
problem of your patient
-From the data you have collected
then you can formulate what is the
problem of your patient
-In identifying the problem of the
patient of your patient then you can
know if the patient, or what does the
patient needs
-If the patient needs nursing care, so
nursing care that you can give as an
independent intervention? Or does
the patient need collaborative
intervention?
-So you will be able to identify
collaborative problem
-TO whom do you have to refer the
patient. Does the patient needs the
help of our Physical therapist,
speech therapist, respiratory
therapist, dietitian so these are some
of our interdisciplinary team.
-So you would know these one from
assessing you patient.
-Assessments will also help you
identify if collaborative means with
other medical department is needed
-from assessments You will be able
to spot the problems that needs to
be immediately focused.
-In identifying the patient you would
know as well which is the pressing
need of your patient where is the
most important that the doctor needs
to instantly know.
-Since it can affect the life of your
patient, not talking about health, but
already about life threatening
-If it already life threatening then you
should immediately refer the patient
to the physician
-So you would be able to know or
observe or judge these all from the
assessment that you will do to the
patient.
Significance
-Not just about gathering
information about the health status
of a patients, but also:
* Analyzing and synthesizing data
* Making judgments about the
effectiveness of nursing
interventions
* Evaluating client care outcomes
>When evaluating was the
intervention effective to the patient?
Did it work? Was the problem
resolved or not?
>Because you would still go back to
the assessment
>So what was assess and what was
evaluated, do they jive or not? Is it
still the same or is there an
improvement]
>That is why you need as well to use
your critical thinking in assessing
your patient.
Note:
-If patient’s data is already extensive
too many, you would then need to
analyze the data and you would
need to cluster it, which one is
important, which is medium of
importance, and which one is not
important
-You should narrow it down, what is
the most important, most needed by
our patient, and from there you can
make a judgment if according to
what you have assessed in the
patient and what intervention you
have given to the patient if this is
effective or not
>Was the intervention that i gave to
the patient correct?
>Because if not you would have to
go back to your assessment
>Since you base your intervention to
the assessment of your patient.
-Analyze the data of your patient
segregate the information from the
minor to major concerns that needs
to be addressed.
-From this you will be able to make a
judgment on how to proceed and or
deal with your patients problem.
Overview of the Nursing
Process
The Nursing Process
-Systemic and rational method of
planning and providing nursing
care.
>So when you talk about nursing
care, is the diagnosis and treatment
of human response to an actual and
potential health problem.
>So you identify and assess your
patient should be done in a
systematic way, and in a rational
way, so that it will not be confusing.
>So that you can analyze and
synthesize it better. (You will be able
to understand, connect the dots, and
will be able to deduce which is more
important and which is not more
easily)
>So that when you provide care for
your patient you would know where
you are at.
- It is cyclical, logical, and more than
one component (or phase) may be
involved at one time.
The Nursing Process
Note:
-These are the nursing process
-So it all revolves around individual,
families, or community, these are our
main client
-How can you be systematic> First
you A then you D then you identify
which result you would want to see
in your patient so you use P here,
Outcome Identification and Planning
is almost similar in definition., and
then you I the interventions that you
have come up with according to the
problem you have identified in your
patient, then you E after if the
interventions that you have given to
your patient is effective or not
-Evaluation overlaps with
Assessment because it is an on
going process, it is dynamic meaning
it changes according to what is
happening to your patient
-Either ADOPIE or ADPIE since
Outcome Identification and Planning
is almost the same in definition.
-Assessment and Evaluation is an
ongoing process
Phases of the Nursing Process
Phase 1 :
Title :Assessment
Description :
-Collecting subjective and objective
data
>When we talk about subjective
data, it is coming from the client
itself
>Objective data is what can be
observed or what we can observed
form the patient
Phase 2 :
Title :Diagnosis
Description :
-Analyzing data to make a
professional nursing judgment
(nursing diagnosis, collaborative
problem, or referral)
>So you are done assessing and
have a list of the cues of your patient
and you analyze it. Where from
these information is the problem and
is the most important for our patient?
>So that you can come up with a
nursing diagnosis
>From that nursing diagnosis you
can make a nursing judgment. DO
you need to refer the patient? Or do
you need collaborate? So that the
problem can be solve
Phase 3 :
Title : Planning
Description :
-Determining outcome criteria and
developing a plan
>In identifying the problem of your
patient you then make a plan. How
you can solve or help you client
>You will have a criteria, Ex. In the
end of my 8 hour shift the cliet
should be able to tolerate 1/2 plate
of food. (patient has problem with
food intake, patient has low food
intake)
>So that is the outcome you would
want to see from you patient
>So how can you make the patient
able to do the criteria you have set?
This is where you implementation
and intervention would come in
Phase 4 :
Title : Implementation/Intervention
Description :
-Carrying out the plan
>You can give health teachings to
your patient about the importnace of
nutrition (In relation to the example
up top)
>You can also include there making
the food presentable
>So these are one of the
implementation or intervention that
can be used so as to achieve your
outcome or goal your patient’s goal.
>After that one if all the
interventions and implementations
have been carried out then you
would then have to evaluate
Phase 5 :
Title : Evaluation
Description :
-Assessing if outcome criteria have
been met and revising the plan as
necessary (revisit all steps -> collect
new data --> adjustment)
>Was the intervention effective or
not?
>You are assessing if the outcome
criteria have been met or unmet and
if revisions are needed.
Note:
-Was the outcome criteria achieved
or not? Then you revisit the steps,
meaning going back to assessment
and review or look for more data or
collect new data that you may have
missed that can maybe help with
your patient’s problem and then you
adjust it.
>Add or reduce you outcome criteria
and add different interventions so
that you can meet your outcome
criteria, resulting to your patient
achieving Goals met (goal met)
Circular & not linear
Note:
-Assessment and evaluation goes
two ways since it is an ongoing
process
-You cannot diagnose first without
assessing you patient
-You have to follow a flow when
doing your nursing process
-The arrow between assessment
and evaluation is a two way because
it goes on both directions because it
is an ongoing process.
-since if your evaluation changes
then you would have to assess it
again, so if the assessment will be
different the evaluation would be
affected as well
-Even though both of them are
separate phases, all of these phases
are overlapping and are overlapping
each other.
Responsibilities of the Nurse
-conduct and document a nursing
assessment of the health status of
the client
-Collect subjective and objective
data
-Modify the assessment as the
client’s status changes
-Report assessment as needed to
the other members of the health
team.
Note:
-So the nurse is like a trumpet
(trumpo) because the nurse will be
the one doing the assessment but
the nurse will be the one as well to
be the stop sign. So the nurse will be
the one to judge if the patient needs
collaboration with the other health
care team or not
-The nurse will be the one to see to it
on which health care team members
or our interdisciplinary team that
comes and goes in interacting with
our patient.
-At the same time the nurse is the
one who assesses and evaluate, so
if the patient status changes, the
nurse assess again because of the
change in th status of the patient, it
would affect as well the needs of you
patient, since there was a change in
the patient.
Functions of the Nurse
-Independent
*Licensed to initiate on the basis of
Knowledge and skills
>So the nurse can initiate
interventions that does not need to
be ordered by the doctor. (or does
not need doctor’s orders)
>So is the nurse allowed to
administer oxygen to the patient?
>It is not because administration of
oxygen needs a medical order since
oxygen is a treatment so it requires
doctor’s order
>But we have a leeway with that
because we have what we call as
well a collaborative, although it still
needs doctor’s order, but if you are
able to justify it then the nurse can
give oxygen
>But in ideal set-up starting of
oxygen needs a medical order.
>So what are the things the nurse
can do if he/she cannot give the
oxygen so independent nursing
action would entail that you can put
your patient up in a high Fowler’s
position, so you let the patient sit, or
you elevate the ehad of the patient’s
bed, so this is an independent
nursing action
>Why did you elevate it? Because of
your knowledge, you have
knowledge beforehand that if the
patient is upright then the patient will
have more expansion in their lugs.
>Neonatal, if the baby is having
difficulty in breathing, we then put
the baby in prone position, because
it facilitates expansion and
compression of the stomach. So
their stomach will be compressed
because apparently bloating of their
stomach causes them to have
difficulty in breathing, doing this
intervention will settle the baby’s
breathing.
>So that is because of the
knowledge and skill that you have
that you are able to do this kind of
independent nursing action
*Do not require an order from
another professional
>Ex. Oral care of patient,giving
teaching to your patient, positioning
of your patient.
*Include physical care, ongoing
assessment, emotional support
(comforting your patient, or Actived
listening), teaching, counseling,
environmental, management, ad
making referrals
>Active listing, to your patient, you
are actively listening to your patient;s
needs. You by listening in to your
patient without being judgmental.
Then you are giving emotional
support already and is considered as
an independent nursing intervention
you are doing to your client
>Environmental management, it is
the manipulation of your patient’s
environment, so if the patient for
example is admitted to the hospital
and the patient is having chills so
you assess the patient and ask why
your patient is having chills and ask
what is the problem.
-And when you assessed the patient
you found out the temperature of
your patient’s AC in the room is low
so managing the environment of
your patient would also be part of a
nurse’s function
-IF it would help with the overall
health of your patient then
manipulation of the patient’s
environment falls under the function
of a nurse.
-If the patient is almost dying then
you refer them immediately to the
physician
Examples of Independent
Functions
- Identify patterns of human
responses to actual or potential
health problems
- Assess health status
- Select, perform, manage, and
evaluate nursing actions
-Dependent
*Under orders or supervisions of a
licensed physician or another health
care provider authorized to write
orders for nursing care (NP) (nurse
practitioner)
>So these are our nurse practitioner
who have the capacity to write down
orders for the nursing care of your
patient.
>Ex, They would order the nurse to
do CPT suctioning Q4, Chest
physiotherapy with suctioning every
4 hours
>So they are licensed already to
write the nursing care or order the
nursing care for the patient
*Include providing medication,
intravenous therapy, diagnostic
tests, treatments, diet, and activity
>The nurse is not allowed to order
the medication, it must be from the
doctor’s order, the nurse can
administer it, but only the doctor can
order the medication, which
medication to be given especially…
>Nurse is not allowed to order CBC
>It is not part of the scope of being a
nurse it is a dependent intervention
which needs doctor’s order
*Nurse is responsible for assessing
need for, explaining, and
administering medical orders (with
client)
Note:
-once the doctor or the physician
ordered something for the client, the
nurse apart from administering it, it is
the function and duty, or
responsibility of the nurse as well to
explain to the patient what is this for
-That is why it is also needed for the
nurse to have a background
knowledge
-in doing an intervention needs
background knowledge to answer
any questions asked by the patient
concerning your intervention.
-You should have a prior knowledge
why you are doing a certain
intervention
-If the patient needs this one or not,
even if the doctor ordered it but the
patient does not need it anymore
-Ex. Doctor ordered anolgesic
because the patient was having
headache and when you went to
your patient;s bedside and you
reassessed you patient and he/she
tells you that he/she does not have
anymore headache that would entail
that the order of the doctor should
not be given because there is no
need for it.
Examples of Dependent Functions
-Administering medication
-Giving treatment
-Execute regimens prescribed by
physicians
Interdependent/Collaborative
*Implemented in collaboration or
consultation with another
professional (PT, social workers,
dietitians, and primary care
providers, RT)
>once the nurse assesses the
patient and the patient needs
exercises because the patient just
had a knee surgery so as a nurse
can you help the patient mobilize
after a few days alone? Or You can
refer this one to our physical
therapist so that safe and effective
exercises can be given to the patient
since it is their specialization.
-So I should refer the patient to our
other health care team members or
collaborative partners in doing care
to our patient.
-So the nurse will be the one to
coordinate with the Physical therapy
department or other collaborative
department.
-So that the Physical therapist can
visit the patient and give teaching on
how to do proper ROM exercises
that are safe and effective (Range of
Motion)
*Includes physical therapy to teach
crutch-walking. (Nurse coordinates
with physical therapy department,
including PT sessions)
Examples of Interdependent
Functions
- Administration of Oxygen
>It became interdependent because
its needs doctors order, but in times
of emergency situation then it can
become an interdependent function,
so you can give it to your patient but
of course you still have to refer and
to inform the physician so that giving
care or intervention to our patient will
not be delayed
- Referral to registered social
workers
- Physical therapy sessions
Criteria for Choosing
Interventions
>In choosing the interventions, so
you now have your assessment, you
problem, your goal, how do you
choose your intervention how do
make intervention?
-Safe and appropriate for Individual
age, health and condition
>Do you think the intervention for a
pediatric case is the same with a
geriatric cases? No because they
have different needs and health
conditions, and their safety margins
are also different
-Achievable with available
resources
>So if you put interventions is it
readily available? Can it be easily
done? Do we have the equipment
needed?
-Congruent with client;’s values,
beliefs, and culture (as well as other
therapies)
Note:
-Interventions must not disrespect
the culture and religious beliefs of
the patient, hence why we must look
at the patient holistically
-You cannot force your beliefs onto
your patient. It is disrespectful
-So you need to see if the
interventions you are doing is in line
with your patient, if the patient would
like the intervention or not? If the
patient would have a hard time in
doing the intervention or not?
-That is why is it very important to be
mindful about this one
Continuation….
-Based on Nursing Knowledge and
experience from relevant sciences
>So we have a basis on where these
interventions that we do come from.
-Within established standards of
care as determined by state laws
and organizations
>It is very important for example this
is important as well if you are talking
about Medicolegal (Medical and
Law)
>So if the standard of care you are
giving to the patient is in congruence
with our law and our hospital policies
or protocols
“The amount of time the nurse
spends in an independent versus a
collaborative or dependent role
varies according to the clinical area,
type of institution, and specific
position of the nurse.”
>Not all intervention is applicable to
your patient, sometimes your
independent nursing action or
intervention is not as effective if
collaborative or dependent nursing
intervention was applied
>Ex. Patient complained of Migraine,
for your independent nursing action
you can do guided imagery so that
the patient will not think about the
headache the patient is
experiencing. So this displace our
patient of not thinking about his/her
headache. But for our dependent
nursing intervention the doctor
ordered pain medication giving
medication to our patient so you
would give importance to the
dependent action because it would
help relieve your patient’s migraine
Beginning of the Nursing
Process
Assessment Phase
-It is a systematic, and deliberate
process
- The nurse collects and analyzes
data about the patient.
- Continuous process carried out
during all phases of the Nursing
Process
>remember ADOPIE we will always
start from our assessment.
>Because the assessment phase
sets the tone, on what is the problem
of your patient it sets the flow to
which direction does your nursling
process goes to next.
- Most critical and crucial
>That is why assessment is very…
- Data Collection
>Assessment is data collection
Focus of Health
Assessment
-Consists of a health history and a
physical examination
>So in taking our health history, you
would ask the patient what are the
pertinent data that is related to
his.her current health status.
>Ex. Patient has a hard time
breathing, so you ask the patient
relevant questions like are you a
smoker? Or do you live in a
household with somebody who is a
smoker? So this is getting pertinent
information that can help in the
assessment of your patient
>Physical examination is where we
look at the patient themselves, which
would include our IPPA
-Purpose?
*To Collect holistic subjective and
objective data to determine a
client’s overall functioning.
*In order to make a professional
clinical judgement
*Includes physiological,
psychological, developmental, and
spiritual data.
Note:
-Subjective data, patient centered,
the patient is the only one that can
say, identify, and verify this kind of
data, Ex. The feeling of itch, pain,
worry, anxiety, etc.
>The feeling of itch you as a nurse
would only know that the area is red,
but the patient is the only one who
can verify or say if that area is itchy
or not, not unless the patient would
scratch it and you notice this cue.
>Patient can only be the one to tell
you if the patient is in pain or not,
nurse cannot identify the pain in
behalf of the patient.
-Objective data, These are signs, or
overt datas something that you can
instantly see in your patient, that are
needed, that we health professionals
used to validate the subjective
data of the patient, Ex. Vital signs,
such as blood pressure, heart rate,
respiration, etc.
>if the patient complains of pain you
would validate that one through
getting the patient;s objective data
like getting their vital signs. So
patients that are in pain would have
increase heart rate, blood pressure,
and respiration.
>So that is an objective data that
can validate the subjective data or
cue of your patient telling that the
patient is really in pain.
Continuation….
-Focuses on how client’s health
status affects activities of daily
living, and how those ADLS affect
the client’s health
>So if you assess the client and the
client is having swelling on their
lower extremities so the assessment
of having this swelling does it affect
the client’s ADLs? Can the patient
walk or not due to this? That is one
of the purpose as why we do the
health assessment of our patient
>What affects can it do to our
patient’s mental health and what
effects will this cause
-Assess how clients interact within
their family and community, and how
client’s health status affects the
family and community. Also, how
the family and community affect
the client’s health status.
>So it is two way how the patient’s
health affect his/her family and
community and how the patient;s
family and community affect the
patient’s health
Case: Diabetic Patient
-A diabetic patient cannot eat the
same food the family enjoys.
-Complications (amputation) limit
him from performing his gardening
task. (Limits his abilities and activity)
>If patient’s already has a diabetic
foot that needs amputation then it
limits the patient o perform tasks.
-Cannot help in the community as a
bus driver (Affects the patient’s ADL
and Source of Income)
Note:
-ADL means Activity of daily living
Continuation…
-A supportive family may find
alternative ways of cooking tasteful
food considered healthy for the
entire family
-Community may or may not have a
diabetes support group for the client
and family
Nursing VS other
Profession on
Assessment
>Once the patient is admitted to the
hospital the first one to assess the
patient is the doctor and the doctor
will do health history, etc.
-So how does nursing assessment
differ from other professional
assessment.
NHA (Nursing Health
assessment) VS other Health
Professionals
-Nursing
*Includes subjective and objective
data
>So we are interviewing the patient
*Physiological, sociocultural,
psychological, and spiritual data.
>Apart from interviewing the patient,
we are also seeing, objective datas
are also being taken from the
patient, not only are we doing
physiological assessment we do
holistic assessment we assess as a
whole.
>Nursing focuses on the whole
aspect of the patient
-Other Examinations/Professions
*Focuses on one aspect only (MD,
PT, and RT)
>Especially for the doctor
*Framework used is different
>They also use a different kind of
framework, Different processionals
use different specific framework on
how they would assess the patient
How about NHS vs MD
(Doctor) assessment?
-according to Dillon:
*Very similar but there are
important differences
*Difference are defined by the
focus and scope of a medical vs
nursing practice
>Meaning if the assessment would
cover the work or responsibility of
the nurse or not.
*Questions may be similar but the
underlying rationale differs
>So same questions with what the
doctor ask but you as a nurse would
have a different rationale on why you
asked this certain question
>When the doctor asks the patient
“where do you feel the patient in
your stomach?” They have a
different rationale why they asked
this, they instantly think of the
medical diagnosis
-The nurse asks is it radiating?, etc.
Because you would assess the
patient holistically on why and the
reason behind the pain of your
patient;s stomach.
Note:
-Doctors/MD focus on one area only
while Nurses treat holistically
Continuation….
*Physicians diagnose and treat
illness
>Doctors do this automatically,
doctor when asking the patient or
assessing the patient they are
already thinking of the possible
reason on why the patient has this
kind of experience, disease, pain
and what would be the treatment
*Nurses diagnose and treat the
patient;’s response to a health
problem.
>nurse treats patient according to >In treating the patient or nursing
the response of the patient to the care for the patient I does not end at
pain the hospital premises, Nursing care
>if the patient;s pain affects their plan also extends to their homes or
ADL, so the nurse would focus the once they return home
intervention on that one, how to *Use data to develop care plan
remove the pain so that the patient including perioperative and
would be able to perform his.her discharge (rehabilitative) plans
ADL >So once the patient arrives and the
>What is the patient;s reaction to nurse is assessing, the assessment
pain, that is the main focus of our would include as well data that is
nursing diagnosis. needed or that we can get so for
example when the patient is already
Case from Dillon in the rehabilitation phase or so that
-Mary Johnson, 81 years old, the patient can return home.
admitted to the hospital due to a
fractured hip. This is How Collaboration looks
-Medical History --> focus on what like
caused the fracture in order to
determine extent of injuries, also
identify pre-existing medical
conditions which would increase
surgical risk.
>Doctor instantly thinks on what
caused the fracture and how to treat
it.
>The Nurse, Doctor, another nurse,
-Nursing History --> focus on what and sometimes other health care
cause the fracture, as well as team are there (PT, speech therapy)
determining the response to injury, would talk and discuss on how to
how it affects every aspect of her continue on with the patients care.
life.
>Nurse does not just focus on the Let’s Collaborate
hip fracture but also what this hip Complete Blood Count (CBC) :
fracture affected the patient;s life as Diagnosis?
a whole.
*How injury affects her ADLs,
looking for strengths that can be
incorporated into the plan of care,
identifying support systems,
incorporated into the discharge plan.
>not only do we stop at treating the
patient we also see how the patient
will be at home. Is there somebody
at home that will help the patient?
>So these are the assessments that
we can take so that we would know >In our CBC we can see what are
as well once that patient would go the important results that we can get
home there is somebody that would from this one.
help that patient recover.
Comparison of Diagnosis
-Iron-deficiency anemia, secondary
to chronic kidney disease (MD-
diagnosis)
>Doctor would diagnose this one
as… because hemoglobin is too low
-Activity Intolerance related to NHA vs Other Health
verbal report of fatigue or weakness
Professionals
as evidence by imbalance between
-Physician:
oxygen supply and demand (Nursing
*Community - Acquired Pneumonia
- Diagnosis)
(CAP), Low Risk
>But if it is as nurse..
>If the Doctor / Physician would be
>So what is the relation? Because of
the one to diagnose this one, their
the low Hemoglobin, Since
diagnosis would be the problem
hemoglobin functions as oxygen
which is the pneumonia or the CAP
carrying capacity, so if lesser oxygen
goes into our system there would be
-Nurse:
imbalance, weakness and fatigue,
*Lobar (Lobular) Pneumonia
which leads to activity intolerance.
(Medical-Surgical Nursing)
>One lobe is only the problem
Note:
>But if you make a problem out of
-further investigate, on what is the
this chest X-ray then the problem will
reason behind the fatigue or
be…
weakness.
*Ineffective airway clearance related
-Based on the background
to increased tracheobronchial
knowledge that you have that is
secretions as evidence by crackles
where the oxygenation would come,
on both lung fields
and then you can make a nursing
>So you described what happens in
diagnosis
pneumonia, Which are there is
-Assess your patient so that you can
crackles in the patient’s lungs,
create a Nursing Diagnosis
secretions, patient will have difficulty
-When making your nursing care
in breathing, patient would have
plan Always put in mind that the
many secretions that cannot be
Diagnosis is based on the patient’s
removed easily
response
>So you will have different Cues and
-Patient’s response is the core
datas from looking at this X-ray or
focus of our nursing diagnostic
the information and then from there
you can make a nursing diagnosis or
Chest Radio graph : Diagnosis?
make a nursing judgment.
>Diagnosis is similar but approach is
different from the medical doctor,
doctor treats the pneumonia, they
will focus more on the treatment to
cure the pneumonia, entialing a lot of
antibiotics for the patient
-While the Nursing Intervention
would be based on the patient’s
response, So nursing diagnosis
(read nursing management)
Medical Management
Nursing Management
Note:
-Based on the Patient’s response
-Respiratory status, did it improve or
deteriorate?
- You would also assess the depth,
the effort, skin color, and mucus of
our patient so you would know as
well what is the status of your patient
-Monitor level of consciousness, if
these secretions blocking your
patient;s airway is affecting already
the patient;s consciousness because
it would affect the oxygenation of
your patient
-In the management of the patient
you can also include the instruction,
patient health teaching, in the patient
health teaching you would instruct
deep breathing, coughing
techniques, so these will relive the
symptoms, or would help the patient
cough out the secretions
-And from these interventions you
are already solving the problems of
your patient.
-Administering analgesics is a
dependent or collaborative nursling
intervention
-When to refer the patient already
can also be a nursing intervention
Skills of Assessment
-Cognitive Skills
* Considered to be a “Thinking”
process
>You need to do a thinking process
which is needed for….
* Needed for critical and creative
thinking, and clinical decision
making
>Is it or is it not pertinent to my
patient;s need or not?
>is this important for my patient or
not?
>Would I be able to identify which is
important in my patient or not
* Theoretical knowledge base
enables you to holistically assess
patients, differentiate normal from
abnormal, as well as identify and
prioritize actual and potential
problems.
>If you assess the patient, you don’t
assess or focus only on what is the
actual problem.
>In assessing the patient as a whole
you can discover as well if the
patient have potential problems]
>So if the patient as well have
potential problems
* Reflective, and reasonable thinking
* Not just doing, but asking “Why”
>Why? For what? Why is my patient
like this?
* Involves inquiry, interpretation,
analysis, and synthesis.
>In doing so you would be able to
inquire better, you can ask more
properly, you can interpret it more
properly, and you can deduce which
is important and which is not
>That is why in assessment it is not
just what you see is what you get,
you have to really reflect and to see
if this is needed or pertinent to your
patient or not.
Critical Thinking Skills
-In doing the assessment you need
to do all these things, you need
critical thinking skills
>In identifying assumptions, so you
identify assumption what was
given in the assessment, so that
according to that one you can make
assumptions based on the data that
have been collected
>Once these data are collected, then
you can organize it and to make it
comprehensive or comprehensible,
your assessment can be understood.
~You cannot assess starting from
the head then you jumped to the
lower extremities
~this is done to avoid confusion
when reviewing the data and
validating the data.
Note:
-Validation, Objective and
subjective data, you cannot
oppose subjective data for it
can only be taken from the
client itself, but what you can
do as a nurse is you can
validate it. You validate it
through our objective datas.
From the objective datas you
would be able to know if the
subjective data that was given
by the patient is really true or
not. So form your own
observation, assessment, and
examination then you can
validate the data you have
collected from the patient. By
matching it with the objective
data extracted from the patient.
-And you should be able to
distinguish what is normal
from abnormal, what is normal
in our patient and what is
abnormal.
-Clustering related cues
(clustering), so you have all
these extensive data, so you
need to cluster these datas,
you group the related cues, are
these needed or should be
considered or not? So that you
can have a more
comprehensive assessment.
by relating them as and
categorized them as related
cues.
-Disgusting relevant from
irrelevant
-Recognizing
inconsistencies, in validation
you can do this one already,
you can already recognize
inconsistencies, what patient
reports and what you examined
are different and does not
match. They do not jive.
-Identifying patterns, this can
be related to behaviors, So
when you do interviews you
don’t only interview the patient
itself in asses you could also
collect data from the people
around the client, not just from
the client themselves. Then you
can identify behavioral patterns
and from there you would know
as well what the patient is
holistically as a whole.
-Identifying missing
information, For missing
information you can ask from
the next of kin of the patient or
the people around the patient,
because some information
maybe omitted because the
patient may be shy, etc.So
these are missing information
that the nurse can pick up if the
nurse asks to others related to
the patient.
>Nurse must think critically on
where can the nurse extract
more information from
-Promoting health by
identifying risk factors. If you
do your assessment you would
be able to identify problems
and risk problems and risk
factors that can contribute to a
problem or the problem of your
patient.
-Diagnosing actual and
potential problems from the
assessment data, so from this
you can set your priorities
and determine patient-
centered expected outcomes.
>So if you have your data you
can already identify your
problem and you can identify
as well what patient outcome
you want your patient to have
-Determining specific
interventions that will
achieve your outcomes,
Interventions must be in line
specifically with the patient’s
needs and problem.
-Evaluating and correcting
thinking, so evaluation is an
ongoing process, so it is
dynamic, so if there are
changes in the patient, or once
we get to the evaluation, and
evaluate if it is affective or not?
If it turns out to not be effective
you then go back to your
assessment. Ask why is the
intervention ineffective? Did I
miss something when
assessing my patient. Then you
correct it why is it not effective
why is the intervention not goal
met so you do the correcting
part and go back to your
assessment.. evaluate your
intervention and if it is goals not
met then return to your
assessment and correct the
mistakes.
-Determining correct plan of
care, if you have the right data
for your assessment and have
collected pertinent data it will
set a tone, it will set the tone on
which direction will your
patient;s care will go or lead to.
Because you know where the
patient is lacking at, where the
deficiency of our patient is, so
we can supplement these ones
and make a care plan out of
this one.
Types of Assessment
According to weber
1. Initial Comprehensive
2. Ongoing or Partial
3. Focused or Problem Oriented
4. Emergency
Initial Comprehensive
-Total or complete assessment
>So you did head to toes
assessment with your patient,
physical assessment, interviewing
the patient, so all aspect of the
patient;’s information that you are
getting
-Other members of the health team
may also participate (hospital -->
physician, PT, dietitian)
>These other health team members
will be present and are getting the
information that they want from the
patient and need as well
-collection of Data
>So In getting all these data we
would have an initial comprehensive
data collection
*Subjective (client’s perception of his
condition)
*Objective (physical examination)
>Not only interviewing the patient,
but you also see what is the
perception of the patient on his/her
condition what the patient thinks,
feel, spiritual, cultural, psychological,
mental, so all these things you would
have to take into consideration as
well.
>And objective date you would have
you PA
Ongoing or Partial
-Occurs after comprehensive
database is established
>So you already have a database or
data of your patient
-Mini-overview of body systems and
health patterns
>but as time goes on there are
changes happening in our patient
sop you are doing an ongoing
assessment, because there are
changes happening to the patient.
-Functions as follow-up on the
health status
>You already have a establish
database created prior, but because
of the changes in the status of your
patient then you do an ongoing
assessment it now serves as well as
a follow-up
>You follow-up on what are the
changes, what happened?, What
was the difference from the
database that you have establish
beforehand to what is happening to
the patient now.
-Problems initially detected are
reassessed to determine changes
(deterioration/improvement)
>If there is something different in our
patient, assess if there is
deterioration or improvement
happening to your patient.
-Brief reassessment to detect new
problems
>or even potential problems
-Usually done by another nurse or
health professional (called the next
shift in the hospital)
>It does not follow that you who has
the done the initial assessment or
the prior database you would be the
one to do a partial or ongoing
assessment, no!
>There would be someone else who
would do the follow up, In hospital
settings it is called the next shift
-Can be done in hospital,
community, or at home.
>Community setting, nurse would
visit, and next week a different
Community health worker would
arrive or would do the follow up
>Would do the follow up if they did
the follow the advice of the
community nurse last week.
-Frequency is determined by acuity
of client
>Acuity, is how toxic is the patient,
so if the patient is really sick then
you need to do reassessment often,
Because the change in the status of
your patient’s health is fast, often,
frequent.
>That is why the Frequency in
reassessment would be determined
by the patient’s acuity
>If the patient is unstable that means
you would need to reassess
frequently
Focused or Problem
Oriented.
-Does not replace comprehensive
assessment
>So there should still be
comprehensive assessment and that
should never be discarded, because
nursling assessment would include
holistic approach.
>We do not replace our
comprehensive assessment and
should always be included
-Done after database is established
(OPOPC, OPNC)
>But the Focused or Problem
oriented can be done when…
>We can do this only if we have
already assessed the patient
holistically
-Thorough assessment of
particular problem.
-Does not cover areas not related
to the complaint
>So Focused or Problem would
focus more on a particular problem,
here we much more thoroughly
assess the patient because this is
the highlighted problem of our
patient.
>So we focus more or do thorough
assessment because there is
already an identified problem for
your patient that is why a thorough
assessment is needed
>If you are doing Focused or
Problem, you will focus on one area
and will disregarded other areas that
the patient did not complain about.
Emergency
-Very rapid assessment during life-
threatening situations (Choking,
cardiac arrest, drowning)
>So if you do not do it or assess the
patient in a live and fasten or quick
manner it can cause death to the
patient.
>So you need to do fast rapid
assessment because you need as
well…..
-Immediate assessment to provide
prompt treatments
>From there you would react
instantly to get the kid that is
drowning and that is your rapid
response.
-Major and only concern is
determine status of client’s life-
sustaining physical functions
>In doing so, in the way you treat or
give intervention to your patient,
would that one impair? Or help the
patient with their life sustaining
physical function.
>Ex. Hospital setting, the patient is
having difficulty in breathing, as a
nurse in this situation, you see the
patient gasping for air, and you
would prompt to give the patient
oxygen because this can sustain the
a life of your patient, and it can avoid
as well life altering disability to your
patient.
Culture and Illness
What is culture?
-Frame of reference in interpreting
and understanding the world
-Values and norms
*All verbal and behavioral systems
that transmit meaning
>So how a Filipino is a Filipino is
compare to a Caucasian, so what
differs us as a person being a
Filipino, as compared to others being
Ex. An American.so that is with our
values and cultural norms is what
differs us from them.
Characteristics of Culture
1. Learned
Note:
-Through life’s experiences and
contact with other culture groups and
transmitted from one generation to
another
>So culture can be acquired through
socialization, and can be learned
through socialization
-We can learn culture through
socialization
2. Shared
Note:
-Norms for behaviour, values, and
belief are shared by a group to a
great extent
-So we have health practices that is
based on the cultural norm
>One example, that is now banned
to be practice is in Africa there is one
group in Africa that they do
Circumcision for women.
3. Associated with Adaptation to
Environment
Note:
-So as the environment changes,
group also changes to improve its
ability to survive
-So culture for example. Badjao in
the past they only stay in their place
or village and they do not want to go
to big cities, but due to the
developmental changes, like no
more or there are fewer fish to catch,
so they need to adapt to the
environment so that they can
survive, so they will go to the cities
so that they can improve or survive
in terms of securing food for their
table or tribe
4. Universal
Note:
-Humans cannot exist without it.
-There is no Human that does not
have a culture that they follow or
belonging to a specific culture
-Anywhere in the world have their
own set of beliefs and set of values
-It may vary between groups but it is
universal
-meaning Culture is always present
Cause of Illness
- Biomedical
- Naturalistic
*(Yin/yang theory, Hot/cold theory of
illness) (Chi)
- Magico-Religious
*(faith healing, witchcraft, healing
rituals)
>because of these ones if the patient
gets sick would first consult these
types of healing or healing that they
believe in or are practicing before
consulting to the actual Doctor
(Makukulam) So that is how th
relationship of our culture would
affect our illness and our health.
Culture-Based Syndromes
-Perceived to be separate Illnesses
within cultures
>Ex. Kid’s stomach aches because
of the culture he would just say that
it is only Empatcho? Or LBM so the
immediate response because of the
culture base knowledge and culture
base belief that it is only Empatcho
or LBM
-Illnesses defined by a specific
cultural group, but interpreted
differently or not even perceived as
illnesses by other groups
>Ex. For us Filipinos after eating
large amount of food the stomach
would ache they would only think
that is is empatcho, but if a different
culture were to experience the same
thing they would think differently
about the situation due to the
difference in culture.
Steps of The Health
Assessment
Steps in Nursing
Assessment
-The steps are:
1. Collection of subjective data
2. Collection of objective Data
3. Validation of Data
4. Documentation of Data
>You don’t stop only in collection but
you need to validate it as well, is it
right? Is it congruent with the
objective data that I got, Then lastly
you need to document it, remember
if it was not documented then that is
not present in your patient.
-Tend to overlap
>These steps can overlap with each
other, so while you are asking you
are observing the patient, and while
you are observing you are validation,
and as you do all these you are
documenting.
-May perform 2 or 3 steps
concurrently
>So you can do these ones
simultaneously or concurrently
Preparing for the
Assessment
Client Preparation
-Review the client’s medical record
>So you must have prior knowledge
about the patient
>Before you go to the patient’s
bedside you review the medical
record of your patient.
>Life interviewing the patient and not
reviewing the medical record of your
patient and apparently you did not
know the patient is deaf.
-keep an open mind and avoid
premature judgments (dec.
(decrease) Accuracy of data
collection)
>Do not be biased when taking the
data of you patient which will lead to
a decrease accuracy in the data
collection
>DO not judge others base on your
beliefs and values
-Use time to educate self about
diagnosis and test performed
>You need to know the
interventions, tests, diagnosis that
was performed on the patient.
-Self-awareness (reflect on own
feelings) regarding first encounter
with the client
>Be aware of your own feeling so
that you will not contaminate or
influence your data collection (keep
your feelings to yourself)
-Prepare all materials needed
>You must have all the materials
needed for the interventions, test or
diagnosis you will do to the patient
before hand.
>So you will not take up the time of
your patient, and you will not lose
the flow of your assessment
-Review the Client’s medical record
*Familiarize biographical data (age,
sex, religion, educational level and
occupation)
>So that when you ask your patient
you would already know what is
important or not
*Provides background of chronic
disease and clues how the present
illness impacts ADLs
>So does the patient have any
comorbidity in their complaint today,
did his./her comorbidity affect in
his/her sickness today.
*Awareness of past and current
health status guides interactions
with client
*Information can also be procured
from other members of health team,
and significant other.
>If an information is not present in
the charting of your patient, so you
can ask other health care team
members. Since they have their own
assessment
>You can also ask the next of kin
-keep an open mind and avoid
premature judgments (dec.
(decrease) Accuracy of data )
* Do not assume a 30-year old
female client, an RN knows
everything about hospital routine and
medical care
>Do not make a premature
judgment, you do not make any
assumptions, or you do not assume
anything if the nurse is practicing or
not.
>Because if you are assuming the
data of your patient, or are assuming
the knowledge that your patient has
you are already decreasing the
accuracy of your data.
*Nor assume a 60-year old male
client with DM (Diabetes) needs
client teaching regarding diet
>You do not assume that the patient
needs further teaching because the
patine this already s old or old
enough, this will decrease accuracy
of data collection
*Do validate information and be
prepared to collect additional data
>So when you ask or validate the
data that the patient told you, so
when you validate information to
them be prepared there is a follow
up question and follow up data that
needs to be documented too.
-Use time to educate self about
diagnosis and tests performed
* Unfamiliar medical diagnosis
>You need to educate yourself, what
is this test for and how do you do
these test
>If patient as well has an unfamiliar
medical diagnosis and when you
check the patient’s chat is
ALLTCALL, and you do not know so
you need to know and educate
yourself on what is this one
>Then you instantly go to your
patients room without knowing what
is anything at all and when you
arrived you were reprimanded by the
watcher because why did you enter
the patient’s room
>Because ALLTCALL is Acute
lymphobastic leeukemia to consider
acute mycoblastic leukemia, so
patient has leukemia and they do not
want some people to just get in their
room because the patient is
immunocompromised
>So the nurse should know what is
the statues of your patient
* Special blood tests (abnormal
results)
* Consult available resources
(laboratory manual, textbook, or
electronic references)
>So if we have unknown test that we
do not know what are their purpose
then use the available resources to
educate yourself.
-Self-awareness (reflect on own
feelings) regarding first encounter
with the client
>You prejudged and you have a bias
so you are not already objective and
you as a nurse become subjective In What is Data Collection?
collecting your data, SO NO!
>Subjective data should be from the What is A Database?
patient alone
*Case : 22-year old with drug Definition to Know
addiction, but you do not drink, -Data collection
smoke, take illegal drugs, or drink * Process of gathering information
caffeine about a client’s health status
>You did not know that he became a
drug addict because of prescription -Database
drugs, So do not judge and be *All the information (pooled) about
biased the client
*To avoid biases, judgment, and >That you got from the client
projecting those judgments (be *Nursing health history, physician’s
objective and open) history and PE (Physical
*Other cases : STDs, amputation, Assessment/Examination), results of
paralysis, HIS/AIDS, abortion, sexual laboratory and diagnostic tests, and
preferences, PWDs who are other material contributed by
cognitively challenged. members of the health care team.
>Just because the patient has HIV
you distance yourself, (NO!) Collecting Subjective
>Instead of talking to the patient face
to face you distance your self, So Data
think of how the patient would feel,
so you would already be biased in Subjective Data
your data collection -Sensation or symptoms (Pain,
hunger)
Note: -Feelings (happiness, sadness)
-The nurse must not be Subjective >Patient will be the only one to
and input his/her own Subjective verbalize this one
views and data about the Patient, -Perceptions
THE SUBJECTIVE DATA MUST BE -Desire
FROM THE PATIENT. -Beliefs and Ideas
-Values
-Prepare all materials needed -Personal Information elicited and
*Equipment (stethoscope, verified only by the client himself
thermometer, etc.)
*Interview tools/questions.forms Note:
-This information can be retrieved
Note: through our client
-Interview tools/questions.forms -remember that this data can only be
should be ready and prepared verbalized by the patient
before hand to avoid dead air
conversation with the patient. Subjective Data
-Helpful when losing your train of -Sensations or Symptoms (pain,
thought hunger)
-Ready forms you want to follow - Feelings (happiness, sadness)
-Perceptions
-Desires
-Beliefs and Ideas
-Values >So subjectively the patine this
-Personal Information elicited and saying that he/she bathe but
verified only by the client himself obstructively as an observer you
look that the patient is really untidy
-Major areas: you are already validating see.
* Biographical Information (name, * Behavior (mood, affect)
age, religion. Occupation, etc.) >apart from what the patient is
* History of present Health saying and one of our subjective
concern (physical symptoms related data is the patient's mood
to each body part) >So you can observe the behavior of
*Personal and Family Health the patient and the face or facial
history expression of the patient to to
*Health and Lifestyle practices validate the mood of the patient.
(risky, nutrition, activity, >Even the intonation of the patient;s
relationships, cultural beliefs, voice can be observed from the
practices, family structure and patient’s behavior
function (bread winner, etc.), * Measurements (BP, height,
community environment) weight, temperature)
* Laboratory test results
>patient should be the one to give (complete blood count, x-ray)
these information >You have result that becomes an
>Nutrition, what is he/she eating, objective data that is tangible and
how much is the patient eating in a you can touch, and see.
day *Obtained by general observation
>Even the family structure, if the and PE techniques (inspect,
patient is married, divorced, auscultate, palpate, percuss)
adopted? >We can also get objective date by
>and even the function of the patient doing a Physical Exam or Physical
in the family, bread winner, light of Assessment.
the house, etc. *Taken from EMHR (another source
(of data)), through the entries of
Collecting Objective Data other health care professionals
>EMHR it is a data source of the
patient’s information, this is where
Objective Data we gather and put our
-Directly Observed by the documentation, so this is the
examiner: documentation of the database.
>When you do direct you look at the >Our database is usually found in
patient by looking at the… our EMHR and is another source of
* Physical characteristics (Skin data that we can get from our client,
color, posture) *Can also be from patient’s family
* Body functions (heart rate, members
respiratory rate)
>You have a number or data that *obtained to validate subjective
you can see data and to complete the
* Appearance (dress and hygiene) assessment phase of the nursing
>So you ask if the patient has bathe process.
but when you look at them they look >Once there is a subjective data
like they haven’t bathe or they smell then you have to validate it using
your objective data, does the
subjective data jive with my objective
data to complete the assessment
phase of the nursing process.
>So in our Nursing assessment
objective and subjective data should
always be present

In Comparison

Factor Data Objective

Description Data Data directly/indirectly observed through measurement
elicited and
verified by
the client
Client Observations and PE by the nurse or other professional
Resources (even if our assessment is done by the doctor or other
health care professional these are still data that we can
use because we are not the only ones who take care of
the patient it is a collaborative team work ) (So objective
data is shared with our health care workers)
Client Documentation of assessments made (If you examined
record the patient you should record tour observations and what
is the result of your examination)
Other Observations by client’s family of significant others
health
professiona
ls
Factor I have a headache
Method Client interview
used
Interview and therapeutic Inspection
Skills communication skills
needed Caring ability and empathy
Listening Skills
I have a headache
Example It frightens me.
s I am not hungry
-In summary if subjective data, then
it is gotten or taken from interviews
-For objective data it can be taken
from Observation or physical
assessment or Physical examination
-Skills that you would need in getting
the subjective data you would have
to have good communication skills,
you know how to communicate with
you patient, you know how to listen
and to be empathic to your patient,
you know how to state your
questions in a way that is respectful
and you know how to listen to your
patient’s response.
-In objective date, You would use
you IPPA (Observation, Palpation,
Percussion, and auscultation) that is
how you can get you objective data.
-Reminder if there is a subjective
data from your patient it should be
written in verbatim, exactly what your
patient told that is exactly what
-------------------------------------------------------------------------------------------------------
Validation of Data
>The act of double-checking or
verifying data to confirm that it is
accurate and factual
>Not all data require validation e.g.
Height, weight, birthdate (most data
can be measured with an accurate
scale)
I have a headache
Observation and PE
Palpation
Percussion
Auscultation
RR - 16 bpm or cpm
BP 180/100 mmHg
X-ray film reveals fractured pelvis
should be transcribed, it should be
word form word from what the
patient said , you cannot rephrase or
translate it as well.
-So “I have a headache” so that is
subjective data because the patient
is the one telling you that he/she has
a headache
-so how you check for the objective
data of the headache? You check
the vital signs of the patient
-You found out that the BP of the
patient is high so it further proves
that the patient is really experiencing
a headache, so that is the difference
in data that you can have
>RULE: Validate data when there
are discrepancies between data
obtained during the interview and the
physical exam, or when the client’s
statements differ at different times
-Crucial part
>because you need to know if these
data are reliable or not, since if your
data is not reliable your diagnosis
will be wrong, and if your diagnosis
is wrong you plan of care and
intervention will also be wrong
-Occurs along with collection of
data
>So validation is overlapping, you re
ask the patient or reconfirm to the
patient, or re-observe from the
patient.
-Ensures the assessment process is
not ended prematurely (all relevant
data is collected)
>When you assess the patient make
sure you complete the information to
prevent frequent asking of the
patient for data.
-Help prevent documenting
inaccurate data
>So if you are able to validate it, the
lesser the chance that you would
have an inaccurate data since you
have already validated or rechecked
it.
-Process of confirming or verifying
the data collected are reliable and
accurate
-Steps:
1. Decide which data need
validation
2. Determine ways to validate data
3. Identify areas which data are
missing
>So when validating your patients
information you have to see or make
sure what from all these information
is real or not, reliable or not
>You look on the data the you have
collected since it is a different matter
as well if you validate everything
>The patient would have an
impression that you are not believing
in what the patient is telling you
>So you have to apply critical
thinking on what among these
information should you validate or
not
>So application of critical thinking is
still very important
>How you validate it
~So who you rephrase it, how you
do the validation
~How do you check or how do you
recheck
~if these information that the patient
told you is real or reliable?
~So you need to determine ways on
how you can validate the data.
Do All Data Require
Validation?
-No, do validate instead:
>No need to validate everything,
what you do need to validate is….
*Discrepancies --> gaps in the
information
>You observe that what you see and
what the patient is saying is not
matching so you validate it.
-subjective vs. Objective data
(happy vs cancer)
Note:
-yes it needs to be validated, for that
patient says his happy despite him in
the state or process of dying.
Continuation…
-What client says at different times
(history of childbirth)
>So when you see the patient says
that she gave birth 2 years ago and
then you look into your data that you
have collected previous to that the
patient’s say the she has a 5 year
old son, SO this is a discrepancy,
and this needs to be validated.
>So do a follow up question (Maam
do you have any other children?)
and validation if what the patient told
is true or not
-Abnormal findings (inconsistencies
in pain/fever presentation)
Note:
-Patient says he is in great pain
despite him looking so relaxed, so
there is inconsistency in the patient;s
pain, although pain is subjective but
how the patient is behaving is not in
congruence with what the patient
reported.
Methods of Validation
-Recheck own data (repeat
assessment)
>You reassess again
-Clarify data by asking additional
questions
>Follow up questions
-Verify data with another health
professional
>Ask the Doctor and to her health
care team.
-Compare the objective data with
subjective data findings
>So comparison to where are the
discrepancies
Identifying Areas of Missing
Data
-Go through the database
established
>Go through the database and look
into what is missing in our database
>Again in our database contains the
patient’s Biodata, biophysical,
spiritual, psychosocial. So all the
data not only the data that you as
the nurse collected but also the data
collected by the other health care
teams
-Consider areas you may have
overlooked:
* 98 lbs patient (lost vs usual weight
over time?)
>So you can know that one if the
patient lost a lot of weight and from
the data base that was taken from
the other health care provider says
that the patient was 120 lbs
>And you are doing an ongoing data
assessment, since we already have
a prior data based, and you collected
that the patient went from 120 lbs to
98 lbs, so this tells you that the
patient lost weight in an X amount of
time.
>So how fast was the weight lost of
the patient?
* Lives alone (existence of support
system, ability for independent
function/self-care and degree of
social involvement)
>Is the patient active in the
community? (Church, community
outreach)
Sources of Data
-Primary --> Client
>primary source that we can get our
data from is form the client itself, the
best source is always the client
>but it does not mean that we can
only strictly get form the patient itself
>Meaning….
*Unless too ill, young, or unable to
communicate clearly (stoke)
>So your source of data would not
bee the client anymore, so we can
get our secondary data
*Emphasis on subjective data only
he can provide
-Secondary --> all sourced other
than the client
*Support system (family members,
friends) (care givers)
>People surrounding the patient
*Client records (medical records,
lab results, therapy records)
>Patients chart, from here we can
get patient’s data about the said
above
*Health care professional
(members of health team which have
had previous or current contact with
the clients)
>Ask other health care professional,
what is the difference in terms of
behavior and in terms of how the
patient is currently
*Literature (nursing and other
professional journals)
>from the literature we can know
what is the norms, or the standard
developmental task, standard height
and weight of a certain age group.
(underweight, obese, overweight)
>These are literatures that can tell
you what is the patient’s information
 > Builds rapport (open-ended
questions, empathy)
~The non-directive or letting the
patient take the wheel to where the
conversation is going….

Data Collection Methods

Note:
-This helps the nurse identify the
Data Collection Methods
what is important to the patient. You
1. Interview
would know that one are you would
2. Observation
be able to pick up that one
3. Physical Assessment
-because the patient would talk more
4. Medical Records Review
about that on, or even if it is negative
you can pick up what was not
Interview Method mentioned by your patient.
-Planned and purposeful
conversation
>There should be a direction that
The Interview Questions
your conversation is following, there
>in doing the interview you have our
should be an end result or data that
close-ended, open-ended, neutral,
you would want to take from the
and leading types of quesition
patient
>So it needs to be or the structure
communication needs to be done to
obtain subjective data.
>So in doing interview method you
need to have communication skill
>In doing the interview you can do it
in 2 approaches: Types Description
A. Directive Closed/close Limits the
>Highly structured and elicits ended response that
specific information can be given
~you follow a certain questionnaire when, where,
or form when interviewing them\ who, what
> Nurse establishes purpose of an DO (did, does)
controls interview (close-ended Is (was, are)
questions) Sometime
~So the nurse will be the one to How
make or be the one to have the say >So what is
in what the questions would be being asked is
B. Non-Directive what the patient
~It is rapport building will answer
> Client controls the purpose, >Most often
subject matter, and pace times the answer
~The nurse allows the client to talk, of our patient is
to what the patient or client wants to only yes or no
verbalize and the nurse simply >So a yes or no
listens. questions
>Ex. Do you feel
 pain? Patient >So you ask
answers Yes or questions from
No? the patient that
Open/open Invites clients to can lead to
ended explore thought answers you
or feelings already know
(Elaborate, that the patient
clarify, or has
illustrate)
>so you ask the Observation Method
Patient “what -Gathering data with the use of
brought you to sense:
the hospital?” >So nurse uses his/her senses, what
>so the patient are these sense:
will elaborate *Vision (body size, skin color and
what brought lesions)
him.her to the >Bruises, or cuts
hospital *Smell (body and breath odors)
>So the pateint *Hearing (lung and heart sounds,
will also and bowel sounds)
elaborate what is *Touch (Skin temperature and
the problem and moisture)
what prompted
him/her to go to
Physical Assessment Method
the hospital
-Inspection --> careful and critical
Neutral No direction or
observation
pressure from
>So you look at the patient, and you
nurse
have to be critical on what you see in
>Basically you
your patient
are just making
>if you patient for Example prefers to
conversation to
sit upright on bed even when
the patient
sleeping so you can see that one, it
>There is no
is a critical observation, ask why this
direction top
is his/her preferred position and what
which you
is the problem that have caused this
conversation with
-Auscultation --> listening through a
the patient or
stethoscope
what you want to
>Equipment is needed
know from the
-Palpation --> touching and feeling
patient is going
.apart from looking you have to
to.
palpate you have to check for the
Leading Directs the are involved
client’s answer -Percussion --> touching, tapping,
>So if you are and listening
pointing out for >You need to listen and tap because
the patient to of the sound that is being emitted.
answer a specific >When you do percussion sound will
question that you be there and from that sound you will
want to hear know what is the meaning of that
from the patient. one.
>So when you percuss waht would
that sound mean? What is the
significance of that one
Obsolete Way of
Auscultation
>In the past this is how you
auscultate, but it is now obsolete and
is not applicable today because you
can be sued for sexual harassment
by the patient
Medical Records Review
Method
-Go through the medical record to
add to the comprehensive
assessment
>When reviewing medical records
we can also get subjective datas
from the medical records as well
>So in getting subjective data we
need to go through our medical
record so that we can add that one
to the comprehensive assessment
>So if the patient was admitted to
your hospital a year ago or
something similar compare the
information in the medical record
from a year ago to the data that you
currently have, patient’s complaint a
year ago to now, the patient’s weight
from today to a year ago.
Organizing The Data
-Use of written (or computerized)
format that organizes the
assessment data systematically
>So by system so that you will not
be Confused
.You start from head to toes and you
note last the reflexes and cranial
nerves so that is why it is important
you do this systematically so that
you will not be lost or confused.
-Organized according to different
models
*Nursing Conceptual models
(Gordon’s functional health patterns,
Orem’s Self-care model, Roy’s
adaptation model)
>So we have conceptual models in
which we can organize the data.
>So this data or problem where
should it be placed? It can be in the
health pattern. For this data can be
in sexual pattern. This data can be in
the health perception.
>So you can organize this one
according to the nursing conceptual
models
*wellness models
>In the wellness model you
categorized them into normal or
abnormal ini your patient
*Non-nursing models (Body
systems model, Maslow’s Hierarchy
of needs, developmental theories)
>So the data you collect, you gather
them according to which model you
want to use.
Body system models, do you place
them according to system
>Maslow’s Hierarchy of needs, can it
be categorized as basic needs?
Spiritual needs? Psychosocial
needs?
What Models Do We Use?
-Maslows’s Hierarchy of Needs
-Gordon’s 11 Functional Patterns
>We use 2 specific models when
doing our assessment or organizing
the data form our health assessment
>To know which is the need of our
patient.
 ~Morality, creativity, spontaneity,
problem solving, lack of prejudice,
acceptance of facts

-So the data you have collected

Maslow’s Hierarchy of Needs
>In identifying the need of your
patient you need to categorize or
organize you data
where do they categorize according
to the hierarchy of needs by
Maslow’s

Gordon’s Typology
Health Self-Perception/
Perception/Managem Self-concept
ent
Nutritional/Metabolic Role/Relationship
Elimination Sexuality/
Gordon’s 11 Functional
Reproductive
Activity/Exercise Coping/Stress- Patterns
Tolerance -Another model that we use it
Sleep-rest Value/Belief Gordon’s Functional health patterns
Cognitive/Perceptual -In Gordon’s Functional Health
Patterns we have 11

>if the data you collected does it talk

about nutrition, is the data you have
collected about the nutrition of your
patient
>or is it about Health perception,
what the patient view about his/her
health, so what the patient thinks
-So in organizing the data according
about his/her own health
to Maslow’s Hierarchy of Needs
>Elimination, if the bowel pattern of
your patient is normal or abnormal
-So you categorize if the data is:
*Physiological
>So once you have the data
~Breathing, food, water, sex, sleep,
grouped and organized then from
homeostasis, excretion
there you would be able to focus and
*Safety
you can further narrow down what is
~Security of body, of employment, of
really the problem of the patient.
resources, of morality, of the family,
>You would be able to narrow it
of health, of property
done and you will be able to focus in
*Love/Belonging
making a plan and intervention for
~Friendship, family, sexual intimacy
your patient.
*Esteem
~Self-esteem, confidence,
achievement, respect of others,
respect by others
*Self-actualization
 Constructs of Cultural
Documenting the Data Competence

Documentation Cultural Assessment

-Record in a factual manner (do not -Systematic appraisal of individual
interpret) (do not summarize) beliefs
>Nurse cannot interpret
>What the patient said should be the Cultural Competence
one that is written down, transcribed, -Complex integration of knowledge,
or documented (Verbatim or word attitudes, and skills
per word) -Enhance cross-cultural
>If it is a subjective data it should be communication
recorded in verbatim, word per word, -Promote meaningful interactions
cannot be translated or interpreted. with patients
-Enable one to provide culturally
appropriate, congruent, and relevant
Documenting Data
health care
-Data are recorded in a factual
manner and not interpreted by the
Components
nurse.
1. Cultural awareness -
*Example
2. Cultural Skill
The nurse records a client’s
3. Cultural Knowledge
breakfast intake:
4. Cultural Encounters
“coffee 240 ml, juice 120 ml, 1 egg, 1
5. Cultural Desire
slice of toast”
>So if the nurse records a specific
Cultural Awareness
data and the nurse is factual then it
-Deliberate, cognitive process in
becomes an objective data (This is
which the healthcare provider
good)
becomes:
>Appreciative and sensitive to the
“Appetite good”
values, beliefs, life ways, and
.But if the nurse records appetite
practices of a client’s culture
good then it becomes a judgment,
on the nurses part, so the nurse
Stages of Cultural Awareness
interprets, nurse already has bias in
his/her observation and data.
Unconscious Incompetence -->
Conscious Incompetence -->.
-To increase accuracy, thee nurse
Conscious competence -->
records subjective data in the client’s
Unconscious competence
own words.
>Recording should be verbatim

Increasing Accuracy in
Documentation
-Record subjective data in the
client’s own words

Unconscious Incompetence
- Not aware that one lacks cultural
knowledge. Not aware that cultural
difference exists
Conscious Incompetence
- Aware that one lacks knowledge
about another culture
- Aware that cultural difference exists
- Doesn’t know how to communicate
with a client from a different culture
Conscious Competence
- Consciously (actively) learning
about a client’s culture
- Providing culturally relevant
interventions
- Aware of differences between
cultures
- Able to interact effectively (despite
this)
Unconscious Competence
- Able to automatically provide
culturally congruent care to clients
from different cultures
- Experienced with a variety of
cultural groups
Causes of Illness
-Biomedical
-Naturalistic (Yin/yang theory,
Hot/cold theory of illness)
- Magico-Religious (faith healing,
witchcraft, healing rituals)
Culture-Based Syndromes
-Perceived to be separate illnesses
within cultures
-Illnesses defined by a specific
cultural group, but interpreted
differently or not even perceived as
illnesses by other groups
Culture-Based Syndromes
-Latin (American/Mediterranean)
-Africa and African Origin in
Americas
-Native American
-Middle Eastern
-Asian (South or East)
-North American/Western Europe
Latin (American/Mediterranean)
Ataque de nervios - Results from
stressful event and build up of anger
over time. Shouting, crying,
trembling, verbal or physical
aggression, sense of heat in chest
rising to head.
Empacho- Especially in young
children, Soft foods believed to
adhere to stomach wall, Abdominal
fullness, stomachache, diarrhea with
pain, vomiting; Confirmed by rolling
egg over stomach and egg appears
to stick to an area.

Mal de ojo- Children, infants, at
greatest risk? Women more at risk
than men? Cause often thought to
be a stranger’s touch or attention?
Sudden onset of fitful sleep, crying
without apparent cause, diarrhea,
vomiting, and fever?

Mal puesto/Brujeria - Belief that
illnesses are supernatural in origin
(witchcraft, voodoo, evil spirits, or
evil person; Anxiety, gastrointestinal
complaints, fear of being poisoned or
killed.

Susto- Spanish for “fright”;
Caused by natural (cultural
stressors) or supernatural (sorcery
or witnessing supernatural
phenomenon). Nervousness,
anorexia, insomnia, listlessness, Confusion, Excitement, May have
fatigue, muscle tics, diarrhea hallucinations or paranoia.
 
Caida de la mollera - Mexican term Low Blood - Not enough or weak
for “fallen fontanel” Caused by blood caused by diet.
midwife failing to press on palate
after delivery, Falling on the head, Native American
Removing the nipple from baby’s Ghost sickness (Navajo) - Feelings
mouth inappropriately, Failing to put of danger, confusion, futility,
on a cap on newborn’s head; Crying, suffocation, bad dreams, fainting,
fever, dizziness, hallucinations, loss of
vomiting, diarrhea are indicators of consciousness; Possible
this condition, Similarity to preoccupation with death or
dehydration someone who died.

Africa and African Origin Hi-Wa itck (Mohave) - Unwanted
(Americas) separation from a loved one;
Falling out/Blacking out - Sudden Insomnia, depression, loss of
collapse preceded by dizziness, appetite, suicide.
spinning sensation; Eyes may 
remain open but unable to see, May Pibloktoq or Arctic hysteria
hear and understand what is (Greenland Eskimos) - Abrupt
happening around them but unable onset, Extreme excitement of up to
to interact. 30 minutes, Followed by convulsive
seizures and coma lasting 12 hours
Rootwork - Belief that illnesses are with amnesia of event. Withdrawn or
supernatural in origin (witchcraft, mildly irritable for hours or days
voodoo, evil spirits, or evil person; before attack, During attack may tear
Anxiety, gastrointestinal complaints, off clothing, break furniture, shout
fear of being poisoned or killed obscenities, eat feces, run out into
 snow, do other irrational or
Spell - Communicates with dead dangerous acts
relatives or spirits; Often with distinct 
personality changes. Not considered Wacinko (Oglala Sioux) - Often
pathologic in culture of origin. reaction to disappointment or
 interpersonal problems; Anger,
High blood - Slang term for high withdrawal, mutism, immobility, often
blood pressure; Also for thick or leads to attempted suicide.
excessive blood that rises in the
body, Often believed to be caused Middle Eastern
by overly rich foods Zar - Experience of spirit
 possession, Laughing, shouting,
Bad blood - Blood contaminated; weeping, singing, hitting head
Often refers to sexually transmitted against wall. May be apathetic,
infections. withdrawn, refuse food, unable to
 carry out daily tasks. May develop
BOUFEE DELIRIANTE (HAITI) - long-term relationship with
Panic disorder with sudden agitated possessing spirit. Not considered
outbursts; Aggressive behavior, pathologic in the culture.
Asian (South or East)
Amok (Malaysia) -Occurs among
males (20-45 years old) after
perceived or slight insult. Aggressive
outbursts, violent or homicidal,
aimed at people or objects, often
with ideas of persecution; Amnesia,
exhaustion, finally returns to
previous state.

Koro (Malaysia, Southeast Asia) -
Fear that genitalia will retract into the
body; Possibly leading to death,
Causes vary, including inappropriate
sex, mass cases from belief that
eating swine fluvaccinated pork is a
cause. Similar to conditions in China,
Thailand, and other areas
 So it uses your sense of vision
Latah (Malaysia) - Occurs after
traumatic episode or surprise.
Exaggerated startle response
(usually in women). Screaming,
cursing, dancing, hysterical laughter,
may imitate people,
hypersuggestibility.
 you can do the assessment with the
Shen kui (China)/ Dhat (india) -
Similar conditions that result from
belief that semen (or “vital essence”)
is being lost; Anxiety, panic, sexual
complaints, fatigue, weakness, loss
of appetite, guilt, sexual dysfunction,
with no physical findings.
 talk, or if the patient is pediatric or
Wind illness (Asia) - Fear of wind or
cold exposure, Causing loss of
YANG energy.
North America or Western
Europe
Anorexia nervosa - Associated with
intense fear of obesity; Severely
restricted food and calorie intake.
 disability from your patient, example
Bulimia nervosa - Associated with
intense fear of obesity; Binge-eating
and self-induced vomiting; Use of
laxatives, or diuretics
End questions:
-Observation is what you can
observe from the patient without
doing anything to the patient yet
-So you observe already you patient
-but when you do physical
assessment so you do physical
examination still you use senses on
you patient but you now you already
have a physical contact with your
patient.
-if the patient is not cooperative then
family members or the people
around the patient. So not all
assessment can be get from the
patient alone especially if the patient
is extremely sick, patient is
intubated, or has a hard time
breathing making them unable to
neonatal, or if the patient is having
problems what communication, so
then you can use the family
members to get subjective datas.
-We have specific nursing
interventions, in emergency
situations you can give patient
oxygen since it can save the
patient’s life or it can prevent
if the patient is really having a hard
time breathing to the point there is
already decreased oxygen in the
brain causing Hypoxia which may
lead to our patient getting eschemia.
-so because of that one you can by *So you will not be loss in your
pass it only in emergency situation, it documentation
is not done always but only during -Assessment should be systematic
emergency stuations
-Because again Oxygen is needs a 4 types of assessment
medical Doctor or it needs doctor’s 1. Initial comprehensive
Order since it is a treatment *Holistic data should be collected
-because you are trying to save a life *New patients
during an emergency situation and in 2. Ongoing
saving that life this intervention *Old patient (has pre-existing data in
needs to be done that is why it can the data base)
be done again there is a leeway 3. Focused/Problem - oriented
when we can give oxygen to the *if there is a specif problem a patient
patient even without the doctor’s is complaining about
order. 4. Emergency
*
Tools/Equipments needed
-Penlight (white light) Diagnosis
-Gauze pad -Once you have all the data you
-Tongue depressor should then cluster these data
-Ruler through Maslows’s hierarchy of
-Scissors (Bandage Scissor) needs and Grodon’s Health patterns
-Pencil -Once data has been clustered then
-alcohol you can proceed to diagnosing it
-Face mask -From the nursing diagnosis you can
-Cotton buds identify what the problem is from the
-Acetone patient if its is…
-Cotton balls or buds *Problem based
-Snellens Chart (Optional) *Risk based
-auto scope (Optional) *Health maintenance (if patient has
-Tuning Fork (Optional) no problem) (further solidify the
knowledge of your patient so that
Review: they can maintain their health)
Nursing Process -NANDA (North American Nursing
A - Assessment Diagnosis Association) where all the
D - Diagnosis diagnosis can be found for each
P - Planning possible problem a patient is facing.
I _ Implementation/Intervention -Nursing diagnosis is Based on the
E - Evaluation patient’s Human response
-While medical diagnosis talks about
Assessment the illness itself
-Collecting of Data -While the nursing diagnosis talks
*Subjective data about the patient’s response to the
*Objective Data illness
-needs critical thinking for
assessment to identify Normal from Planning
abnormal -After the Nursing DIagnosis
-Validate your data -here you Identify your goal, Goal
-Document your Data planning, Identify what your are
patient‘s needs
-When Planning for a goal of Care or
plan of care always remember the
acronym SMART
S - Specific
M - Measurable (should be gauge)
A - Attainable (achievable with the
set time?)
R - Realistic ()
T - Timely ()

Intervention
-Nursing action you want to do to
your patient
-These action can change the
outcome of your patient
-Your nursing intervention must
change the outcome of your patient
-Nursing actions
*Independent - no need doctors
order
*Dependent - need doctors order
*Interdependent/Collaborative -
referral to other professional

Evaluation
-Here you would know if its effective
and successful or not
-If not then Re-Assess or Do go back
to your Assessment and assess the
patient again.