INSTRUCTOR MANUAL for Health & Physical Assessment in Nursing 3rd Edition by D'Amico & Barbarito.

CHAPTER 1 HEALTH ASSESSMENT

Learning Outcomes 1. Distinguish various definitions of health.

• Suggested Classroom Activity: Ask students to distinguish between the older traditional definition of health and the current definitions of health.

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Suggested Clinical Activity: Have students ask a healthcare provider which model of health he or she incorporates in to his or her practice.

2. Relate the goals and objectives of Healthy People 2020 to health assessment in nursing.

• Suggested Classroom Activity: Ask students to review the health topics in Healthy People 2020 listed in this chapter and then ask students to provide one healthcare topic they would add to the list of public health concerns and discuss the importance of that topic.

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Suggested Clinical Activity: Ask students to discuss with a healthcare provider how he or she incorporates the goals and objectives of Healthy People 2020 into his or her practice.

3. Explain the steps of the nursing process.

• Suggested Classroom Activity: Ask students to choose a healthcare topic of public concern and discuss how they will utilize different elements of the nursing process— assessment, diagnosis, planning, implementing, and evaluation—in assessing that problem in a community or a population.

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Suggested Clinical Activity: Ask students to discuss with a registered nurse the benefits of using the nursing process in managing patients’ care.

4. Identify the key components of health assessment in nursing.

• Suggested Classroom Activity: Ask students to discuss the relationship between effective communications and obtaining accurate data in performing a client’s health assessment.

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Suggested Clinical Activity: Ask students to conduct a focused interview related to an impaired body system of a patient.

5. Explain the role of the professional nurse in health assessment.

• Suggested Classroom Activity: Ask students to discuss the importance of confidentiality in obtaining a client’s health history.

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Suggested Clinical Activity: Ask students to discuss with a registered nurse the advantages and disadvantages of using electronic medical documentation.

6. Apply the critical thinking process to health assessment in nursing.

• Suggested Classroom Activity: Ask students to discuss the role of evidence-based practice in critical thinking.

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Suggested Clinical Activity: Ask students to discuss with a registered nurse his or her definition of critical thinking and explain how he or she uses critical thinking in delivering patient care.

7. Outline the key elements of an effective teaching plan.

• Suggested Classroom Activity: Ask students to assume the role of educator and choose two teaching methods. Compare and contrast the advantages and disadvantages of these two methods.

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Suggested Clinical Activity: Ask students to list factors and patient considerations that they must contemplate in developing a health education presentation for a specific population.

Key Concepts 1. Changes in healthcare reform continue to impact professional nursing.

2. Nurses’ roles are influential in community health, health promotion, and disease prevention.

3. Nurses have greater responsibilities beyond the acute care setting including managing the care of consumers of various ages and diverse communities.

4. Nurses are part of a large group including government, communities, and individuals capable of improving access to health care and facilitating changes in the nation’s health.

5. Healthy People 2020 focuses on eliminating preventable health issues in the United States as well as developing equity of health and health resources.

6. Healthy People 2020 focuses on health promotion, screening, preventive measures, and improving health behaviors across the life span.

7. The health topics and objectives of Healthy People 2020 focus on both individuals and communities.

8. Healthy People 2020 encompasses the changing population demographics of the United States as well as cultural, ethnic, geographic, linguistic, and socioeconomic factors that affect health.

9. The World Health Organization defines health as a state of complete physical, mental, and social well-being (1947).

10. The modern definition of health encompasses a holistic approach that includes physical, psychological, and spiritual components.

11. Wellness reflects a lifestyle that encompasses balance, personal satisfaction, the ability to cope and adapt, and to enhance one’s quality of life.

12. Health encompasses both wellness and health promotion.

13. Nursing theorists have developed several definitions and models of health that reflect client holism.

14. Nursing strives for a holistic approach to health that reflects physical, cultural, environmental, psychological, and social factors.

15. Health assessment is systematic data collection from a patient for the purpose of determining the patient’s health status, assessing health-related risk factors, identifying health-promoting activities, and identifying health education needs.

16. Health assessment includes the interview, physical assessment, documentation, and interpretation of findings.

17. Health assessment data collection should be holistic and include physical, social, cultural, environmental, and emotional factors.

18. Effective communication is a key component in collecting accurate subjective and objective patient data.

19. The nurse uses knowledge of physical and social science in health assessment data collection.

20. Thorough and accurate health assessment forms the foundation of the patient’s plan of care.

21. Level of assessment may differ based on patient status, for example, ambulatory patients, hospitalized patients, or critical patients.

22. The nursing process is a systematic process used by professional nurses to manage patients and provide patient care.

23. The nursing process is applicable to individuals, communities, and to varying populations; to patients of all ages; and is applicable in all levels of health and stages of illness.

24. The nursing process involves five stages: assessment, diagnosis, planning, implementation, and evaluation.

25. The nursing process is a complex process that combines critical thinking, effective communication, and the expansive knowledge base of nursing education.

26. Effective use of the nursing process is predicated upon comprehensive and accurate data collection.

27. Critical thinking is a process of purposeful and creative thinking about resolutions of problems or developing ways to manage situations.

28. Critical thinking is composed of five essential elements: collection of information, analysis of the situation, generation of alternatives, selection of alternatives, and evaluation.

29. Each element in critical thinking consists of skills to assist the nurse in developing a complete, thorough, and competent assessment.

30. Critical thinking applies logic and cognitive skills to the complexities of patient care.

31. Nurses apply critical thinking skills, their knowledge, and available resources to assist patients in achieving their health goals and maintaining their well-being.

32. In the role of educator, the nurse assists patients in maintaining and improving their health, preventing illnesses or injury, managing therapies, and making informed decisions about health and treatment.

33. The nurse teaches patients based on patients’ comprehensive health assessment, patients’ knowledge deficits regarding identified risks, and patients’ readiness to learn.

34. The nurse teaches patients based on the three categories of NANDA-I diagnoses: actual health problems, risk of developing a health problem, and state of wellness.

35. Nurses engage in both informal and formal teaching modalities.

36. The six major components of formal teaching are identified learning needs, teaching goals, learning objectives, content, teaching strategies and appropriate rationales, and evaluation.

CHAPTER 2 HUMAN DEVELOPMENT ACROSS THE LIFE SPAN

Learning Outcomes 1. Relate the principles of growth and development to the nursing process.

• Suggested Classroom Activity: Ask students to discuss environmental factors, internal and external, that affect growth and development that nurses must consider in assessing clients across the life span.

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Suggested Clinical Activity: Ask students to choose an adult client and discuss his or her life accomplishments or milestones. Determine if the client has met the developmental milestones appropriate for his or her age according to Erikson’s psychosocial theory.

2. Examine theories of development.

• Suggested Classroom Activity: Ask students to briefly paraphrase the three major theories of development and identify the major differences between two of these theories.

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Suggested Clinical Activity: Ask students to select a client age 40 or older and discuss his or her developmental milestones across the life span. Ask students to provide examples that demonstrate successfully meeting milestones according to Erikson’s psychosocial theory.

3. Appraise stages of development.

• Suggested Classroom Activity: Ask students to summarize the importance of height, weight, and head circumference in assessing physiological growth of infants.

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Suggested Clinical Activity: Ask students to observe an infant interacting with a parent or primary caregiver and determine goodness of fit between the infant and caregiver. Ask students to note positive and negative observations and suggestions of what can be done to improve interactions between the infant and the adult.

4. Differentiate between various tools used for measurement of growth and development across the age span.

• Suggested Classroom Activity: Ask students to compare and contrast the Denver Developmental Screening Test II and the Child Development Inventory.

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Suggested Clinical Activity: Ask students to select a geriatric client and administer the Geriatric Depression Scale. Recommend follow-up to professional staff should the client produce a score greater than 5.

5. Examine growth and development in relation to health assessment.

• Suggested Classroom Activity: Ask students to pair off and practice role-playing communication methods when assessing the adolescent patient.

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Suggested Clinical Activity: Ask students to observe adolescents in a group setting.

Record methods of communication and interaction including verbal and nonverbal communication as members of the group interact.

6. Appraise factors that influence growth and development.

• Suggested Classroom Activity: Ask students to explain the importance of nutrition to growth and development.

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Suggested Clinical Activity: Ask students to select a patient with an international or ethnic background. Discuss with the patient their family cultural practices that differ from Western or typical American norms and what healthcare providers should know about his or her culture or subculture.

Key Concepts 1. Nurses’ knowledge of normal growth and development across the life span is essential in order to determine abnormalities when assessing patients.

2. Nursing interventions across the life span should reflect and synchronize with the health-related goals of Healthy People 2020.

3. Growth is defined as measurable physical changes that are normally rapid in infancy, slower in childhood until puberty, and slow in adulthood.

4. Development reflects a dynamic and progressively complex evolution of several aspects of the total person beyond physical changes.

5. Rates of growth and development vary based on heredity as well as environmental factors such as nutrition, family, religion, climate, culture, school, community, and socioeconomic status.

6. A single theory does not encompass all aspects of human development.

7. Cognitive theory explores how individuals learn to think, reason, and use language.

8. Piaget theorized that cognitive development is orderly and occurs in four stages: sensory motor, preoperational skills, concrete operations, and formal operations.

9. Psychoanalytical theory is based Freud’s theories of personality development and the structures of personality: the id, ego, and super ego.

10. Psychoanalytical theory posits that children pass through five stages of psychosexual development in which needs must be met without overindulgence or fixation: oral phase, anal phase, phallic phase, latency phase, and the genital stage.

11. Erikson’s psychosocial theory describes eight stages of ego development across the life span.

12. Tasks in each of Erikson’s stages must be met in order to achieve the essential task or milestone in the next stage.

13. Infancy describes ages 1 month to 1 year.

14. Infants develop close relationships with their primary caregiver, and interact with and relate to their environment.

15. Height, weight, and head circumference measurements provide the most consistent growth markers of infants.

16. Early development, infancy to adolescence, focuses on motor development based on neurological maturity, language development, cognitive development, and psychosocial development.

17. Young adulthood represents independence from parents and choices in lifestyle and career.

18. Middle-age adulthood is a time for evaluation of the past and adjustment for the future.

19. Middle-age adulthood represents the beginning of physiological signs of aging such as hormonal changes in both men and women and visual decline.

20. Older adults vary greatly in both psychosocial and physical changes, but generally include adjusting to declining health and physical strength, adjusting to retirement, adjusting to death of friends and spouse, conducting a life review, and preparing for death.

21. Health assessment includes gathering objective and subjective data to develop plans to maintain health or address health needs in patients of all ages.

22. When conducting health assessments, the professional nurse must be able to obtain accurate data and interpret findings in relation to expectations and predicted norms and ranges for patients at various stages of physical and emotional development.

23. Knowledge of anatomical and physiological changes as well as theoretic information about cognitive, psychoanalytical, and psychosocial events and expectations at each stage of human development is invaluable for the nurse.

24. Health assessment includes the use of clinical growth charts to index individual patient measurements of height and weight (and head circumference in infants) as expected normal values for age and gender.

25. In addition to expectations about physical growth and development, there are expectations about cognitive, psychosocial, and emotional development across the age span.

26. Numerous standardized instruments and tools measure growth and assessment from infancy to older-adulthood.

27. Many instruments assess depression, stress, intelligence, and several other personality traits and characteristics.

28. The U.S. Preventive Services Task Force (USPSTF) provides numerous health screening and assessment tools across the life span as preventive measures to healthcare problems.

29. The Geriatric Depression Scale is one instrument that assesses elements of depression in the older-adult population.

30. Malnutrition can delay and prevent growth and development.

31. Slow growth of a child, when compared to growth charts, may indicate inadequate nutrition.

32. The family reflects a social system that influences physical and emotional development and influences values and rituals, safety, nutrition, and support.

33. Cultural factors such as child rearing and family roles influence growth and development.

34. Socioeconomic status is a major factor in growth and development of children.

35. Poverty impacts the ability of a family to meet nutritional needs of children and affects children’s health status and their physical well-being.

CHAPTER 3 WELLNESS AND HEALTH PROMOTION

Learning Outcomes 1. Distinguish between concepts of wellness and health promotion.

• Suggested Classroom Activity: Instruct students to ask a fellow student to distinguish between the concepts of wellness and health promotion.

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Suggested Clinical Activity: Ask students to interview a healthcare provider and ask the provider how he or she implements health promotion activities in caring for patients.

2. Compare and contrast selected theories of wellness.

• Suggested Classroom Activity: Ask students to select a wellness theory they believe to be applicable to their patient population and discuss their reasons for choosing the theory.

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Suggested Clinical Activity: Ask students to discuss wellness theories with two healthcare providers and determine if wellness and wellness theory are active parts of the providers’ patient care model.

3. Relate perspectives of health promotion to the individual, family, and community.

• Suggested Classroom Activity: Ask students to list their personal and current health promotion activities.

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Suggested Clinical Activity: Ask students to review a patient’s admission record and note if health promotion activities are included in the general admission assessment. Interview the patient to determine his or her participation in health promotion activities.

4. Apply the goals and objectives for each topic area in Healthy People 2020 to nursing practice.

• Suggested Classroom Activity: Ask students to develop a list of determinants they believe affect individual and community health without referring to the text or to the Healthy People 2020 website. Then have students review determinants on the Healthy People 2020 website or the text and compare to their individual lists. Ask students to discuss the similarities and differences between their list and the Healthy People 2020 list.

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Suggested Clinical Activity: Ask students to interview a patient and determine the patient’s familiarity with Healthy People 2020, its goals, and its objectives. Ask students to discuss what can be done to increase individual and community awareness of Healthy People 2020.

5. Demonstrate how to use the nursing process to encourage health promotion.

• Suggested Classroom Activity: Ask students to interview each other and develop a diagnosis related to a potential problem. Instruct students to use the nursing process, and with the interviewed student develop interventions and plans for implementation and for evaluation of progress.

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Suggested Clinical Activity: Ask students to interview a patient and develop a diagnosis on an identified current, ongoing, or potential problem. Instruct students to use the nursing process, and with the patient, develop interventions and plans for implementation and for evaluation of progress.

Key Concepts 1. Wellness describes a state of life that is balanced, personally satisfying, and characterized by the ability to adapt and to participate in activities that enhance quality of life.

2. Major concepts of wellness include decisions regarding self-responsibility, nutrition, fitness, stress management, emotional growth and well-being, personal safety, and health care.

3. Perceptions of wellness influence the nurse’s approach to patient care.

4. The nurse focuses on patients’ personal strengths and their abilities to enhance their health.

5. The nurse focuses on the wellness concerns specific to each patient including, when appropriate, the patient’s spiritual and end-of-life needs.

6. Dunn defines wellness for the individual as an integrated method of functioning focused on maximizing the individual’s potential.

7. Leavall and Clark describe the levels of prevention as primary, secondary, and tertiary with actions taken to maintain health, to prevent illness or provide early detection of disease, and to restore the individual to the highest level of optimum functioning.

8. Hattie, Myers, and Sweeney propose a holistic model of wellness and prevention influenced by global events, family, community, religion, media, government, education, and business.

9. Health promotion activities are actions that increase health and well-being.

10. Health promotion is applicable to individuals, families, and communities, and includes actions such as weight-control measures, exercise, stress management, and coping.

11. Individual health promotion includes identifying lifestyle and environmental risks that influence the level of wellness and promote efforts to reduce or eliminate those risks.

12. The Health Belief Model is based on an individual’s perceptions of illness vulnerability, the effect of an illness, prevention, and risk-reduction modifying factors that influence an individual’s decision to act in order to prevent or minimize illness.

13. Pender, Murdaugh, and Parsons define health promotion as “behavior motivated by the desire to increase well-being and actualize human health potential.”

14. Health promotion activities include weight-control measures, exercise, stress management, and methods of coping.

15. Individual health promotion includes identification of lifestyle and environmental risks that influence the level of wellness and promote efforts to reduce or eliminate those risks.

16. The Health Belief Model is a predictive model that analyzes who will participate in health promotion activities.

17. The health promotion model is a framework that describes the interactions between an individual’s interpersonal and physical environments that affect health promotional behaviors.

18. The Theory of Reasoned Action/Planned Behavior hypothesizes that an individual’s intention to perform a health-promoting act is a determinant to actual performance of that behavior and is influenced by subjective norms, attitudes, and self-efficacy.

19. Healthy People 2020 focuses on health determinants versus the healthcare system.

20. Health determinants include personal, social, economic, and environmental factors that influence both individual and population health.

21. Social determinants related to health include family, community, income, education, gender, race/ethnicity, place of residence, and access to health care.

22. Healthy People 2020 offers practical guidelines on using information, providing education, and implementing interventions to improve health.

23. A major focus of Healthy People 2020 is access to health services that has increased with implementation of the Affordable Care Act of 2014.

24. With the influx of individuals receiving health care under the Affordable Care Act, social issues, including cultural sensitivity for the diverse American population such as foreign immigrants and lesbian, gay, bisexual, and transgender individuals, must be addressed.

25. Healthy People 2020 encourages implementation of educational and communitybased programs that focus on numerous health issues including chronic diseases, injury and violence prevention, mental illness, unintended pregnancy, oral health, tobacco use, substance abuse, physical activity, nutrition, and several other factors that influence general health.

26. Comprehensive patient assessment is essential to health promotion.

27. Health-related risk factors are revealed through data collected including age, gender, race, and family history, and information on fitness, lifestyle, stressors, and stress management.

28. The nurse works with the patient to identify current, ongoing, or potential health problems.

29. Diagnoses are established that reflect patients’ problems as well as strengths.

30. The nurse assumes the role of educator, counselor, facilitator, nurturer, and role model upon implementing a plan of care in concert with the patient.

31. The nurse and the patient are involved in ongoing evaluation of progress and meeting established goals as the nurse–patient relationship continues.

32. During evaluation, the patient has the opportunity to modify, continue, or discontinue established goals.

CHAPTER 4 CULTURAL CONSIDERATIONS

1. Examine the components included in the definition of culture.

• Suggested Classroom Activity: Ask students to define culture in their own words and discuss how their personal definition of culture differs from the definitions of other students.

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Suggested Clinical Activity: Ask students to review a patient’s admission assessment and determine if culture is addressed in the admission process, what questions are asked of patients with regard to their culture, and after speaking with the patient determine if culture is addressed sufficiently during the patient’s hospitalization.

2. Practice using terms related to culture.

• Suggested Classroom Activity: Ask students to define and discuss the differences between race, ethnicity, and heritage.

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Suggested Clinical Activity: Ask each student to identify and interview a patient of different ethnic or cultural background and discuss with the patient the assimilation and acculturation process of living in the United States with attention paid to healthcare considerations.

3. Describe the impact of cultural phenomena on health and wellness.

• Suggested Classroom Activity: Ask students to reflect on their culture and cultural beliefs and discuss how culture affects their personal healthcare beliefs.

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Suggested Clinical Activity: Ask students to interview a patient born and raised in a country other than the United States. Discuss with that patient his or her cultural beliefs regarding health and wellness, and factors related to health beliefs and health practices (e.g., magicoreligious, biomedical, and holistic health beliefs).

4. Demonstrate culturally sensitive methods of communication when interacting with patients.

• Suggested Classroom Activity: Ask students to interview each other on a given health or nursing topic of their choice. Instruct the interviewer to note nonverbal and body language cues. After the interview have the interviewer document these cues, interpret their meaning, and discuss these interpretations with the interviewed student to determine their accuracy.

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Suggested Clinical Activity: Ask students to determine and document the linguistic competence of a local healthcare organization or institution and the institution’s

ability to accommodate patients with limited English proficiency, limited literacy skills, a disability, or a hearing impairment.

5. Formulate strategies to promote cultural competence when assessing patients from specific cultural groups.

• Suggested Classroom Activity: Ask students to complete the Cultural Assessment database on a fellow student and discuss new information discovered about the culture of that student.

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Suggested Clinical Activity: Ask students to conduct the Mini Cultural Assessment on a patient with limited English proficiency and then discuss with a member of the nursing staff challenges in completing an assessment for patients with limited English proficiency as well as the benefits of cultural assessment in caring for the patients.

Key Concepts 1. An individual’s culture, race, and ethnicity impact beliefs about health and illness and practices related to both.

2. The United States continues to become an increasingly culturally diverse country.

3. Nurses must possess a knowledge base of how cultural groups perceive life processes, define health and illness, maintain health, determine the causes of illness, and provide care and cure specific to each culture.

4. Culture is defined by the National Institutes of Health (NIH) as a combination of knowledge, beliefs, and behaviors that often are specific to racial, ethnic, geographic, social, or religious groups.

5. Culture frames an individual’s perception of health and illness, and influences how health care information is received, what is considered to be a health problem, how symptoms are perceived, and the types of treatments that may be provided.

6. Subcultures are phenomena that exist within larger cultural groups and are composed of individuals who have a distinct identity based on occupation, membership in a social group, or heritage.

7. Race refers to the identification of an individual or group by shared genetic, heritage, biological, or physical characteristics.

8. Heritage is defined as the full range of inherited traditions, monuments, objects, and culture. It is the range of contemporary activities, meanings, and behaviors drawn from these traditions.

9. Ethnicity is the awareness of belonging to a group in which certain characteristics such as culture and biology differentiate the members of one group from another and reflects shared interests, ethnic heritage, religion, food, politics, or geography and nationality.

10. Ethnocentrism is the belief that one’s own beliefs, way of life, values, and customs are superior to those of others. Ethnocentrism promotes the belief that

one’s customs and values are the standard for judging the customs and values of others.

11. Diversity is defined as the state of being different, and occurs both between and within cultural groups. Characteristics of diversity include nationality, race, color, gender, age, and religion as well as socioeconomic status, education, occupation, and areas of residency.

12. Acculturation refers to the process of adaptation and change that occurs when members of different cultures are exposed to one another.

13. Assimilation refers to the adoption and incorporation of characteristics, customs, and values of the dominant culture by those new to that culture.

14. Cultural competence is the capacity of nurses or health services delivery systems to effectively understand and plan for the needs of a culturally diverse patient population. Cultural competence is complex and includes a combination of knowledge, attitudes, and skills used by healthcare providers to deliver services that attend to patients holistically across cultural boundaries.

15. Culture and heritage influence an individual’s perceptions about internal and external factors that contribute to health or cause illness, as well as the practices individuals follow to prevent and treat health problems.

16. The beliefs and practices of immigrants, families, and groups influence the ways in which individual health care is managed.

17. Adoption of Western or scientific beliefs and practices is influenced by the length of time individuals reside in the United States and often by the age of individuals at the time of immigration.

18. Exposure to and knowledge of a variety of cultural beliefs and healthcare practices have promoted inclusion of many treatments, remedies, and therapies from foreign cultures by healthcare practitioners in the United States.

19. Culture influences patients’ perception of healthcare providers. In many cultures, physicians are perceived as head of the healthcare team and held in high regard.

20. The view of nurses is often dependent on the cultural view of women’s roles in society. In some cultures, nurses continue to be viewed as subservient to physicians.

21. Patients’ health-seeking behaviors are influenced by type of illness, language barriers, and family concerns that cultural rituals surrounding care of the sick and dying will not be respected or permitted in Western health care.

22. Categories of cultural phenomena that impact the provision of health care include communication, patient–provider relationships, family patterns, dietary patterns, health beliefs, and health practices.

23. Communication refers to the verbal and nonverbal methods with which individuals and groups transmit information. Nurses must have knowledge of personal and cultural significance of nonverbal communications as well as body language.

24. Communication is the mechanism through which individuals establish relationships and is dependent on how senders encode and how receivers decode messages.

25. Communication is dependent on numerous factors including culture, ethnicity, religion, nationality, education, health status, level of intelligence, and level of education.

26. Linguistic competence is the ability of an organization and its members to communicate effectively and convey information in such a way that diverse populations (e.g., individuals with limited English proficiency, limited literacy skills, a disability, or a hearing impairment) may easily comprehend intended meaning of information.

27. Nurses should have general familiarity with culturally based beliefs and practices as well as an understanding of implications of culturally based beliefs for nursing care.

28. Healthcare providers should avoid bringing stereotypical cultural beliefs to the communication process.

29. The provider should be considerate of vocal tone, the significance of spoken words, degree of loudness, and body language when communicating with patients.

30. Nonverbal communication includes the use of gestures, facial expressions, and mannerisms that convey information regarding emotions, feelings, and responses during the nurse–patient interaction.

31. Cultural data are essential to the process of obtaining a comprehensive health assessment because this data informs the nurse on a variety of factors and practices that impact the current and future health status of the patient.

32. Understanding the patient’s culture enables the nurse to determine physical and social characteristics that influence the patient’s healthcare decisions.

33. Open-ended questions help to obtain information about the meaning of patients’ statements regarding ethnic and cultural identity.

34. Information about ethnicity and culture can be obtained by conducting a complete cultural assessment within the patient’s health history.

35. The patient’s beliefs regarding spirituality both as an individual and as a member of a particular culture are vitally important to the patient’s perception of a healthcare issue as well as to recommended treatments.

36. The nurse must examine his or her cultural values and beliefs and reflect on their significance prior to encounters and interactions with patients from diverse cultures.

CHAPTER 5 PSYCHOSOCIAL ASSESSMENT

Learning Outcomes 1. Categorize the major components of psychosocial health.

Suggested Classroom Activity: Ask students to identify external factors that may influence an individual’s psychosocial health.

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Suggested Clinical Activity: Ask students to review a patient‘s chart with specific attention to the psychosocial assessment. Have students determine if the psychosocial assessment is sufficient and discuss the reasons why it is or is not. If students believe the psychosocial assessment is insufficient, have them provide components they believe should be added to the assessment.

2. Apply knowledge of psychosocial functioning to assessment of overall health and wellness.

• Suggested Classroom Activity: Ask students to discuss the methods they employ for coping with stress.

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Suggested Clinical Activity: Ask each student to discuss with a patient a stressful event in the patient’s life and the method or methods the patient employed to cope with that event.

3. Examine factors that affect psychosocial health in patients across the life span.

• Suggested Classroom Activity: Ask students to recommend positive actions within the family that may promote psychosocial well-being for younger family members and discuss why they believe these actions are beneficial to younger family members.

Suggested Clinical Activity: Ask each student to discuss with a patient the manner in which the patient believes stress affects his or her health.

4. Describe application of the nursing process in the assessment of psychosocial health.

• Suggested Classroom Activity: Ask students to discuss the importance of knowing patients’ past emotional and psychiatric problems and the effect of prior emotional and psychiatric problems on current psychological and social functioning.

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Suggested Clinical Activity: Ask each student to conduct an interview with a registered nurse on a medical-surgical unit in which the student interviews the nurse focusing on the nurse’s perception of the importance of patients’ psychosocial status to physical health and psychosocial health.

5. Formulate patient-specific strategies for assessment of psychosocial health in patients across the life span.

• Suggested Classroom Activity: Ask students to match the six common abnormal speech patterns with their definitions.

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Suggested Clinical Activity: Ask students to observe the interactions—speech, posture, gait, and body language—of ambulatory patients on a unit and provide components of the patient’s psychosocial assessment within the limits of each student’s observations.

Key Concepts 1. Psychosocial health is defined as mental, emotional, social, and spiritual wellness.

2. Psychosocial health is influenced by both internal and external factors.

3. Families influence psychosocial health and well-being because the family is expected to provide for physical safety and economic needs, and to help members develop physically, emotionally, and spiritually.

4. Self-concept, role development, sexuality, interdependent relationships, stress and coping, and spiritual and belief patterns are additional factors that influence psychosocial health.

5. Psychosocial functioning includes the way a person thinks, feels, acts, and relates to self and to others.

6. Psychosocial functioning is also the ability to cope and tolerate stress, and the capacity for developing a value and belief system.

7. Alterations in psychosocial functioning may result in alterations to physical health and responses to treatments.

8. Psychosocial functioning is a critical factor in mind–body interactions and plays a key role in both health and illness.

9. Internal factors of psychosocial health include genetics, physical health, developmental stage, and physical fitness.

10. Physical health enables an individual to respond to stressors and therefore, to adapt, cope with change, and grow as a functioning individual capable of personal and social interaction.

11. Emotional stress affects numerous facets of health including immunity, healthpromoting behaviors, stress responses, and altered levels of anxiety.

12. External factors that affect psychosocial health include family, culture, geography, and economic status.

13. Children who experience consistent love, attention, and security grow into adults who are able to adapt to change and cope with stress effectively.

14. The nurse uses a holistic approach in assessing the patient‘s psychosocial status.

15. Assessment of a patient‘s psychosocial status includes his or her psychosocial concerns, self-concept, personal beliefs, perception of stress and coping mechanisms, and reasoning ability.

16. While interviewing the patient, the nurse gathers information related to past emotional or psychiatric problems as well as physiological illnesses that may affect the patient‘s present psychological or social functioning.

17. When a patient’s primary health concern is a psychosocial issue such as substance abuse or depression, the nurse integrates questions related to the patient’s psychosocial status into the initial interview during the first contact with the patient.

18. The nurse develops a focused interview structured to obtain the most information with the fewest number of questions when the patient’s primary health concern is a psychosocial problem in order to minimize the patient’s discomfort or anxiety.

19. Psychosocial assessment of a patient’s well-being encompasses a holistic assessment including the patient’s history of psychosocial concerns; history of physiological alterations or diseases; the patient’s self-concept; the patient’s family history with specific attention to psychosocial dysfunction among family members; roles and relationships with friends, neighbors, and coworkers; stress management and coping; sensory perception and cognition; and the patient’s spiritual and belief systems.

20. The nurse employs physical observation of the patient including the patient’s general appearance, posture, gait, and body language.

21. Observations of the patient’s physical appearance provide cues to possible alteration of body image and low self-esteem.

22. Patient’s posture, gait, and body language may offer insight into high levels of anxiety, involuntary physical movements, depression, euphoria, mood swings, flat affect, and poor contact with reality.

23. The nurse observes the patient’s speech pattern and is attuned to the patient experiencing auditory hallucinations or delusions, or experiencing anxiety, fear, or altered thought processes.

24. The nurse employs valid tools and instruments to assist in evaluating specific aspects of the patient’s psychosocial status, for example, the Healthy Days Measures, the Body Image Ideals Questionnaire, and the Multidimensional Health Profile–Psychosocial.

CHAPTER 6 ASSESSMENT OF VULNERABLE POPULATIONS

Learning Outcomes 1. Identify vulnerable patient groups.

• Suggested Classroom Activity: Ask students to discuss the criteria used for defining and identifying a vulnerable patient group.

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Suggested Clinical Activity: Instruct students to select a patient who belongs to an identified vulnerable group and discuss with the patient his or her experience with access to preventive care and recommended screening services.

2. Identify the factors that influence each of the vulnerable populations.

• Suggested Classroom Activity: Instruct students to select two previously identified racial or ethnic groups categorized as vulnerable groups and discuss increased healthrelated risk factors for each group.

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Suggested Clinical Activity: Instruct students to review medical records of five patients of varying races or ethnicities and, based on patients’ health assessment documentation, identify relationships between ethnicity, insurance coverage, and access to health care.

3. Discuss the nursing role in relation to assessment of a person from a vulnerable population.

• Suggested Classroom Activity: Ask students to identify factors that contribute to elder abuse and the role of nurses in assessing patients at risk for elder abuse.

•

Suggested Clinical Activity: Instruct students to form small groups and develop teaching strategies that address the common health issues of an identified vulnerable group.

4. Describe types of abuse and recognize associated signs and symptoms.

• Suggested Classroom Activity: Ask students to discuss the role of ethics in reporting suspected cases of sexual abuse of children.

•

Suggested Clinical Activity: Instruct students to identify a tool or an instrument available to nursing staff to assist in assessing elderly patients for incidents of abuse.

5. Discuss the goals for eliminating health disparities for vulnerable populations.

• Suggested Classroom Activity: Ask each student to provide two interventions he or she can implement while caring for a patient to reduce healthcare disparities and discuss how each intervention improves availability, quality, or care for each patient.

•

Suggested Clinical Activity: Instruct each student to interview a patient and identify teaching needs, guidance, and counseling that will benefit the health concerns of the patient.

6. Describe the physical and social determinants of vulnerable populations.

• Suggested Classroom Activity: Ask each student to discuss the significance of physical determinants of health in assessing the well-being of a client.

•

Suggested Clinical Activity: Instruct each student to select a patient who possesses one of the identified social determinants of health. Instruct students to review their assigned patients’ charts and interview the patients. Instruct students to discuss with the patients the extent to which social determinants have affected access to health care.

Key Concepts

1. Vulnerable populations are groups that are not well integrated into the U.S. healthcare system because of racial, ethnic, cultural, economic, geographic, or health characteristics.

2. Members of vulnerable populations are subject to health disparities and barriers to health care.

3. Racial and ethnic groups identified as vulnerable populations include Asian Americans, African Americans, Hispanics or Latinos, Native Hawaiian and other Pacific Islanders, American Indians, and Alaska Natives.

4. Health disparities are gaps in the quality of health and health care that mirror differences in socioeconomic status, racial and ethnic backgrounds, and levels of education.

5. Health disparity gaps include accessibility to health care, increased risk of disease from occupational exposure, and increased risk of disease from genetic or familial factors.

6. The goal of Healthy People 2020 is to eliminate health disparities by improving access, quality, and health care among identified vulnerable populations.

7. The Centers for Disease Control and Prevention (CDC) assesses vulnerable populations based on race or ethnicity, socioeconomic status, geography, gender, age, disability status, and risk status related to gender.

8. Improving availability, quality, and care among persons who experience health disparities allows for clinical interventions and for the opportunity for individuals to attain their full health potential.

9. Certain systems, for example, the Omaha system, identify and categorize teaching needs, guidance and counseling, treatments and procedures, case management, and surveillance to address health disparities of vulnerable populations.

10. The nurse promotes healthy, respectful, nonviolent relationships among family members from newborns to the elderly, and among intimate partners to decrease the risk of intimate partner violence (IPV).

11. Women ages 18 to 46 should be screened for intimate partner violence with appropriate referrals as needed and with ongoing assessment with each patient encounter.

12. Nurses have a responsibility to infants, children, and adolescents to identify early signs of health risks including the use of alcohol, drugs, and other ageassociated high-risk behaviors.

13. Nurses must observe and assess children, women, and the elderly for signs of abuse such as changes in behavior, unexplained injuries, evidence of neglect, and other indicators of distress as well as previous history of allegations regarding abuse.

14. Nurses must be cognizant of signs of sexual abuse in children as well as signs and symptoms of elder abuse among individuals ages 60 and older usually at the hands of a caregiver or person who the elder trusts.

15. Family caregivers are at risk for increased stress and burden, and therefore are at risk for becoming perpetrators of elder abuse.

16. A comprehensive assessment determines the patient’s current and ongoing health status, predicts risk, and identifies health promotion activities.

17. Cultural competence is the integration and transformation of knowledge and skills about persons of a group and in a community regarding their practices, beliefs, values, attitudes, or policies in order to increase the quality of healthcare services with the goal of providing better health outcomes.

18. Nurses working with vulnerable populations must be aware of their own cultural heritage before they can be sensitive to the heritage of others.

19. Factors that influence vulnerable populations include race and ethnicity, age, gender, sexual orientation, geography, disabilities, and socioeconomic status.

20. Physical abuse may present in a variety of ways including hitting, punching, slapping, burning, choking, shaking, or other ways of harming another person.

21. Patients of all ages can present with signs and symptoms such as bruises at different stages of healing, unexplained injuries, fractures, malnourishment, and marks associated with physical restraint.

22. Sexual abuse may present as rape, sexual assault, molestation, or sexual contact to which the individual has not consented.

23. Sexual abuse also includes incest, sexual exploitation, and prostitution.

24. The psychological and behavioral effects of sexual abuse enhance the victims increasing vulnerability to health problems, illnesses, diseases, and socioeconomic challenges.

25. Psychological abuse is often manifested by depression, withdrawal, low selfesteem, attention-seeking behavior, and changes in personality or changes in behavior.

26. Discriminatory abuse is related to a person’s disability, age, gender, race, sexual orientation, religion, or cultural background and can be difficult for nurses to identify.

27. Child abuse or childhood maltreatment including child neglect is described as any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, or sexual abuse or exploitation, or an act or failure to act that presents an imminent risk of serious harm.

28. Individuals with physical challenges are often referred to as persons with disabilities and are also considered members of a vulnerable population.

29. Several organizations’ classification systems support vulnerable individuals with physical disabilities including the International Classification of Functioning, Disability and Health; the World Health Organization Disability Assessment Schedule 2.0; and the Disability and Health Data System.

30. Physical determinants of health are physical disabilities including problems with hearing, vision, movement, thinking, remembering, learning, and communicating, and also include individuals with mental health and social relationships challenges.

31. Social determinants of health are situations in which a person is born, lives, and works, and also include certain age groups.

32. Health inequities arise from inequalities within and between societies.

33. Social determinants of health also include health insurance status, immigrant and refugee status, incarceration status, and veteran status.

CHAPTER 7 INTERVIEWING AND COMMUNICATION TECHNIQUES

Learning Outcomes 1. Identify strategies that promote effective communication when conducting a health history.

• Suggested Classroom Activity: Ask students to define and provide examples of encoding and decoding when communicating a message. Students should discuss the numerous factors that affect how individuals send and receive messages and their meaning.

•

Suggested Clinical Activity: Assign students to patients and have patients conduct a therapeutic interaction regarding the patient’s hospitalization. Emphasize the need to utilize open-ended questions, silence, paraphrasing, summarizing, and other therapeutic skills during the interaction. Instruct students to analyze the encounter and identify examples of both effective and ineffective types of communications during the encounter.

2. Analyze barriers to effective nurse–patient communication.

• Suggested Classroom Activity: Ask students to discuss barriers to ineffective communication with patients and possible alternatives that facilitate improving communication between the nurse and the patient.

•

Suggested Clinical Activity: Assign students to primary nurses. Instruct students to observe the nurses as they interact with patients and to analyze the interactions, noting barriers to ineffective communication. Have students provide recommendations as alternatives to the barriers they observed.

3. Outline the professional characteristics used in establishing a nurse–patient relationship.

• Suggested Classroom Activity: Ask students to define and discuss professional characteristics in nursing, and the relationship between professional characteristics and effective communication in the nurse–patient relationship.

•

Suggested Clinical Activity: Assign students to primary nurses. Instruct students to observe and to analyze interactions between nurses and patients and observe nurses for professional characteristics. Ask students to provide examples of professional characteristics observed as well as behaviors that may be questionable with regard to professionalism.

4. Explain the potential effects of cultural and lifespan influences on communication between the nurse and the patient.

• Suggested Classroom Activity: Ask students to identify various cultures encountered in the healthcare organization or in their communities and discuss a personal encounter or observed encounter that centered on cultural differences. Have students discuss the outcome.

•

Suggested Clinical Activity: Assign students to primary nurses caring for patients of various cultures. Ask each student to observe the assigned nurse and record if language and cultural consideration played a part in the nurse–patient encounters.

Have students discuss their findings and offer recommendations to improve some of the encounters they observed.

5. Implement effective interviewing and communication techniques throughout each phase of the patient interview.

• Suggested Classroom Activity: Ask student to differentiate between effective and ineffective interviewing and communication techniques during the patient interview.

Ask students to discuss the importance of effective interviewing and communication techniques in obtaining a patient’s health history.

•

Suggested Clinical Activity: Assign students to nurses who will admit new patients.

Ask students to observe the nurses as they interact with the new patient during the admission process. Ask students to observe interactions that facilitate trust between the patient and the nurse. Have students discuss observations that demonstrate development of a trusting nurse–patient relationship.

Key Concepts

1. Communication is defined as the exchange of information between individuals.

2. Communication involves information encoded by the sender and decoded by the receiver.

3. Therapeutic actions promote communication between the nurse and the patient.

4. Interactional skills are actions that are used during encoding and decoding in order to obtain and disseminate information, develop relationships, and promote understanding of self and others.

5. Listening requires paying undivided attention to what the patient says and does, and it also involves interpretation of the patient’s statements.

6. The nurse pays particular attention to a patient’s body language during interactions.

7. The nurse paraphrases, or clarifies, meaning by restating the patient’s basic message.

8. Summarizing is the process of gathering the ideas, feelings, and themes that the patient has discussed throughout the interview and restating them in several general statements that demonstrate that the nurse has been listening to the patient and understands the patient’s concerns.

9. Nontherapeutic interactions, interactions that are harmful to the nurse–patient relationship, hinder the flow of information between the patient and the nurse.

10. Nontherapeutic interactions are sources of discomfort and anxiety for the patient, provoke feelings of insecurity, and provide barriers to effective communication.

11. Examples of barriers to effective communication with patients include false reassurance, interruption or changing of a subject, passing judgment on the patient or his or her actions, cross examining the patient, providing unwanted advice, and using technical terms.

12. The nurse must be sensitive to certain topics that require additional sensitivity when communicating with patients including issues such as abuse, homelessness, emotional and psychological problems, use of drugs and alcohol, self-image, sexuality, and religion.

13. Nurses must employ therapeutic interactions such as allowing patient time to pause and regain composure before carrying on.

14. Professional nurses are cognizant of cultural differences and prepared to recognize and adapt to the cultural differences between themselves and patients.

15. Nurses do not allow their own cultural values and practices to bias their impressions of the patient or to impair establishing a therapeutic interaction.

16. Patients are more willing to discuss their health issues if they perceive that they are in a trusting, helping relationship and have developed a sense of rapport with the interviewing nurse.

17. The nurse interviewer’s attitude plays an important role in the success of an interview.

18. The nurse must display a positive regard with appreciation and respect for the patient as well as a nonjudgmental attitude.

19. Nurses accept patients as valuable individuals and accept each patient regardless of race, religion, culture, ethnic background, or country of origin.

20. Nurses display empathy for patients by showing their understanding and support of the patient’s experiences and feelings through both actions and words.

21. Nurses exhibit genuineness or the ability to present themselves honestly and spontaneously, and therefore appear to the patient as people who are down to earth and real.

22. The nurse speaks to the patient in specific terms and avoids the generalities promoting understanding and a sense of security for the patient.

23. Nurses utilize a health history tool to perform and collect information as part of the comprehensive health interview.

24. The primary source for attaining the health history is the patient; however, in cases of infants or children, patients who are critically ill, patients who are aphasic, or patients who do not speak a common language, a secondary source is used to obtain a patient’s health history.

25. Cultural awareness allows the nurse to be sensitive about certain actions that may be interpreted as inappropriate or rude.

26. Nurses must avoid stereotyping patients based on their cultural background recalling that while culture influences patients, generalizations regarding cultural specifics may be interpreted as stereotypical or bias perceptions.

27. Secondary sources include providers who have cared for the patient previously, a significant other such as a family member or legal guardian, or a close friend or coworker. The significant other who has the closest relationship with the patient is usually the most accurate source of information when the patient is unable or unwilling to speak.

28. The health assessment interview is divided into the pre-interaction, the initial or formal interview, and the focused interview.

29. The nurse gathers data from the medical record regarding the patient in the preinteraction phase and uses this information to plan and to guide the direction of the initial interview.

30. Nurses assess their feelings and prejudices prior to the interview and plan how they will interact with patients.

31. The nurse chooses a time and setting prior to the interview. A quiet private setting that is comfortable with subdued lighting, a moderate temperature, and comfortable seating provides an ambient atmosphere for the interview. Interviews should not be carried out in a rushed manner.

32. In the initial interview, a nurse–patient relationship is established based on mutual trust and communication that provides the nurse with insight into the patient’s lifestyle, values, and feelings about wellness, health, and illness.

CHAPTER 8 THE HEALTH HISTORY Learning Outcomes 1. Discuss the purpose of the nursing health history.

• Suggested Classroom Activity: Ask students to contrast and compare the medical and nursing health histories and discuss the significance of each to patient care.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to review the nursing and medical histories of their patient and document the differences observed between the two.

2. Summarize components of the nursing health history for patients across the life span.

• Suggested Classroom Activity: Ask students to identify each component of the nursing health history.

•

Suggested Clinical Activity: Assign students to patients and instruct students to review their assigned patients’ nursing health history noting if the history is complete and, if not, what components are missing. Instruct students to discuss the importance of the missing components to the patients’ health history.

3. Explain the importance of combining each component of the nursing health history to provide holistic patient care.

• Suggested Classroom Activity: Ask students to explain the meaning of holistic patient care.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to review patients’ charts with attention to nursing notes and nursing diagnoses. Ask students to analyze nursing diagnoses and determine if the nursing diagnoses illustrate holistic patient care. In cases where the nursing diagnoses do not indicate holistic care, instruct the student develop at least one diagnosis that addresses a psychosocial problem related to each patient’s health.

4. Collect a nursing health history that incorporates patient-specific findings related to health, illness, and wellness.

• Suggested Classroom Activity: Instruct students to work in pairs and perform a complete health history on each other. From the history, ask each student to develop three diagnoses that reflect health, illness (this may be fabricated), and wellness of the

other student.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to collect a nursing health history on their assigned patient. From the patient’s history, develop three nursing diagnoses related to health, illness, and wellness.

5. Develop a pedigree.

• Suggested Classroom Activity: Ask students to discuss the importance of genetics and familial health to a patient’s health status. Also, ask students to develop their own pedigree.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to develop a pedigree for their assigned patient that depicts both medical history, and if applicable, genetic relationships in the patient’s family.

Key Concepts

1. The health history is a comprehensive record of the patient’s past and current health that is initiated on the first visit and updated with each subsequent visit.

2. The purpose of the health history is to document the responses of the patient to actual and potential health concerns.

3. The nursing health history differs from the medical history in that the medical history focuses on disease, whereas the health history obtained by the nurse determines the extent to which the patient will need support and teaching.

4. The focus of the nursing health history is on patient-centered care or on the patient’s response to the health concerns as a whole person not just on the involved body system.

5. The health history is comprehensive and contains the following components: biographical data; present health or illness; past medical history including surgical history, hospitalizations, childhood illnesses, allergies and immunizations; family history; psychosocial history; and review of body systems.

6. Biographical data includes the patient’s insurance status as an indicator of access to health care.

7. Biographical data also includes the patient’s occupation as an assessment for work-related injuries or illnesses.

8. The nurse seeks to gather data on the patient’s present health, illness, or complaint (i.e., reason for seeking care). The nurse develops a list of statements that reflect the patient’s major reason for seeking care.

9. The nurse collects information regarding the patient’s health beliefs and practices including health patterns—habits or acts—that affect the patient’s health.

10. The nurse obtains the patient’s family history to determine if genetic or familial patterns of health or illness are contributing factors to the patient’s current health status.

11. The nurse encourages the patient to recall as many generations as possible in order to develop a complete family history.

12. A well-documented family history enables providers to establish a basis to predict the risk or susceptibility for common diseases such as diabetes, cancer, and heart disease, as well as inherited diseases.

13. Evidence-based recommendations that stem from family history are rapidly being implemented. Family history is now considered a critical tool for improving public health.

14. Healthy People 2020 objectives include using genomic tools, including family history, to improve health and prevent illnesses.

15. All healthcare professionals are encouraged to achieve competency in collecting family history information and identifying patients who benefit from genetic services.

16. All healthcare providers should be knowledgeable in developing a pedigree—a graphic representation or diagram that depicts both medical history and genetic relationships in a family.

17. The nurse obtains the patient’s psychosocial history including information regarding his or her financial situation with regard to the ability to obtain health insurance or pay for healthcare services.

18. Low income is associated with lowered health status and predisposition to illness.

19. The psychosocial history includes information regarding the patient’s support systems including family members, friends, neighbors, church membership, and members of the healthcare team.

20. The goal of the interview process is to obtain a health history containing information about the patient’s present health complaint or illness, but also his or her overall health history, and to assess the patient holistically.

21. The nursing health history focuses on the patient’s physical status, patterns of daily living, wellness practices, and self-care activities as well as psychosocial, cultural, environmental, and other factors that influence the patient’s health status.

22. A comprehensive health history allows the nurse to develop appropriate nursing diagnoses that reflect the patient’s health concerns for the present illness as well as potential health problems and wellness.

23. The information in the health history directs collaborative medical and nursing treatment plans that complement each other.

24. The health history fosters effective communication, teamwork, and collaboration between and among nurses, physicians, and other healthcare providers.

25. The nurse utilizes the patient’s health history to create a comprehensive account of the patient’s past and present health.

26. The completed health history is a compilation of all the patient data collected by the nurse combined with information obtained during the nursing physical assessment to form a complete health database for the patient.

27. The patient’s database provides a holistic view of past and present physical, psychological, social, cultural, and spiritual health. It is used to formulate nursing diagnoses and plan the patient’s care.

28. Effective nurse–patient communication is necessary to obtain complete information for the patient’s database.

29. The nurse employs effective communication techniques during the health history interview process.

CHAPTER 9 TECHNIQUES AND EQUIPMENT

Learning Outcomes 1. Differentiate between the four basic techniques used by the professional nurse when performing a physical assessment.

• Suggested Classroom Activity: Ask students to define, describe, and demonstrate the four basic techniques used by the nurse to perform a physical assessment.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to assess their assigned patient’s respiratory system utilizing the four basic techniques of physical assessment.

2. Compare and contrast the purpose of equipment required to perform a complete physical assessment.

• Suggested Classroom Activity: Ask students to discuss various instruments used during a complete physical assessment. (This may require looking a head to future chapters.) Instruct students to discuss use of the stethoscope throughout the complete physical assessment and to distinguish between the use and purpose of the bell and diaphragm of the stethoscope.

•

Suggested Clinical Activity: Assign students to primary nurses. Instruct students to auscultate the heart and lung sounds<CORE> (see <OLINK>Chapters 17 and 19</OLINK>)</CORE> of each patient assigned to that nurse noting any abnormal sounds. If the students auscultate irregular heart or lung sounds, have them discuss these findings with the nurse.

3. Demonstrate patient safety and comfort measures that should be implemented when performing the physical assessment.

• Suggested Classroom Activity: Ask students to discuss the importance of patient safety and comfort during a physical examination, including specific factors that contribute to feeling safe and comfortable.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct a system-focused physical assessment providing each patient with safety and comfort within the limits of the patient’s assigned room or an examination room. Instruct students to observe factors that contribute to the patient’s sense of safety and comfort as well as factors that may inhibit the patient’s sense of safety and comfort. Instruct students to develop a list of recommendations to improve safety and comfort for patients.

4. Apply critical thinking when using the four basic techniques of physical assessment.

• Suggested Classroom Activity: Ask students to discuss the relationship between critical thinking and using the four basic techniques of physical assessment.

•

Suggested Clinical Activity: Assign students to primary nurses. Instruct students to observe primary nurses as they conduct physical assessments on their assigned patients, noting use of the four basic techniques of physical assessment. Instruct students to discuss with the assigned nurse use of critical thinking in relation to use of the four basic techniques in assessing their patients.

5. Apply the principles of standard precautions in practice.

• Suggested Classroom Activity: Ask students to define, discuss, and demonstrate standard precautions while conducting a physical assessment.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct a system-focused physical assessment. Observe the students to ensure the use of standard precautions while assessing patients.

Key Concepts

1. Objective data is gathered through an organized method of physical assessment: inspection, palpation, percussion, and auscultation. This sequence differs when assessing the abdomen: inspection, auscultation, percussion, and palpation.

2. Inspection is the skill of observing the patient in a deliberate, systematic manner that includes the patient’s physical appearance and symmetry of the body, as well as inspection of color, size, shape, contour, symmetry, movement, or any other observable signs.

3. Palpation is the skill of assessing the patient through the sense of touch. The nurse assesses for size, shape, location, and mobility of a part, as well as position, vibrations, temperature, texture, moisture, tenderness, and edema.

4. The nurse is cognizant in applying pressure during the physical examination in order to interpret data accurately. The nurse is also aware of the most sensitive areas of the hands when examining the patient by using light, moderate, and deep palpation.

5. Percussion involves the striking or tapping of the body to produce sound waves that provide characteristic tones based on the body part being assessed.

6. The nurse utilizes direct percussion, blunt percussion, or indirect percussion based on the body part under examination and identifies the characteristics of these sounds.

7. The nurse utilizes various instruments during the physical exam in order to accurately visualize, hear, and measure data.

8. Additional equipment that may be used based on patient cues include a goniometer, skinfold calipers, transilluminator, Wood’s lamp, and other specialized equipment as the physical examination dictates.

9. The nurse performs auscultation by listening without devices or listening with instruments such as the stethoscope.

10. The nurse utilizes the bell or the diaphragm of the stethoscope depending on the area of the body under examination. The nurse listens for intensity, pitch, duration, and quality of sound during auscultation.

11. The nurse utilizes the bell or the diaphragm of the stethoscope to assess specific sounds such as low-pitched heart murmurs that require the use of the bell, compared with normal heart sounds that require the use of the diaphragm.

12. The nurse utilizes the stethoscope to auscultate sounds including blood pressure, heart sounds, respirations, and bowel sounds.

13. The Doppler ultrasound uses ultrasonic waves to assess sounds that are difficult to hear with the regular stethoscope. The Doppler ultrasound stethoscope is used for fetal heart sounds as well as peripheral pulses or pulses that cannot be easily palpated.

14. Other equipment commonly used in physical assessment includes the thermometer, tongue blade, tuning fork, vaginal speculum, vision charts, a timer or watch with a second hand, an ophthalmoscope, and an otoscope.

15. Equipment used during physical assessment provides a method for obtaining objective data.

16. The nurse ensures the patient of safety, comfort, dignity, and privacy prior to beginning the physical assessment.

17. The nurse obtains permission to perform the physical assessment.

18. The nurse communicates with the patient throughout the physical assessment in order to continue to ensure comfort.

19. The nurse encourages the patient to relax, and prevents discomfort by using warm hands; keeping fingernails short, smooth, and trimmed; and not wearing jewelry during the examination.

20. The nurse proceeds slowly and deliberately, and provides the patient with information regarding the next part of the exam in advance.

21. Areas of the body that are painful or provide the patient with significant discomfort should be examined last.

22. The nurse employs the principles of asepsis during physical assessment.

23. The nurse follows principles developed by the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) to protect patients as well as healthcare workers.

24. The nurse employs hand hygiene, use of gloves, use of protective barriers, disposal of sharps, cleaning of equipment after use, handling of specimens, and proper disposal of body wastes per the guidelines of the CDC and OSHA.

25. The nurse utilizes hand hygiene and other precautions in order to reduce and eliminate healthcare-associated infections (HAIs) that lengthen patient hospital stays and complicate the patients’ hospital course.

26. The nurse ensures patient safety during physical assessment. The nurse also anticipates potential hazards and modifies the assessment in order to prevent hazards or adverse events.

27. The nurse uses critical thinking throughout the physical assessment of the patient.

28. The nurse identifies cues from the patient and assesses the relevance of this information.

29. Cues are bits of information that indicate the possibility of a health problem.

30. The nurse becomes skilled at cue recognition in order to determine even slight cues as indicators to a health problem or concern.

31. The nurse interprets cues using critical thinking and by looking for inconsistencies that indicate a health problem.

32. The nurse establishes priorities of care based on data and identified patterns from which outcomes are developed with the patient by using the nursing process.

CHAPTER 10 GENERAL SURVEY

Learning Outcomes 1. Identify the components of the general survey.

• Suggested Classroom Activity: Ask students to discuss in detail the four major components that make up the general survey.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to introduce themselves to patients explaining that he or she is only present for the purpose of observation. Have each student discuss his or her impression of the assigned patient based on the initial encounter and introduction.

2. Apply the general survey to the comprehensive health assessment.

• Suggested Classroom Activity: Ask students to discuss the relationship between the general survey and the comprehensive health assessment.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to introduce themselves to patients. Instruct students to conduct a general survey of the patients at introduction. Instruct the students to then perform a comprehensive health assessment of the patient. Instruct students to document the role of the general survey in completing the comprehensive health assessment.

3. Explain techniques used in the measurement of vital signs.

• Suggested Classroom Activity: Ask students to discuss vital signs and the numerous factors that affect vital signs. Ask students to work in pairs and to demonstrate proper techniques for assessing vital signs.

•

Suggested Clinical Activity: Assign students to primary nurses. Instruct students to measure temperature, manual pulse, apical pulse, blood pressure, respirations, and pain assessment for each patient assigned to a specific nurse.

4. Differentiate the physiological and psychosocial factors that affect vital signs.

• Suggested Classroom Activity: Ask students to discuss specific psychosocial factors that affect vital signs, the physiological explanation for the effect, and concerns for sustained effect.

•

Suggested Clinical Activity: Instruct students to develop a formal teaching plan on stress, its physiological effects, and methods of combating stress for patients

diagnosed with hypertension. Utilize principles of formal teaching<CORE> (see <OLINK>Chapter 1</OLINK>)</CORE> in developing this teaching module.

5. Apply critical thinking during the initial nurse-patient encounter.

• Suggested Classroom Activity: Ask students to discuss the role of critical thinking during the initial nurse-patient encounter.

•

Suggested Clinical Activity: Ask students to utilize critical thinking during the first encounter with an assigned patient. Instruct students to document health, hygiene, or psychosocial needs based solely on the initial encounter noting aspects of the patient’s appearance, facial expression, personality, or mobility that led to the conclusions to address the specific issues chosen by the student.

Key Concepts

1. The four major categories of observation in the general survey are physical appearance, mental status, mobility, and patient behavior.

2. The nurse observes the patient from the time of introduction and during the gathering of subjective data to develop an initial impression regarding the patient’s health and to formulate strategies for the physical assessment.

3. The initial impression includes what the nurse sees, hears, and smells during the initial phase of the assessment.

4. The nurse prioritizes the patient’s complaint and determines if a health problem must be addressed urgently before proceeding with the interview.

5. For pediatric patients, the nurse assesses mental status by comparing the patient’s developmental stage to the expected findings based on age. The nurse notes the interactions between the child and his or her parent or caregiver.

6. Data collection during the general survey will guide the nurse during later assessment of the body regions and systems.

7. Height and weight are part of the general survey of the patient’s health status.

Patients should be asked their height and weight prior to measurement.

Discrepancies may indicate unexpected weight loss, possibly due to illness, or weight gain.

8. The nurse measures height and weight with appropriately calibrated instruments.

Height should be measured without shoes and patients should be weighed without wearing clothes or shoes.

9. Scales should be calibrated to zero. Special equipment should be available and used to obtain the weight of patients who are unable to stand.

10. Height and weight are used to calculate body mass index (BMI), a more reliable indicator of healthy weight than height-weight comparison charts.

11. Head circumference measured at the widest point of the head, usually around the widest part of the occiput and above the eyebrows, is an indicator of growth used in assessing children ages 3 and younger.

12. Vital signs include body temperature, pulse, respiratory rate, blood pressure, and assessment of pain. Oxygen saturation is sometimes included as one of the vital signs.

13. Sensors in the hypothalamus regulate the body’s core temperature, which is influenced by age, diurnal variations, exercise, hormones, stress, and illness.

14. A pulse is a force of blood against the walls of arteries that generates a wave pressure that can be detected at various landmarks on the body.

15. Factors that influence pulse rate include age, gender, exercise, stress, fever, hemorrhage, medications, and patient position.

16. Four factors to consider when assessing a pulse are rate, rhythm, force, and elasticity.

17. The nurse assesses respiratory rate by counting the number of respiratory cycles, inspiration and expiration, in 30 seconds multiplied by 2. If respirations are irregular, the respiratory rate should be counted for a full minute.

18. Respiratory rate is affected by exercise, stress, increased temperature, increased altitude, and medications as well as obesity and certain disease processes.

19. Oxygen saturation is measured using a pulse oximeter.

20. Systolic blood pressure is the pressure of blood at the height of ventricular contraction. Diastolic blood pressure is the pressure between ventricular contractions when the heart is at rest.

21. Vital signs are affected by physiological factors including a patient’s age, health status, gender, medications, positioning, and disease process.

22. Vital signs are affected by psychosocial factors including stress, anxiety, nervousness, race, and inadequate diet.

23. Age, diurnal variations, exercise, hormones, stress, and illness affect the patient’s temperature.

24. Factors that affect a patient’s pulse include age, gender, exercise, stress, fever, hemorrhage, medications, and changes in position.

25. Respiratory rate is affected by exercise, stress, increased temperature, and increased altitude. Some medications may increase or decrease a patient’s respiratory rate.

26. Blood pressure is affected by age, gender, race, obesity, physical activity, stress, diurnal variations, and medication.

27. Critical thinking begins with the initial observations of patients.

28. The nurse assesses patient’s awareness, vision, and hearing from early introduction.

29. The nurse observes for ease of mobility, gait, and strength by observing the patient’s mobility.

30. The nurse observes the patient’s facial expressions with relation to movement in order to assess pain or discomfort associated with mobility.

31. The nurse assesses the patient’s facial features for obesity, hygiene practice, nutritional deficits, hydration, and symmetry.

32. The nurse observes the patient for weight proportional to height and for muscle tone.

33. The nurse is able to draw conclusions and assess cues from observations prior to the interview in order to begin his or her assessment of the patient through the use of critical thinking.

CHAPTER 11 PAIN ASSESSMENT

Learning Outcomes 1. Explore the concept of pain.

• Suggested Classroom Activity: Ask students to compare and contrast two theories that explain the concept of pain.

•

Suggested Clinical Activity: Ask students to review the admission assessments of three patients’ charts and identify if pain is consistently assessed as the fifth vital sign.

2. Outline the physiological process involved in the perception of pain.

• Suggested Classroom Activity: Ask students to choose and explain two of the four processes involved in nociception or pain perception.

•

Suggested Clinical Activity: Ask students to identify a patient with mechanical or chemical pain stimuli. Ask the student to discuss with the patient his or her perception of the type of pain being experienced.

3. Differentiate between the various types of pain.

• Suggested Classroom Activity: Ask students to discuss their understanding of acute and chronic pain and to compare and contrast these two types of pain.

•

Suggested Clinical Activity: Ask students to identify a patient who is experiencing intractable pain or chronic pain, and discuss with the patient the use of both pharmacological and nonpharmacological methods of pain relief and the effectiveness of these methods in relieving pain.

4. Examine factors that influence pain perception and expression of pain.

• Suggested Classroom Activity: Ask students to discuss differences in expression of pain between school-age children and adolescents, and discuss the appropriate nursing interventions for each age group.

•

Suggested Clinical Activity: Ask students to discuss with a patient his or her previous episodes of pain related to a prior illness and to compare past and present experiences of pain.

5. Identify cultural and developmental influences that affect assessment of pain for patients across the life span.

• Suggested Classroom Activity: Ask students to provide at least one evidenced-based study that examine the differences in pain perception between two cultures.

•

Suggested Clinical Activity: Ask students to choose two patients of different ethnic or cultural backgrounds and compare and contrast their management of pain at home.

6. Demonstrate techniques used for assessment of a patient having pain.

• Suggested Classroom Activity: Ask students to choose a pain assessment tool and identify its benefits and shortcomings to the class.

•

Suggested Clinical Activity: Ask students to discuss with a patient who has recently experienced pain how effectively the staff managed his or her complaint of pain and how the patient believes management of pain may be better handled.

Key Concepts 1. An individual’s perception of pain is influenced by age, culture, and previous experience with pain.

2. Pain is assessed as the fifth vital sign.

3. Accurate assessment of pain is essential to developing, monitoring, and evaluating the effectiveness of pain relief interventions.

4. No two people experience pain in the same manner. Pain is subjective and individualized.

5. The nurse cannot see or feel pain being experienced by the patient; however, the nurse is able to assess for physiological, psychological, and behavioral changes that reflect pain.

6. The pain response is complex and incorporates both physiological and psychosocial aspects.

7. Pain stimuli can be divided into three categories: mechanical stimuli, thermal stimuli, and chemical stimuli.

8. The physiological process related to pain perception is described as nociception.

9. Nociception involves four processes: transduction, transmission, perception, and modulation.

10. The initial response to pain is centered in the sympathetic nervous system stimulation that triggers the fight-or-flight response.

11. As the body adapts to pain, the parasympathetic nervous system reverses many of the initial sympathetic physiological responses.

12. Pain is described in terms of duration, location, or etiology.

13. Acute pain describes pain that lasts through an illness or recovery and may be due to an injury or surgery. Acute pain can last from a few minutes to several weeks but not longer than 6 months.

14. Chronic pain refers to pain that is prolonged, recurring, or persisting for 6 months or longer. Chronic pain affects functioning and the performance of activities of daily living.

15. Pain may be categorized based on its location. Pain may be categorized as cutaneous, somatic, or visceral.

16. Pain may be described in accordance with its location in the body. Radiating pain describes pain that extends to nearby tissue.

17. Referred pain is felt in a part of the body that is considerably removed from the tissue that actually causes pain.

18. Intractable pain is pain that is highly resistant to relief such as that experienced with cancer malignancy.

19. Neuropathic pain is the result of current or past damage to the peripheral or central nervous system. Neuropathic pain does not require a stimulus.

20. Phantom pain is the perception of pain in a body part that is missing such as an amputated extremity.

21. Age and developmental stage are factors that influence the patient’s perception of pain.

22. Newborns, regardless of their gestational age, possess the anatomical, physiological, and biochemical elements for pain.

23. Authoritative pediatric bodies have recommended that environmental, nonpharmacological, and pharmacological interventions be used to prevent, reduce, and eliminate pain in neonates.

24. Gender influences pain. In many cultures, women are more likely to express pain compared to men.

25. Children, depending on their age, developmental stage, and psychosocial factors, present with previously identified behaviors that represent their perception of pain.

26. Ethnic background and cultural heritage influence both expression and reaction to pain.

27. Cultural background affects the level of pain that an individual tolerates.

28. Significant variation in the expression of pain exists between cultures.

29. Nurses must assess their attitudes regarding expressions and expectations about pain.

30. Nurses must exhibit caution in either denying or minimizing the pain observed in patients.

31. Accurate and timely patient assessment is imperative for effective pain management.

32. The frequency and extent of pain assessment vary according to individual situations and complaints of pain.

33. For patients with acute or severe pain, the nurse focuses on location, quality, severity, and early and immediate intervention.

34. The nurse must initiate pain assessment for patients who do not voice or express that they are experiencing pain.

35. The nurse determines the meaning of pain to the patient and the patient’s ability to cope with pain based on the patient’s pain history.

36. The nurse utilizes the acronyms OLDCART & ICE as a consistent method in assessing pain.

37. The nurse observes the patient’s behavioral responses to pain through direct observation. Responses may include elevation in blood pressure, pulse, respiratory rate, pallor, and diaphoresis.

CHAPTER 12 NUTRITIONAL ASSESSMENT

Learning Outcomes 1. Define nutritional health.

• Suggested Classroom Activity: Ask students to provide their personal definition of nutrition and compare and contrast their definition with that of the text.

•

Suggested Clinical Activity: Assign students to patients. Ask students to discuss with their assigned patients their definitions of nutrition and their perception of their nutritional status.

2. Outline risk factors that affect nutritional health status.

• Suggested Classroom Activity: Ask students to discuss risk factors that affect nutritional status and health education that can be implemented to counter those effects.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to review assigned patients’ charts and identify risk factors for nutritional health. Instruct students to develop appropriate teaching plans for their assigned patients based on the students’ assessment of assigned patients’ nutritional status.

3. Discuss the objectives described in Healthy People 2020 that relate to nutrition.

• Suggested Classroom Activity: Ask students to discuss Healthy People 2020 objectives related to nutrition and discuss methods that can be implemented to improve the nutritional status of the U.S. population.

•

Suggested Clinical Activity: Assign students to patients. Ask students to assess their assigned patients’ awareness and knowledge of Healthy People 2020 and the objectives related to nutrition. Ask students to develop teaching plans for their assigned patients specific to Healthy People 2020 nutritional objectives.

4. Identify the physical and laboratory parameters utilized in a nutritional assessment.

• Suggested Classroom Activity: Ask students to identify the laboratory parameters used in a nutritional assessment and also identify the specific biological or physical complication indicated by alterations in these values.

•

Suggested Clinical Activity: Assign students to patients. Ask students to review assigned patients’ laboratory studies and assess those values for alteration in their patients’ nutritional status. Ask students to determine if the nutritional alteration indicated by the laboratory values is addressed in the patient’s treatment plan. If so,

what is the treatment plan? If not, what is the reason the alteration in not being addressed?

5. Identify the components of the diet history and techniques for gathering diet history data.

• Suggested Classroom Activity: Ask students to perform a 24-hour diet recall of their intake and determine if the recall is an accurate reflection of their normal intake habits.

•

Suggested Clinical Activity: Assign students to patients. Ask students to conduct and complete the Food Frequency Questionnaire with their patients in order to gain insight into patients’ intake habits and nutritionals status.

6. Describe existing validated nutritional assessment tools.

• Suggested Classroom Activity: Ask students to compare and contrast two nutritional screening and assessment tools<CORE> listed in the text</CORE>.

•

Suggested Clinical Activity: Ask students to contact a hospital or organization’s dietitian and discuss with the dietitian nutrition screening tools used in the facility.

Instruct students to review the dietitian’s notes on their assigned patients’ and discuss with the dietitian the basis for his or her dietary recommendations during the patients’ hospitalization.

7. Develop questions to be used when completing a focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct a focused interview on nutritional history with dietary recall.

•

Suggested Clinical Activity: Ask students to conduct focused interviews with assigned patients regarding patients’ nutritional history including a food record used by the institution or of the students’ choosing.

8. Differentiate between normal and abnormal findings in a nutritional assessment.

• Suggested Classroom Activity: Ask students to discuss possible abnormal findings when conducting a nutritional assessment and to discuss appropriate interventions to improve these alterations.

•

Suggested Clinical Activity: Assign students to patients and instruct students to conduct a physical assessment. Ask students to discuss specific physical findings that indicate nutritional status alterations and discuss possible interventions to improve the alterations in patients’ nutritional status.

9. Determine specific nutritional assessment techniques and tools appropriate for unique stages in the life span.

• Suggested Classroom Activity: Ask students to identify specific considerations in conducting nutritional assessments on infants, children, pregnant females, lactating females, and older adults.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct nutritional assessments on their patients and develop nursing diagnoses related to patients’ nutritional status with specific consideration of the patient’s current health status and primary diagnosis.

10. Discuss strategies for integrating a complete nutritional assessment into the nursing care process.

• Suggested Classroom Activity: Ask students to discuss the relationship between the nutritional assessment and the nursing care process.

•

Suggested Clinical Activity: Assign students to patients and instruct students to conduct nutritional assessments of their patients. Instruct students to develop two nursing diagnoses related to each patient’s health status that addresses the patient’s nutritional status. The student should develop nutritional objectives with consideration for the patient’s physical, psychosocial, cultural, and spiritual being.

Key Concepts 1. The assessment portion of the nursing care process incorporates gathering and interpreting data often used as part of a nutritional assessment.

2. Data gathered in this assessment aid in developing appropriate nursing and nutritional interventions to improve nutritional health status.

3. The prevention or treatment of malnutrition or in some cases overnutrition requires a full nutritional assessment.

4. Information regarding an individual’s nutritional status should be gathered during the nursing assessment in order to determine a patient’s current nutritional status as well as his or her risks for poor nutritional health.

5. Data gathered in the nutritional assessment create the foundation for later development of appropriate nursing and nutritional interventions aimed at preserving or improving nutritional health using the nursing process.

6. Nutritional health is defined as the physical results of the balance between nutrient intake and nutritional requirement.

7. It is important for the nurse to recognize the relationship between nutritional intake, nutritional health, and disease processes.

8. The patient who consumes adequate nutrition to meet individual needs and avoids habitual excesses and insufficiencies is considered to be in good nutritional health.

9. Individuals are at risk for both undernutrition and overnutrition.

10. Risk factors for undernutrition include chronic diseases, acute illnesses, wounds or injuries, their symptoms, and their treatments.

11. Medications and medication side effects are sources of undernutrition and place patients at risk for poor nutritional health.

12. Restrictive eating due to medications, food intolerances, and allergies place patients at risk for undernutrition.

13. Self-diagnoses or self-prescribed diets place patients at risk for undernutrition and at risk for poor nutritional health.

14. Several other factors including psychological health, poor dental health, and alterations in sensory perception are sources of undernutrition and risk factors for poor nutritional health.

15. Overnutrition or excessive nutrient intake or stores may be caused by excessive intake of solid fat, added sugars, or calories.

16. Sedentary lifestyle, alcohol abuse, and decreased knowledge or skills about food preparation, health recommendations, and general nutrition increase the risk of poor nutritional health.

17. Healthy People 2020 provides comprehensive objectives related to nutrition and weight status.

18. Objectives of Healthy People 2020 include the need to increase the proportion of healthcare providers who regularly measure the body mass index (BMI) of their patients and provide patients with education related to weight and nutrition.

19. Healthy People 2020 objectives attempt to reduce the proportion of children and adolescents considered obese and to prevent inappropriate weight gain in youth and adulthood.

20. Healthy People 2020 attempts to increase the number of states that provide regional standards for food and beverages to school-age children and children in child care.

21. Healthy People 2020 looks to decrease hunger among children in the United States.

22. Healthy People 2020 provides comprehensive objectives for nutrition and weight status (NWS) and Maternal, Infant, and Child Health (MICH) by improving the diet of children 2 years and older, by increasing consumption of vegetables and by reducing the consumption of solid fats, added sugars, saturated fat, and sodium.

23. A patient’s nutritional status can be influenced by disease, medication, or environment.

24. The nutritional assessment is carried out using multiple variables versus the use of a single tool or data set.

25. The nurse is educated to identify nutritionally at-risk patients who require interventions in achieving nutritional health.

26. Dietary recall, a frequency questionnaire, and a food record are components of a patient’s nutritional history.

27. Dietary recall asks patients to verbally recall foods, beverages, and nutritional supplements consumed in the past 24-hour period.

28. A 24-hour recall is a one-day example of dietary intake and may not be an indicator of normal dietary habits.

29. Repeated recalls with supplemental visits provides a more accurate record of the patient’s nutritional intake.

30. A food frequency questionnaire assesses intake of a variety of food groups on a daily, weekly, or longer period.

31. A food record or diary is generally a three-day record that supplements the patient’s additional dietary history.

32. A dietary recall, food frequency questionnaire, or food diary can be used alone or in combination for a quick nutritional assessment.

33. A focused interview in combination with dietary recall, food frequency questionnaire, or food diary gives the best and clearest picture of a patient’s nutritional status.

34. A nutrition-focused interview can easily occur at the same time as a dietary recall.

35. During a dietary recall, the nurse has the opportunity to ask pertinent ancillary questions.

36. During the nutrition-focused interview, the nurse has the opportunity to ask additional questions regarding food consumption, allergies, food intolerances, and excesses from patient’s cues during the food recall. The focused interview should also include questions about past chronic dieting, use of supplements, or any past therapeutic diets.

37. Nutritional assessment may reveal abnormal findings through the use of nutritional tools or instruments, physical assessment, or laboratory results.

38. Nutritional assessment tools may reveal under- and overnutrition of the patient or provide cues that require further exploration.

39. Weight history is obtained to determine the presence of any intentional or unplanned weight loss.

40. Weight history is important in following childhood and pregnant female development, and in monitoring growth as well as development.

41. Unintentional weight loss of 5% or more over a month or 10% over 6 months is considered clinically significant and warrants further investigation and attention.

42. Body mass index (BMI) is frequently used to assess weight-to-height proportion, however, body mass index does not account for muscle mass, body fat, or bone mineral content; its usefulness is limited.

43. Waist circumference, body composition measurement including skinfold measurements, mid-arm muscle circumference, and calf circumference, along with other high-tech measurements, may be used as part of a comprehensive nutritional assessment.

44. Laboratory measurements indicative of nutritional status may correlate with physiological findings on physical examination.

45. Physical findings on exam including poor dental health, problems with chewing or swallowing, gastrointestinal complaints, functional decline, physical and mental status changes, and sensory decline including vision, taste, and smell are indicative of abnormalities in nutritional health.

46. Biochemical and laboratory parameters utilized in nutritional assessment include albumin; prealbumin; transferrin; cholesterol; studies specific to macrocytic, microcytic, and iron deficiency anemia; plasma protein; lymphocyte count; nitrogen balance; and studies that evaluate immunocompetence.

47. The nurse provides special consideration for lactating females, pregnant females, infants, children, adolescents, and older adults regarding the significance of abnormal findings in assessing their nutritional status.

48. The physical assessment portion of the nutritional assessment consists of anthropometric measurements of the patient.

49. The anthropometric measurements include the patient’s height, weight, and measurements of body fat and composition.

50. Components of nutritional assessment include physical assessment, anthropometric measurements, laboratory values, and nutritional history.

51. Nutritional assessment is the foundation on which nursing diagnoses are developed to implement nutritional goals and objectives.

52. Several parameters are required for a complete nutritional assessment versus one instrument, tool, or dataset.

53. Several nutritional screening and assessment tools exist; however, none are considered a gold standard for most of the population.

54. Nutritional screening tools provide quick assessments of risk factors for nutritional health.

55. Screening tools give only an estimate of an individual’s nutritional status.

56. The U.S. Department of Health and Human Services provides dietary guidelines for Americans ages 2 years and older. These guidelines promote good dietary habits, and emphasize the relationship between healthy eating habits and a reduction in the risk of acquiring a major chronic disease. The guidelines entitled MyPlate can be accessed at www.choosemyplate.gov.

57. The DETERMINE Checklist, the Minimum Data Set (MDS), and the Mini Nutritional Assessment (MNA) and Subjective Global Assessment, and the Malnutrition Universal Screening Tool (MUST) are among nutritional assessment tools used to evaluate patients’ nutritional health.

CHAPTER 13 SKIN, HAIR, AND NAILS

Learning Outcomes 1. Identify the anatomy and physiology of the skin, hair, and nails.

• Suggested Classroom Activity: Ask students to discuss detailed information that may be obtained from assessing a patient’s skin, hair, and nails.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to perform an assessment of their assigned patient’s skin, hair, and nails. Ask students to discuss their findings and possible indications.

2. Develop questions to be used in completing the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct focused interviews related to skin, hair, and nails.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct a focused interview on their assigned patient related to skin, hair, and nails.

3. Outline the techniques used for assessment of the skin, hair, and nails.

• Suggested Classroom Activity: Ask students to work in pairs and practice the techniques required for assessment of skin, hair, and nails.

•

Suggested Clinical Activity: Assign students to patients and have students demonstrate the proper technique required for assessment of the skin, hair, and nails.

4. Explain patient preparation for assessment of the skin, hair, and nails.

• Suggested Classroom Activity: Ask students to work in pairs and demonstrate preparing the patient for assessment of the skin, hair, and nails.

•

Suggested Clinical Activity: Assign students to patients and have students explain to patients preparation for assessment of the skin, hair, and nails.

5. Differentiate normal from abnormal findings in physical assessment of the skin, hair, and nails.

• Suggested Classroom Activity: Ask students to discuss abnormal findings on physical assessment of the skin, hair, and nails<CORE> as documented in the text</CORE>.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct a physical assessment of the skin, hair, and nails on their assigned patient noting any abnormal findings.

6. Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

• Suggested Classroom Activity: Ask students to discuss developmental, psychosocial, cultural, and environmental variations and factors in assessing patients’ skin, hair, and nails.

•

Suggested Clinical Activity: Assign students to patients. Have students conduct an assessment of their assigned patient’s skin, hair, and nails. Then instruct students to review the patient’s records. Document any findings on assessment of skin, hair, and nails in the record indicating developmental, psychosocial, cultural, and environmental factors that contribute to findings related to skin, hair, and nails.

7. Relate integumentary health to Healthy People 2020 objectives.

• Suggested Classroom Activity: Ask students to discuss objectives of Healthy People 2020 that relate to skin, hair, and nail health. Ask students to give specific examples of environmental factors that affect skin and methods patients can use to protect and prevent skin damage.

•

Suggested Clinical Activity: Divide students into groups. Instruct each group to develop a formal teaching module for patients that addresses a health issue related to skin, hair, and nails based on Healthy People 2020 objectives. Instruct students to utilize the principles of formal teaching<CORE> (see <OLINK>Chapter 1</OLINK>)</CORE>.

8. Apply critical thinking to the physical assessment of the skin, hair, and nails.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in caring for patients with alterations in skin, hair, and nails.

•

Suggested Clinical Activity: Assign students to patients. Ask each student to utilize critical thinking in developing three nursing diagnoses and assessing his or her patient’s psychosocial needs related to the patient’s skin, hair, and nails.

Key Concepts 1. The skin, hair, and nails are the major components of the integumentary system.

The integumentary system consists of the skin and the accessory structures, sweat and oil glands, hair, and nails.

2. The skin is the largest organ of the body and has a surface area of approximately 20 feet.

3. A thorough assessment of the skin, hair, and nails provides valuable information about general health.

4. The appearance of the skin, hair, and nails affects self-concept of the individual.

5. Skin, hair, and nails can also reveal alterations in activity, sleep and rest, level of stress, self-care, and self-care ability.

6. Identification and reduction of environmental risk factors for skin diseases including skin cancer and occupational skin disorders are among the objectives of Healthy People 2020.

7. Healthy People 2020 objectives related to the integumentary system are designed to promote health and wellness among individuals across the life span.

8. Awareness of the dangers related to harmful ultraviolet irradiation and sunburn are among the objectives of Healthy People 2020.

9. Healthy People 2020 also seeks to reduce occupational skin diseases or disorders among workers and to reduce the incidences of pressure ulcer development among hospitalized patients.

10. The nurse is cognizant of integumentary variations among different age and cultural groups.

11. Infants and young children have an array of variations related to the integumentary system with which the nurse must be familiar in order to determine normal from abnormal skin lesions.

12. Pigmentation of various body parts during pregnancy is generally considered normal. The nurse is aware of changes in the integumentary system during pregnancy in order to alleviate concerns of the pregnant female and to determine normal from abnormal findings.

13. As skin ages, the epidermis thins, stretches out, and collagen and elastin fibers decrease, giving skin a wrinkled appearance.

14. Older adults have delicate skin and an increased susceptibility to skin injury.

15. Psychosocial considerations related to skin include exacerbation of certain skin conditions, such as rashes or acne, due to stress.

16. Lack of cleanliness of the skin, hair, or nails may indicate emotional stress, poor self-esteem, or a disturbed body image.

17. A patient’s culture, socioeconomic status, home environment, and employment may affect the health of their skin, hair, and nails.

18. The nurse is aware of color variations between light and dark skin and alterations in appearance of different conditions due to skin color.

19. The nurse uses a variety of communication techniques to elicit general and specific information about the condition of the patient’s skin, hair, and nails.

20. The focused interview guides the physical assessment of the integumentary system; therefore, the nurse must consider age, gender, race, culture, environment, health practices, and past and current problems when forming questions during the interview.

21. The nurse asks questions addressing illness and infection, pain, behaviors, habits, and practices in accordance with the patient’s age and environment, as well as questions related to pregnancy in childbearing females.

22. One approach to questioning patients about skin, hair, and nail health is to use the OLDCART & ICE acronym to provide consistency in eliciting information from the patient.

23. The nurse prepares the patient for physical assessment of skin, hair, and nails by discussing the purpose of the exam.

24. The nurse provides a warm, comfortable, and private environment to reduce patient’s anxiety.

25. The nurse provides specific instructions and explains the purpose of removing clothing, jewelry, hairpieces, and nail enamel.

26. The nurse maintains the patient’s dignity by using draping techniques during the exam.

27. The nurse is sensitive to cultural issues and preferences.

28. Physical assessment of the skin, hair, and nails requires the use of inspection and palpation.

29. Inspection includes looking at the skin, hair, and nails to determine color, consistency, shape, and hygiene-related factors.

30. Knowledge of norms or expected findings is essential in determining the meaning of the data as the nurse performs the physical assessment.

31. The nurse is cognizant of irregular but nonabnormal findings such as freckles, birthmarks, and normal age variations.

32. Physical assessment of the skin, hair, and nails follows an organized pattern that begins with survey and inspection of the skin, followed by palpation of the skin.

33. Inspection and palpation of the hair and nails are then carried out.

34. When lesions are present, measurements are used to identify the size of the lesions and the location in relation to accepted landmarks.

35. The nurse is aware of normal findings in assessing skin, hair, and nails across the life span and across different ethnicities in order to differentiate abnormal findings.

36. Skin abnormalities include edema, primary lesions, secondary lesions, vascular lesions, skin infections, allergic and inflammatory lesions, and malignant lesions that require additional investigation.

37. The nurse assesses for abnormal hair loss and hirsutism, both of which require additional investigation, follow-up questions, and may require additional workup.

38. Other abnormal findings related to hair include tinea capitis, seborrheic dermatitis, folliculitis, and furuncles and abscesses.

39. The nurse assesses nails and nail beds for (among other issues) clubbing, a sign of hypoxia; nutritional deficiencies; paronychia; koilonychias; and Beau’s lines.

40. The nurse assesses lesions suspicious for cancer malignancy using the ABCDE criteria for melanoma assessment.

41. The nurse uses critical thinking and the nursing process to identify factors considered in collecting data related to the integumentary system.

42. Some of the factors considered include age, developmental level, race, ethnicity, work history, living conditions, socioeconomic status, and the patient’s emotional well-being.

43. The nurse categorizes and clusters data from both the subjective and objective data of the assessment.

44. The nurse analyzes these clusters of data and prioritizes concerns regarding the patient’s physical and psychosocial well-being.

45. In assessing collected data, the nurse develops diagnoses, sets goals, develops interventions, and implements a plan with the patient.

46. As educator, the nurse teaches the patient about risks of sun exposure and develops interventions to minimize and eliminate risks and promote health.

CHAPTER 14 HEAD, NECK, AND RELATED LYMPHATICS

Learning Outcomes 1. Describe the anatomy and physiology of the structures of the head, neck, and related lymphatics.

• Suggested Classroom Activity: Using simulation models, ask students to discuss the anatomy and physiology of the head and neck, and discuss the lymphatic system of this area of the body.

•

Suggested Clinical Activity: Assign students to patients and instruct students to assess their assigned patient’s head, neck, and lymphatics.

2. Develop questions to be used when completing the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct focused interviews of the head, neck, and related lymphatics on each other.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct focused interviews on the head, neck, and related lymphatics of their assigned patient.

3. Outline the techniques used for assessment of the head, neck, and related lymphatics.

• Suggested Classroom Activity: Ask students to work in pairs and practice the techniques required for assessment of the head, neck, and related lymphatics.

•

Suggested Clinical Activity: Assign students to patients and instruct students to demonstrate the proper technique required for assessment of the head, neck, and related lymphatics of their assigned patient.

4. Explain patient preparation for assessment of the head, neck, and related lymphatics.

• Suggested Classroom Activity: Ask students to work in pairs and demonstrate preparing the patient for assessment of head, neck, and related lymphatics.

•

Suggested Clinical Activity: Assign students to patients and have students explain to patients preparation for assessment of the head, neck, and related lymphatics.

5. Differentiate normal from abnormal findings in the physical assessment of the head, neck, and related lymphatics.

• Suggested Classroom Activity: Ask students to discuss abnormal findings on physical assessment of the head, neck, and related lymphatics<CORE> as documented in the text</CORE>.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct a physical assessment of the head, neck, and related lymphatics on their assigned patient, noting any abnormal findings.

6. Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

• Suggested Classroom Activity: Ask students to discuss developmental, psychosocial, cultural, and environmental variations and factors in assessing the head, neck, and related lymphatics.

•

Suggested Clinical Activity: Instruct students to select one of the following topics and develop a formal teaching plan for patients utilizing the principles of teaching<CORE> (see <OLINK>Chapter 1</OLINK>)</CORE>: o Bell’s palsy o Tension headaches o Hyperthyroidism

7. Relate overall health of the head, neck, and related lymphatics to Healthy People 2020 objectives.

• Suggested Classroom Activity: Ask students to discuss objectives of Healthy People 2020 that relate to prevention of head injuries and accidents.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to assess the related lymphatics of the head and neck of their assigned patient. Instruct students to discuss with patients the benefits of lymph node assessment as a form of early detection of some types of cancers.

8. Apply critical thinking to the physical assessment of the head, neck, and related lymphatics.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in caring for patients with alterations of the head and neck.

•

Suggested Clinical Activity: Assign students to patients with an alteration of the head or neck. Ask each student to utilize critical thinking in developing three nursing diagnoses and assessing his or her patient’s needs related to alterations of the head or neck.

Key Concepts 1. Assessment of the head, neck, and lymphatics involves assessing several body systems simultaneously.

2. The nurse must consider the interrelationship of multiple systems when assessing the patient’s head and neck in which the patient’s nutritional status, airway clearance, tissue perfusion, metabolism, level of activity and rest, level of stress, and self-care ability may be apparent.

3. The nurse is aware of psychosocial-associated factors in assessment of the head and neck, including stress and anxiety that can influence health in this area of the body.

4. The structures of the head include the skull and facial bones as well as cartilage, muscles, glands, and major blood vessels that are found in the neck.

5. A large supply of lymph nodes is located in the head and neck region of the body.

6. A patient’s developmental stage influences the appearance and function of the head and neck region.

7. The nurse is familiar with the circumference of the newborn’s head in relation to the size and the circumference of the chest.

8. An infant’s head should be measured at every visit until the age of 2.

9. The nurse is familiar with the structures of the skull and fontanels of the newborn and very young children.

10. The nurse is familiar with the structure of the thyroid gland with regard to age and developmental stages of children, young adults, and older adults.

11. All states require screening newborns for congenital hypothyroidism or reduced thyroid function.

12. The pregnant female may exhibit pigmented spots, facial edema, and an enlarged thyroid gland.

13. The pregnant female should be questioned regarding headaches, which may be a sign of preeclampsia.

14. Healthy People 2020 identifies prevention of injury and violence as national objectives with specific attention to reducing the number of injuries and disabilities that result from head injuries.

15. Healthy People 2020 objectives include detecting and preventing cancer as well as promoting survival among individuals who undergo cancer treatment. Almost every form of cancer, including breast cancer and lung cancer, spreads to lymph nodes through metastasis, which may then cause the lymph nodes to become firm and inflamed.

16. Routine screening that includes assessment and palpitation of the lymph nodes located in the neck may help in early identification of cancer, which may lead to early treatment.

17. Other Healthy People 2020 objectives related to head and neck health include reducing fatal and nonfatal traumatic brain injuries, increasing use of seat belts, and increasing use of age-appropriate vehicle restraint systems for children between the ages of 0 to 12 years.

18. Additional Healthy People 2020 objectives related to head and neck health include reducing the incidence of fetal alcohol syndrome (FAS), reducing sports and recreational injuries, and preventing fall-related deaths.

19. The focused interview for the head and neck elicits data related to the head, the face, and the structures of the neck including the thyroid, trachea, and lymph nodes.

20. The nurse must be prepared to observe the patient for cues related to the functions of structures within the head and neck.

21. Follow-up questions are required for cues that require clarification of data and gathering missing information.

22. Follow-up questions may identify the source of problems, explain the duration of problems, discuss ways to alleviate problems, and provide cues about the patient’s knowledge of his or her health.

23. The focused interview guides the physical assessment of the head and neck; therefore, the nurse must consider the patient’s age, gender, race, culture, environment, health practices, past and current problems, and therapies when framing questions and using techniques to elicit information.

24. The nurse may use the acronym OLDCART & ICE in order to illicit information from the patient systematically.

25. The nurse utilizes inspection, palpation, and auscultation during examination of the head and neck regions.

26. Inspection includes looking at skin color, the scalp, the skull, and the face for symmetry of bone and structures.

27. The trachea is palpated for position.

28. The thyroid is palpated for movement, texture, and identification of size or abnormalities.

29. The lymph nodes of the head and neck are palpated to assess for enlargement, tenderness, and mobility.

30. The nurse is aware of normal physical findings of the head, neck, and lymphatics in order to ascertain abnormal findings.

31. The nurse provides an environment that offers the patient, warmth, comfort, and privacy.

32. The nurse explains to the patient what is expected with each step of the assessment.

33. The nurse explains to the patient the need to remove any items that would impede the examination and assessment including jewelry, hats, scarves, veils, earpieces, and wigs.

34. The nurse explains the purpose of each procedure to the patient.

35. The nurse uses standard precautions while examining the patient.

36. Abnormal findings in the head and neck include headaches, abnormalities in the size and contour of skull, malformations or abnormalities of the face and neck, thyroid enlargement, and enlarged lymph nodes. An episodic isolated enlarged lymph node is not considered significant.

37. The nurse is aware that headaches vary in terms of type and duration. Follow-up questions should provide information regarding headache triggers especially with regard to migraine headache.

38. The patient should be educated regarding foods found to provoke headaches including tyramine-rich foods, and certain food additives including food coloring and nitrates.

39. The nurse should elicit information from the patient to differentiate between classic migraine headaches, cluster headaches, and tension headaches.

40. In conjunction with laboratory results, objective findings for hyperthyroidism include enlarged thyroid gland, exophthalmos, cardiac changes including tachycardia and the patient’s subjective complaint of palpitations, as well as changes in the integumentary system including skin thinning and fine brittle hair, weight loss, an increased diaphoresis.

41. The nurse assesses the patient for thyroid disorders based on cues that indicate hyper- or hypothyroidism in conjunction with physical assessment.

42. The nurse collects subjective and objective data during the interview and physical assessment.

43. Some of the factors considered in critical thinking related to the head, neck, and lymphatics system include age, developmental stage, work history, living conditions, socioeconomic status, and the patient’s emotional well-being.

44. The nurse clusters data to determine potential and actual diagnoses.

45. The nurse assesses data to determine a diagnosis, the need for diagnostic studies to assist in determining a patient’s diagnosis, and when applicable, implementing a plan of care with the patient.

CHAPTER 15 EYE

Learning Outcomes 1. Describe the anatomy and physiology of the eye.

• Suggested Classroom Activity: Using a simulation model, ask students to discuss the anatomy and physiology of the eye.

•

Suggested Clinical Activity: Assign students to patients with an alteration in their vision or injury to an eye. Ask students to review with their assigned patient the structures and functions of the eye related to the patient’s diagnosis.

2. Develop questions to be used when completing the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct focused interviews related to the eyes on each other.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct focused interviews related to the eyes on their assigned patient.

3. Outline the techniques used for assessment of the eye.

• Suggested Classroom Activity: Ask students to work in pairs and practice the techniques required for assessment of the eyes.

•

Suggested Clinical Activity: Assign students to patients and instruct students to demonstrate the proper technique required for assessment of the eyes of their assigned patient.

4. Explain patient preparation for assessment of the eye.

• Suggested Classroom Activity: Ask students to work in pairs and demonstrate preparing the patient for assessment of eyes.

•

Suggested Clinical Activity: Assign students to patients and have students explain to patients preparation for assessment of the eyes.

5. Explain the use of the ophthalmoscope.

• Suggested Classroom Activity: Ask students to work in pairs and demonstrate proper use of the ophthalmoscope for the eye assessment.

•

Suggested Clinical Activity: Assign students to patients and instruct students to perform an eye assessment on their assigned patient using the ophthalmoscope.

6. Differentiate normal from abnormal findings in physical assessment of the eye.

• Suggested Classroom Activity: Ask students to discuss abnormal findings on physical assessment of the eyes<CORE> as documented in the text</CORE>.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct an eye assessment on their assigned patient noting any abnormal findings. Discuss these findings with the patient’s primary nurse.

7. Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the eye.

• Suggested Classroom Activity: Ask students to identify and discuss cultural factors and variances related to eye health.

•

Suggested Clinical Activity: Instruct students to develop formal teaching plans for patients from the following selection using teaching principles<CORE> (see <OLINK>Chapter 1</OLINK>)</CORE>: o Glaucoma in the African American population o Eye health in patients with hypertension o Eye health in patients with diabetes

8. Discuss the objectives related to overall health of the eyes and vision as presented in Healthy People 2020.

• Suggested Classroom Activity: Ask students to discuss the objectives of Healthy People 2020 as they relate to vision and eye health with attention to reducing and preventing occupational and recreational injuries.

•

Suggested Clinical Activity: Instruct students to develop a formal teaching plan for parents of preschool children ages 5 and younger to promote early vision screening.

Utilize the principles of formal teaching for this activity<CORE> (see <OLINK>Chapter 1</OLINK>)</CORE>.

9. Apply critical thinking to the physical assessment of the eye.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in caring for patients with alterations in vision or eye health problems.

Instruct students to emphasize a holistic view of patients and the effect of visual alterations on various aspects of patients’ lives.

•

Suggested Clinical Activity: Assign students to patients with an alteration in vision or eye health problem. Instruct each student to utilize critical thinking in developing three nursing diagnoses and addressing his or her patient’s needs related to alterations in vision.

Key Concepts

1. The eyes are the sensory organs responsible for vision. Vision affects how an individual interacts and communicates with the world through learning, working, and playing.

2. The eyes receive light waves and transmit these waves to the brain for interpretation of visual images.

3. Major functioning parts of the eye include the sclera, the cornea, the choroid, the iris, and the pupil.

4. The third cranial nerve controls pupillary constriction and dilation.

5. The parasympathetic branch of the third cranial nerves stimulates pupillary constriction while the sympathetic branch stimulates dilation.

6. Health People 2020 objectives have been created to improve visual health by prevention, early diagnosis, prompt treatment, and rehabilitation of the eyes.

7. Specific objectives related to eye health in Health People 2020 include increasing the proportion of preschool children under the age of 5 who receive vision screening.

8. Health People 2020 objectives also seek to reduce blindness and visual impairment in children and adolescents ages 17 years and younger.

9. Health People 2020 addresses environmental concerns in its initiative to reduce occupational eye injuries and increase the use of personal protective eyewear in recreational activities and hazardous situations in homes.

10. Newborns do not obtain permanent color of their iris until approximately 3 months of age.

11. Tears are not present at birth but begin to appear by 4 weeks after birth.

Binocular vision, vision in both eyes, begins to develop by 6 weeks of age.

12. An infant who cannot focus on objects requires further evaluation.

13. The pregnant female may describe visual changes due to shifting fluid in the cornea during the pregnancy. She may also report some visual changes that are expected to return to the pre-pregnancy state within the first 6 weeks after birth.

14. The aging adult experiences several visual changes. Presbyopia begins by the age of 45 due to changes in the ciliary muscle of the eye, decreasing the ability of the lens to change shape.

15. Other visual changes related to aging include arcus senilis and cataracts.

16. Children with visual impairments may experience developmental delays and may require specialist and assistive social and educational services into adulthood.

17. Decreased visual acuity may cause individuals to experience compromised independence and decreased quality of life. Some may have difficulty obtaining employment.

18. Eye contact is a factor in the communication process and may vary depending on an individual’s culture.

19. African Americans are diagnosed with glaucoma at higher rates than people of other ethnic groups.

20. Age-related macula degeneration among Caucasians is a cultural consideration related to eye health.

21. Environmental concerns regarding eye health include use of safety glasses and protective eyewear when the eyes are at risk, sun exposure, and use of medications.

22. The focused interview with the patient elicits data related to the structures of the internal and external eye and concerns related to vision.

23. The nurse listens for cues that relate to the status and function of the eye as well as compromised vision.

24. The nurse must consider the patient’s age, gender, race, culture, environment, health practices, and past and current problems with visual acuity or diseases that affect the eye.

25. Questions in the focused interview should address illness and infection; symptoms; pain; patient behaviors including habits and practices related to eye health; pregnancy, when applicable; and environmental concerns.

26. The nurse ensures patient comfort and safety by providing a warm, comfortable environment in which to assess the eyes.

27. The nurse prepares the patient for examination of the eyes by explaining each part of the examination in advance.

28. The nurse positions the patient in accordance with each part of the examination.

29. The nurse uses standard precautions in assessment of the eyes.

30. Physical assessment of the eye requires the use of inspection, palpation, and tests of the function of the eyes.

31. Inspection includes looking at the size, shape, and symmetry of the eye, eyelids, eyebrows, and eye movements.

32. Physical assessment of the eye follows an organized pattern that begins with visual acuity followed by assessment of visual fields, muscle function, and external eye structures.

33. Assessment of the eye concludes with the use of an ophthalmoscope for the internal examination.

34. Proficient use of the ophthalmoscope is an advanced skill that requires significant practice.

35. The nurse adjusts the diopter wheel of the ophthalmoscope to compensate for patients with myopic and hyperopic vision.

36. The nurse uses the ophthalmoscope to examine the fundus, red reflex, optic disc, macula, blood vessels, and other internal structures of the eye.

37. The nurse is able to recognize abnormal findings in physical assessment of the eye that may require more in-depth examination by an ophthalmologist.

38. Abnormal findings on assessment of the eyes may be associated with vision, eye movement, or the internal or external structures of the eye.

39. Abnormal findings on assessment of the eye may be discovered based on cues and complaints presented in the focused interview.

40. Abnormal findings related to the eyelid include blepharitis, chalazion, hordeolum, basal cell carcinoma, ptosis, and exophthalmus.

41. Abnormal findings related to the eye include conjunctivitis, iritis, subconjunctival hemorrhage, pterygium, cataracts, and acute glaucoma.

42. Other abnormal findings include conditions related to pupillary response and abnormalities of the fundus found on assessment with the ophthalmoscope including diabetic retinopathy and age-related macular degeneration.

43. The nurse uses critical thinking and the nursing process to identify factors to be considered while collecting data related to the eyes and to vision.

44. The nurse collects data based on the focused interview and categorizes the data to develop diagnoses related to the patient’s eye health.

45. The nurse prioritizes patient’s needs based on this collection of data from the focused interview and from the physical assessment.

46. In addition to developing diagnoses related to the patient’s current eye health, the nurse provides education related to expected changes based on age, culture or ethnicity, and, when applicable, pregnancy. The nurse also provides recommendations based on data related to the home and work environments and to recreational activities.

CHAPTER 16 EAR, NOSE, MOUTH, AND THROAT

Learning Outcomes 1. Describe the anatomy and physiology of the ear, nose, mouth, and throat.

• Suggested Classroom Activity: Using a simulation model, ask students to discuss the anatomy and physiology of the ear, nose, mouth, and throat.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to perform a physical assessment on the ears, nose, mouth, and throat of their assigned patient within the limits of the patient’s ability.

2. Develop questions to be used when completing the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs. Have each student complete a focused interview of the ear, nose, mouth, and throat on each other.

•

Suggested Clinical Activity: Assign students to patients. Have each student complete the focused interview on the assigned patient for the ear, nose, mouth, and throat.

3. Outline the techniques used for assessment of the structures of the ear, nose, mouth, and throat.

• Suggested Classroom Activity: Ask students to work in pairs. Have students outline the techniques used for assessment of the structures of the ear, nose, mouth, and throat.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to outline the techniques used for assessment of the ear, nose, mouth, and throat prior to conducting the assessment on their assigned patient.

4. Demonstrate correct use of the otoscope.

• Suggested Classroom Activity: Ask students to work in pairs. Have students demonstrate correct use of the otoscope in examining the ear and nose.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to perform assessments of their assigned patient’s ears demonstrating proper use of the otoscope.

5. Differentiate normal from abnormal findings in the physical assessment of the ear, nose, mouth, and throat.

Suggested Classroom Activity: Ask students to discuss possible abnormal findings in the physical assessment of the ear, nose, mouth, and throat.

•

Suggested Clinical Activity: Assign students to patient. Instruct students to discuss with their assigned patient who has a current or past ear, nose, mouth, or throat health problem, findings on physical assessment that contributed to the appropriate diagnosis.

6. Describe the developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

• Suggested Classroom Activity: Ask students to discuss developmental, psychosocial, cultural, and environmental variations in assessment technique and in findings related to ear, nose, mouth, and throat.

•

Suggested Clinical Activity: Assign students to patients and have students interview their assigned patient with attention to developmental, psychological, cultural, and environmental variations related to findings on assessment of the ear, nose, mouth, or throat.

7. Relate ear, nose, mouth, and throat health to Healthy People 2020 objectives.

• Suggested Classroom Activity: Ask students to discuss the objectives of Healthy People 2020 and the role of nurses in implementing interventions to obtain the objectives related to ear, nose, mouth, and throat health.

•

Suggested Clinical Activity: Ask students to interview nurses caring for patients with ear, nose, mouth, or throat disorders with attention to nurses’ perception of the importance of Healthy People 2020 objectives in caring for these patients.

8. Apply critical thinking to the physical assessment of the structures of the ear, nose, mouth, and throat.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in caring for patients with ear, nose, mouth, and throat health problems.

•

Suggested Clinical Activity: Ask each student to interview a patient with a health problem involving the ear, nose, mouth, or throat. Based on the interview and using critical thinking, have the student develop two nursing diagnoses that reflect the psychosocial component of the patient’s health problem. Instruct the students to work with their assigned patient to develop objectives, interventions, implementation plans, and evaluation plans that address the nursing diagnoses.

Key Concepts

1. Structures of the ear, nose, mouth, and throat are responsible for the senses of hearing, smelling, and tasting.

2. The interrelationships of the senses and their structures provide data for several body systems.

3. The ears are the sensory organs that function in both hearing and equilibrium.

4. The major functions of the ears are collecting and transporting sound vibrations to the brain and maintaining the sense of equilibrium.

5. The major functions of the nose and sinuses are providing an airway for respiration; filtering, warming, and humidifying air for the respiratory tract; providing resonance for sound; and housing the receptors for olfaction or smell.

6. The oral cavity or the mouth contains several structures involved with digestion, speech, and swallowing.

7. The throat or pharynx connects the nose, mouth, larynx, and esophagus and is involved in respiration, phonation, and digestion.

8. The nurse is aware of developmental differences and normal variants when examining patients of different ages, especially children.

9. The pregnant female may experience rhinitis due to increased vascularity during pregnancy.

10. The pregnant female may experience an increase in snoring due to changes in blood vessels and connective tissues in the mouth during pregnancy.

11. The pregnant female may experience gingivitis and hyperplastic overgrowth of the gums during pregnancy that recede after birth.

12. Older adults experience numerous changes to the ear, nose, mouth, and throat as they age including loss of sensitivity to high-frequency tones, presbycusis, and loss of hair cells in the inner ear.

13. Older adults experience changes in olfactory senses, taste buds, and salivary production among other changes that contribute to decreased appetite and poor nutrition.

14. Patients who experience a great deal of stress may be prone to mouth ulcers and lip biting.

15. Healthy People 2020 objectives related to ear, nose, mouth, and throat health include improvement in hearing and in the prevention and control of oral diseases.

16. As part of preventing hearing loss, screening for hearing deficits is included among Healthy People 2020 objectives related to promoting health of the ears, nose, and throat.

17. Goals of Healthy People 2020 include encouraging individuals to seek assessment and treatment for sensory-related disorders.

18. Healthy People 2020 aims to increase the proportion of newborns screened for hearing loss by the age of 1 month, and to reduce otitis media in children and adolescents.

19. Healthy People 2020 provides initiatives to improve oral health by preventing tooth decay and increasing access to care for individuals who develop tooth decay and by promoting preventive dental care.

20. The focused interview guides the physical assessment of the ear, nose, mouth, and throat.

21. The nurse must consider age, gender, race, culture, environment, health practices, past and current problems, and therapies when framing questions and using techniques to elicit information.

22. Questions related to gathering data on the ears, nose, mouth, and throat include addressing illnesses, infection, symptoms, pain, behaviors, habits and practices, and questions specific to patients according to their age; pregnancy, for the childbearing female; and questions that address environmental concerns.

23. The nurse may utilize the acronym OLDCART & ICE as a consistent method of evaluating patients in the focused interview.

24. Physical assessment of the ears, nose, mouth, and throat requires the use of inspection, palpation, percussion, and transillumination of the sinuses.

25. Physical assessment of the ear, nose, mouth, and throat follows an organized pattern.

26. Physical assessment begins with instructing the patient and proceeding with inspection, palpation, and the otoscope examination of the ears.

27. Hearing assessment and the Romberg test follow.

28. The nose is inspected and the internal aspects are visualized using the speculum and the otoscope.

29. The sinuses are palpated, percussed, and transilluminated.

30. The assessment concludes with inspection of the external mouth, the internal structures of the mouth, and assessment of the throat.

31. The otoscope is used to examine the structures and patency of the ears.

32. The nurse pulls the earlobe of a child age 3 or younger down and back when examining the tympanic membrane.

33. The nurse is familiar with the proper use and manipulation of the otoscope during an examination.

34. The nurse is aware of the sensitivity of the inner ear and exhibits caution during assessment of the inner ear by avoiding pressing the speculum on either side of the auditory canal.

35. The otoscope is also used to examine the nasal cavity.

36. Abnormal findings during the physical assessment of the ear, nose, mouth, and throat may be based on cues and follow-up questions from the patient during the focused examination.

37. The nurse is cognizant of normal findings in order to ascertain abnormal findings of the ear, nose, mouth, and throat.

38. The nurse considers age, environment, health practices, past and current problems, in assessing normal from abnormal findings in the patient.

39. Abnormal findings may require referral to specialists and additional follow-up management and care with an otolaryngologist.

40. The nurse utilizes critical thinking by asking follow-up questions to cues from patients in order to elicit additional data.

41. The nurse clusters and organizes data in order to form conclusions and develop nursing diagnoses related to patient’s present complaints and health problems as well as potential problems.

42. The nurse prioritizes patient needs based on data collected from the focused interview and from the physical assessment.

43. The nurse provides recommendations and discusses with patients expectations based on age, health status, home and work environments, and other related factors.

CHAPTER 17 RESPIRATORY SYSTEM

Learning Outcomes 1. Describe the anatomy and physiology of the respiratory system.

• Suggested Classroom Activity: Using a simulation model, ask students to discuss the anatomy and physiology of the respiratory system.

•

Suggested Clinical Activity: Assign students to patients and ask students to conduct a respiratory system assessment on their assigned patient.

2. Identify landmarks that guide assessment of the respiratory system.

• Suggested Classroom Activity: Using the simulation model and a fellow student, ask each student to identify the landmarks that guide the assessment of the respiratory system.

•

Suggested Clinical Activity: Assign student to patients and have students demonstrate the landmarks that guide assessment of the respiratory system prior to conducting the respiratory system assessment.

3. Develop questions to be used when completing a focused interview.

• Ask students to work in pairs and conduct the respiratory system focused interview on each other.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct a respiratory system focused interview with their assigned patient.

4. Explain patient preparation for assessment of the respiratory system.

• Suggested Classroom Activity: Ask students to work in pairs and demonstrate preparing the patient for assessment of the respiratory system.

•

Suggested Clinical Activity: Assign students to patients and have students demonstrate preparing their assigned patient for assessment of the respiratory system before completing the respiratory system assessment.

5. Describe the techniques required for assessment of the respiratory system.

• Suggested Classroom Activity: Ask students to work in pairs and practice the techniques required for assessment of the respiratory system including demonstrating the use of appropriate landmarks.

•

Suggested Clinical Activity: Assign students to patients and instruct students to describe and demonstrate on their assigned patient the proper technique required for assessment of the respiratory system including landmarks.

6. Differentiate normal from abnormal findings in physical assessment of the respiratory system.

• Suggested Classroom Activity: Ask students to discuss possible abnormal findings on assessment of the respiratory system and the possible indications of those findings.

•

Suggested Clinical Activity: Assign students to patients diagnosed with a respiratory system problem, present or past. Ask students to discuss with patients findings on physical assessment that led to a diagnosis.

7. Describe developmental, psychosocial, cultural, and environmental variations of assessment techniques and findings related to the respiratory system.

• Suggested Classroom Activity: Ask students to discuss developmental, psychosocial, cultural, and environmental factors that may affect respiratory system health.

•

Suggested Clinical Activity: Assign students to patients. Have students conduct a physical assessment on their assigned patient and review the patient’s chart.

Document findings indicating developmental, psychosocial, cultural, and environmental factors that contribute to the patient’s current respiratory health problem and that may be a factor in the patient’s recovery.

8. Discuss the objectives related to the overall health of the respiratory system as presented in Healthy People 2020.

• Suggested Classroom Activity: Ask students to discuss objectives of Healthy People 2020 related to respiratory system health.

•

Suggested Clinical Activity: Assign students to nurses caring for patients with respiratory system health problems. Ask students to interview a nurse with attention to the nurse’s perception and integration of Healthy People 2020 objectives in caring for patients with respiratory system health problems.

9. Apply critical thinking to the physical assessment of the respiratory system.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in patients with respiratory system health problems.

•

Suggested Clinical Activity: Assign students to patients with respiratory system health problems. Ask each student to utilize critical thinking in developing three nursing diagnoses and assessing his or her patient’s needs related to the respiratory system.

Key Concepts

1. The primary responsibility of the respiratory system is the exchange of gases in the body. Exchange of oxygen and carbon dioxide is essential to the homeostatic and hemodynamic processes of the body.

2. The respiratory system has a major role in helping the body to maintain acid– base balance.

3. The respiratory system is influential in the production of vocal sounds or speech based on the movement of air out of the lungs and over the vocal cords.

4. Developmental factors are considered in assessing the respiratory system.

5. Environmental factors contribute to respiratory difficulties as well as pathologies that affect respiratory function.

6. Major structures of the respiratory system are situated in the thoracic cavity.

7. Major parts of the respiratory system include the trachea; bronchi; lungs, including alveolar sacks and alveoli; the pleural membranes; and the mediastinum.

8. Location of landmarks helps the nurse develop a mental picture of the structures of the respiratory system.

9. Major landmarks include the manubrium, the angle of Louis, and the clavicle.

10. The 12 pairs of ribs and their associated intercostal spaces provide bony landmarks for respiratory assessment.

11. The vertebral column or spine and the 12 vertebrae of the thoracic cavity provide vertical landmarks in assessment of the respiratory system.

12. Descriptions of the thorax are typically described as anterior, lateral, and posterior in accordance with bony structures such as the clavicle, sternum, scapula, ribs, and intercostal spaces.

13. The nurse identifies factors that influence physical assessment such as age, developmental level, race, ethnicity, work history, living conditions, socioeconomic status, and emotional wellness.

14. Oxygen needs are higher in smaller children because of their increased metabolic rate.

15. The risk of respiratory failure is greatest in infants, toddlers, and preschoolers.

Children of all ages experience respiratory failure much more quickly than adults.

16. Respiratory variances at birth include use of abdominal muscles; therefore, inspection of the abdomen provides a more accurate respiratory rate. Abdominal breathing continues through childhood until the ages of 5 to 7.

17. During pregnancy, the diaphragm rises into the chest to accommodate the fetus, and the pregnant female’s respirations become diaphragmatic.

18. Shortness of breath and dyspnea are common in the last trimester of pregnancy due to increased maternal and fetal oxygen demands.

19. Numerous respiratory changes accompany aging, including loss of elasticity of the lungs, and weakening of skeletal muscles that result in difficulty taking deep breaths and causing older adults to inhale and exhale smaller amounts of air with an increase in respiratory rate.

20. Asthma has a greater prevalence among Puerto Ricans, American Indians, and African Americans than among individuals of other ethnic groups.

21. Healthy People 2020 includes objectives to promote respiratory health through prevention, detection, treatment, and education.

22. Objectives of Healthy People 2020 related to the respiratory system include prevention of asthma and COPD, and reduction of exposure to known respiratory hazards.

23. Healthy People 2020 objectives also include reducing hospitalizations and deaths due to asthma as well as reducing emergency department visits, missed school or work days, and missed activities due to asthma.

24. Objectives of Healthy People 2020 related to the respiratory system include increasing the number or individuals who receive formal patient education about asthma.

25. There is a general focus of Healthy People 2020 objectives related to respiratory health and promoting health and wellness of the respiratory system across the life span.

26. The nurse is cognizant of factors that influence respiratory health. The focused interview and cues elicited from the patient will formulate and guide the physical assessment.

27. The focused interview for the respiratory system gathers data related to the structures and functions of the system.

28. The nurse observes and listens for cues related to the function of the respiratory system.

29. Follow-up questions identify the source(s) of problems, duration of difficulties with respirations, and measures taken to alleviate respiratory problems.

30. The nurse assesses information from the focused interview in relation to norms and expectations of respiratory function.

31. The nurse considers the patient’s age, gender, race, culture, environment, health practices, past medical problems, and therapies when asking questions and using techniques to elicit information during the focused interview.

32. The nurse asks questions that address illness, infection and related symptoms, pain, discomfort, behaviors and habits, and practices in accordance with age, pregnancy in the childbearing female, and environmental concerns.

33. The nurse uses the acronym OLDCART & ICE for consistent evaluation of the respiratory system.

34. Physical examination of the respiratory system follows an organized pattern.

35. Physical examination begins with a general patient survey that includes assessing the patient’s respiratory rate and rhythm, followed by inspection of the anterior thorax and complete assessment of the posterior thorax.

36. The assessment ends with palpation, percussion, and auscultation of the anterior thorax.

37. The nurse includes the anterior, posterior, and lateral aspects of the thorax when conducting each of the assessments.

38. Patient preparation for physical assessment involves providing an environment that is comfortable and private with limited exposure of body parts during the examination.

39. The nurse explains each step of the assessment to the patient.

40. The nurse provides specific instructions about what the patient may expect and provides clear and concise directions for each procedure.

41. The nurse pays attention to nonverbal cues that may indicate some degree of discomfort and seeks to clarify if the patient experiences discomfort during the examination.

42. The nurse uses standard precautions during the examination.

43. Abnormal findings during the physical assessment of the respiratory system may be based on cues, follow-up questions, and responses from the patient during the focused interview.

44. The nurse is cognizant of normal findings in order to ascertain abnormal findings in assessing the respiratory system.

45. The nurse must consider age, environment, health practices, and past and current problems in assessing normal from abnormal findings during physical assessment of the respiratory system.

46. Individuals experiencing pain or dyspnea, who are restless, anxious, and unable to follow directions, require immediate medical assistance.

47. Abnormal findings may require referral to pulmonary specialists and additional follow-up management and care.

48. The nurse uses critical thinking and the nursing process to identify factors to be considered while collecting data related to the respiratory system.

49. The nurse collects data based on the focused interview, and clusters and categorizes the data to develop diagnoses related to respiratory dysfunction and respiratory health.

50. The nurse prioritizes a patient’s needs based on the data collected from the focused interview and from the physical assessment.

51. In addition to developing diagnoses related to the patient’s current respiratory status, the nurse provides education related to expected changes based on age and other lifespan considerations, and provides recommendations based on data related to the home and work environment as appropriate.

CHAPTER 18 BREAST AND AXILLAE

Learning Outcomes 1. Describe the anatomy and physiology of the breasts and axillae.

• Suggested Classroom Activity: Using simulation models, ask students to discuss the anatomy and physiology of the breast and axillae.

•

Suggested Clinical Activity: Assign students to patients and ask students to conduct an assessment of the breasts and axillae on their assigned patient.

2. Develop questions to be used when completing the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct the breasts and axillae focused interview on each other.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct a breast and axillae focused interview on their assigned patient.

3. Explain patient preparation for examination of the breasts and axillae.

• Suggested Classroom Activity: Ask students to work in pairs and demonstrate preparing the patient for assessment of the breast and axillae.

•

Suggested Clinical Activity: Ask students to develop a teaching plan focused on breast and axillae health for patients that includes demonstration of proper breast selfexamination.

4. Outline the techniques used for assessment of the breast and axillae.

• Suggested Classroom Activity: Ask students to work in pairs and practice the techniques required for assessment of the breasts and axillae including landmarks.

•

Suggested Clinical Activity: Assign students to patients and instruct students to demonstrate the proper technique required for assessment of the breasts and axillae.

5. Differentiate normal from abnormal findings in the physical assessment of the breast and axillae.

• Suggested Classroom Activity: Ask students to discuss possible abnormal findings on assessment of the breasts and axillae.

•

Suggested Clinical Activity: Assign students to patients with breast health problems, present or past. Ask students to discuss with their assigned patient findings on physical assessment that led to diagnosis.

6. Identify the anatomical, physiological, developmental, psychosocial, and cultural variations that guide assessment.

• Suggested Classroom Activity: Ask students to discuss anatomical, physiological, developmental, psychosocial, and cultural variations involved in assessing breasts and axillae.

•

Suggested Clinical Activity: Assign students to patients with past or present breast health problems. Ask students to discuss with their assigned patient anatomical, physiological, developmental, psychosocial, and cultural factors that the patient believes are important in having healthcare providers assess their breasts.

7. Relate Healthy People 2020 objectives to issues of the female breast and axillae.

• Suggested Classroom Activity: Ask students to discuss objectives of Healthy People 2020 that relate breast health.

•

Suggested Clinical Activity: Assign students to nurses caring for patients with past or present breast health problems. Ask students to interview a nurse with attention to the nurse’s perception and integration of Healthy People 2020 objectives related to breast health.

8. Apply critical thinking to assessment of the breasts and axillae.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in caring for patients with breast health problems.

•

Suggested Clinical Activity: Assign students to patients with breast health problems.

Ask each student to utilize critical thinking in developing three nursing diagnoses and assessing patient needs related to breast and axillae health.

Key Concepts

1. The breasts are located on the anterior chest and supported by muscles and ligaments.

2. Breast tissue extends from the second or third rib to the six or seventh rib and from the sternal margin to the midaxillary line depending on body shape and size.

3. Breast tissue may extend superiorly and laterally into the axilla as the axillary tail or tails of Spence.

4. The breasts include the areola and nipple as well as glandular, adipose, and fibrous tissue.

5. For the purpose of documentation, breasts are divided into four quadrants defined by vertical and horizontal lines that intersect at the nipple.

6. Locations of clinical findings are described according to clock positions.

7. Male breasts possess small nipple and flat areola.

8. A complex system of lymph nodes drains lymph from the breasts and axillae, and returns the lymph to the blood.

9. Major muscles of the chest wall support the breasts and contribute to its shape.

These muscles include the pectoralis major and the serratus anterior muscle.

10. Objectives of Healthy People 2020 related to breast health include reducing the female breast cancer death rate, reducing late-stage diagnosis of female breast cancer, and increasing the proportion of women who receive a breast cancer screening based on the most recent guidelines.

11. The U.S. Preventive Services Task Force (USPSTF) recommends that women ages 50 to 74 undergo a mammogram every 2 years, a recommendation supported by Healthy People 2020.

12. Factors that contribute to lower than recommended rates of breast screening include anxiety and fear of cancer-related surgery, lack of access to health care, lack of health insurance, recent immigration, and lack of education.

13. The nurse is aware of variations in findings related to breasts and axillae across the life span due to physiological, developmental, psychosocial, and cultural variations.

14. Inverted nipples are evident at birth and common until adolescence.

15. Maternal estrogen and prolactin may cause both male and female infants to have milky white discharge from their nipples, a condition that resolves within 1 or 2 weeks after birth.

16. Breast tissue begins to enlarge in females with the onset of puberty between the ages of 9 and 13. These changes correlate with increased levels of estrogen and progesterone in the body as sexual maturity begins.

17. Gynecomastia is not uncommon in adolescent males. This condition is usually self-limiting and resolves spontaneously.

18. During pregnancy, breast tissue enlarges as glandular and ductal tissues increase in preparation for lactation.

19. The physical appearance of the breasts changes significantly in older adult females.

20. Gynecomastia may occur in older males as a result of hormonal changes, disease states, or medications.

21. Breast cancer becomes increasingly more common with age.

22. The nurse is cognizant of a longer amount of time necessary to interview older patients regarding breasts and breast health due to modesty. Older females may be uncomfortable discussing their breasts.

23. The nurse must educate older females regarding periodic breast examination and screening for breast cancer.

24. The female patient’s sense of self-esteem may be reflected in her feelings regarding her breasts. The nurse must be cognizant of such feelings and provide open discussions regarding body image disturbances, self-esteem disturbances, and dysfunctional grieving related to women who undergo mastectomy as well as women who may be dissatisfied with the size or appearance of their breasts.

25. During the focused interview, the nurse gathers additional information by asking pertinent questions related to the patient’s general health and by asking questions about breasts and lymph nodes.

26. The nurse is aware of factors such as preventive screening, particularly in women ages 40 years and older who have higher incidence rates and are at risk for breast cancer.

27. The focused interview for the breasts and axillae provides data related to the structure and function of the breasts as well as the lymphatic system.

28. The nurse must be prepared to observe the patient and listen for cues related to the breasts and axillae.

29. The nurse addresses cues with follow-up questions in order to elicit additional information and provide a thorough database on which to draw conclusions.

30. Follow-up questions are aimed at identifying the source of problems, duration of difficulties, measures to alleviate problems, and clues about the patient’s knowledge of his or her health.

31. The nurse may utilize the acronym OLDCART & ICE in order to provide consistency in evaluating patients regarding breast and axillae health.

32. The nurse helps to relieve patient anxiety by providing the patient with an environment that is warm, comfortable, and private for the physical assessment.

33. The nurse ascertains whether the patient has a preference for a nurse of the same gender for assessment of the breasts.

34. The nurse provides the patient with specific instructions for each part of the exam ensuring that instructions are clear and concise.

35. The nurse minimizes exposure of the patient as much as possible.

36. The nurse utilizes standard precautions during the assessment.

37. Physical assessment of the breasts and axillae follows an organized pattern.

38. Physical assessment of the breasts requires the use of inspection and palpation.

39. Assessment begins with the general patient survey followed by inspection of the breasts while the patient assumes various positions.

40. Palpation includes the entire surface of the breast including the tail of Spence, and the lymph nodes of the axillae.

41. Physical assessment is an opportunity to teach the patient proper technique for self-breast examination.

42. The nurse is cognizant of normal findings related to the breasts and axillae in order to ascertain abnormal findings.

43. Several abnormal yet benign conditions exist regarding the breasts that may require collaboration and consultation with other providers.

44. Benign breast disease, fibroadenoma, intraductal papilloma, mammary duct ectasia, and breast masses that may be malignant, are abnormalities and conditions found on physical assessment of the breasts and axillae.

45. Common findings that raise the suspicion of breast cancer include breast lump or thickening of local area of breast tissue, dimpling of the skin over the tumor, deviation of the breast or nipple from its normal alignment, nipple retraction, edema caused by blockage of lymphatic ducts, and discharge that may be bloody or clear.

46. Gynecomastia may be a finding in male patients with etiology related to medications, pituitary or testicular tumors, or liver, adrenal, or thyroid disease.

47. Male breast cancer is rare but many of the same objective findings are found on assessment of the male patient as the female patient.

48. The nurse applies critical thinking to assess the patient’s state of health and to identify the factors that may influence breast health.

49. The nurse collects data based on the focused interview, and clusters and categorizes the data to develop diagnoses related to breasts and axillae health.

50. The nurse prioritizes patient needs based on the data collected from the focused interview and from the physical assessment of the breasts and axillae.

51. In addition to developing diagnoses related to the patient’s current health status, the nurse provides education on breast self-examination and mammography screening as appropriate, and on expected changes based on age and lifespan considerations, and provides recommendations that align with Healthy People 2020 objectives.

CHAPTER 19 CARDIOVASCULAR SYSTEM

Learning Outcomes 1.

Recognize the anatomy and physiology of the cardiovascular system.

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Suggested Classroom Activity: Using simulation models, ask students to discuss the anatomy and physiology of the cardiovascular system.

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Suggested Clinical Activity: Assign students to patients and ask students to conduct a cardiovascular system assessment.

2. Recognize landmarks that guide assessment of the cardiovascular system.

• Suggested Classroom Activity: Ask students to discuss and demonstrate the landmarks used in cardiovascular system assessment.

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Suggested Clinical Activity: Assign students to patients and have students demonstrate finding the appropriate landmarks on their assigned patient while conducting a cardiovascular system assessment.

3. Develop questions to be used when completing the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct the cardiovascular system focused interview on each other.

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Suggested Clinical Activity: Assign students to patients. Instruct students to conduct cardiovascular system focused interviews on their assigned patient.

• 4. Explained patient preparation for assessment of the cardiovascular system.

• Suggested Classroom Activity: Ask students to work in pairs and demonstrate preparing the patient for assessment of the cardiovascular system.

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Suggested Clinical Activity: Assign students to patients and instruct students to explain to patients preparation for assessment of the cardiovascular system.

5. Outline the techniques required for assessment of the cardiovascular system • Suggested Classroom Activity: Ask students to work in pairs and practice the techniques required for assessment of the cardiovascular system.

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Suggested Clinical Activity: Assign students to patients and instruct students to demonstrate the proper technique required for assessment of the cardiovascular system on their assigned patient.

6. Differentiate normal from abnormal findings in the physical assessment cardiovascular system.

• Suggested Classroom Activity: Ask students to discuss abnormal findings on physical assessment of the cardiovascular system<CORE> as documented in the text</CORE>.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct a physical assessment of the cardiovascular system on their assigned patient noting any abnormal findings.

7. Describe the developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings.

• Suggested Classroom Activity: Ask students to discuss developmental, psychosocial, cultural, and environmental variations and factors in assessing cardiovascular system health.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct physical assessments on their assigned patients and to review the patients’ charts.

Students should document findings indicating developmental, psychosocial, cultural, and environmental factors that contribute to the patient’s current cardiovascular health problem and that may contribute to the patient’s recovery.

8. Relate Healthy People 2020 objectives to the cardiovascular system.

• Suggested Classroom Activity: Ask students to discuss objectives of Healthy People 2020 that relate to cardiovascular system health.

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Suggested Clinical Activity: Assigned students to nurses caring for patients with cardiovascular system health problems. Ask students to interview a nurse with attention to the nurse’s perception and integration of Healthy People 2020 objectives in managing patients with cardiovascular health problems.

9. Apply critical thinking to the physical assessment of the cardiovascular system.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in caring for patients with cardiovascular health problems.

•

Suggested Clinical Activity: Assign students to patients with cardiovascular health problems. Instruct each student to utilize critical thinking in developing three nursing diagnoses and assessing patient needs related to cardiovascular system health.

Key Concepts

1. The cardiovascular system is composed of the heart and vascular system. The heart includes the cardiac muscle, atria, ventricles, valves, coronary arteries, cardiac veins, electrical conducting structures, and cardiac nerves.

2. The vascular system is composed of the blood vessels of the body: the arteries, arterioles, veins, venules, and capillaries.

3. The major functions of the cardiovascular system are transporting nutrients and oxygen to the body, removing wastes and carbon dioxide, and maintaining adequate perfusion of organs and tissues.

4. A thin sac, the pericardium, composed of fibroserous material surrounds the heart. The heart is composed of the heart wall; the heart chambers, including the right atrium, right ventricle, left atrium, left ventricle; valves, including the atrioventricular, tricuspid, mitral, semilunar, aortic, and pulmonic valves; and the coronary arteries and veins.

5. Closure of valves of the heart gives rise to heart sounds that are associated with the contraction and relaxation phases of the cardiac cycle.

6. Heart sounds are interpreted based on characteristics of pitch, duration, intensity, phase, and location of the precordium.

7. Systole refers to the phase of ventricular contraction.

8. Diastole refers to the phase of ventricular relaxation.

9. Landmarks for assessing the cardiovascular system include the sternum, clavicles, ribs, and intercostal spaces.

10. During cardiovascular assessment, the sternum is used as a vertical landmark and the angle of Louis is used to locate the second intercostal space.

11. The left midclavicular line (LMCL) is used as a landmark for cardiovascular assessment.

12. The intercostal spaces are horizontal landmarks for cardiac assessment and are used to locate the base of the heart and the apex of the heart and to auscultate for valvular sounds.

13. Shortly after birth, the foramen ovale and the ductus arteriosus close due to multiple physiological events. Murmurs may be heard on auscultation if these openings remain patent.

14. Cardiovascular assessment of the newborn is imperative due to the significant changes at birth and during the first few days of life.

15. During pregnancy, a female’s body undergoes phenomenal adaptation especially in the cardiovascular system. The heart is displaced to the left and upward, and the apex is pushed laterally to the left as pregnancy progresses.

16. Blood volume and cardiac output may increase as much as 30% to 50% during pregnancy.

17. The pregnant female may experience an increase in resting pulse and may develop a systolic murmur.

18. For older adults, the heart may stay the same size, enlarge, or atrophy.

19. Aging contributes to loss of ventricular compliance as the cardiac valves and large vessels become more rigid.

20. The nurse is mindful of the presence of extra heart sounds other than S1 and S2 or any change in characteristics of preexisting heart sounds.

21. Stress causes an individual to experience an increase in the workload of the heart, which may cause systemic vascular resistance when stress is experienced for long periods of time. Patients may require counseling, relaxation, yoga, meditation, or other interventions to help reduce stress levels.

22. Cultural considerations of the cardiovascular system include family history of hypertension, diabetes, or elevated lipid levels.

23. Other cultural considerations include the individual’s perception of a healthy body, the selection and preparation of foods, and the individual’s perceived correlation between diet and cardiovascular health.

24. Healthy People 2020 promotes initiatives to increase overall cardiovascular health in the U.S. population.

25. Initiatives of Healthy People 2020 related to cardiovascular health include increasing the proportion of adults ages 20 years and older who are aware of symptoms of and how to respond to a heart attack.

26. Initiatives of Healthy People 2020 related to cardiovascular health include increasing the proportion of adults ages 20 years and older who are aware of the symptoms of and how to respond to a stroke.

27. Healthy People 2020 initiatives seek to increase the proportion of eligible patients with heart attacks or strokes who receive timely artery-opening therapy as specified by current guidelines.

28. Healthy People 2020 promotes initiatives to increase the proportion of adults with coronary artery heart disease or stroke who have their low density lipoprotein (LDL) cholesterol level at or below recommended levels.

29. Healthy People 2020 looks to increase the proportion of adult heart attack and stroke survivors who are referred to cardiac or stroke rehabilitation programs at discharge.

30. Healthy People 2020 objectives seek to reduce hospitalizations of older adults with heart failure as the principal diagnosis.

31. The focus of the interview for the cardiovascular system concerns data related to the structures and functions of the cardiovascular system.

32. The nurse observes the patient and listens for cues related to the functions of the cardiovascular system.

33. The focused interview guides the physical assessment of the cardiovascular system.

34. The nurse considers age, gender, race, culture, environment, health practices, past and current problems, and therapies when framing questions and using techniques to elicit information during the focused interview.

35. The nurse may utilize the acronym OLDCART & ICE in order to elicit information from the patient regarding the cardiovascular system.

36. The nurse provides the patient with an environment that is warm, comfortable, and ensures privacy.

37. The nurse provides specific instructions throughout the assessment and explains what is expected of the patient.

38. Assessment of the heart will require several position changes. The nurse should assist the patient, if necessary; allow time for movement if the patient is uncomfortable; and explain the purpose of the position changes.

39. The nurse’s hands and the stethoscope should be warmed before beginning the assessment.

40. The room should be quiet so that subtle sounds may be heard on auscultation.

41. The nurse provides adequate draping to prevent unnecessary exposure of the female breasts.

42. Physical assessment of the cardiovascular system requires the use of inspection, palpation, percussion, and auscultation.

43. During each of the procedures, the nurse gathers objective data related to the function of the heart as determined by the heart rate and the quality and characteristics of the heart sounds.

44. The nurse observes for signs of appropriate cardiac function in relation to oxygen perfusion by assessing skin color and temperature, abnormal pulsations, and the characteristics of the patient’s respiratory effort.

45. Physical assessment of the cardiovascular system follows an organized pattern.

It begins with inspection of the patient’s head and neck, including the eyes, ears, lips, face, skull, and neck vessels.

46. The nurse then inspects the patient’s upper extremities, chest, abdomen, and lower extremities.

47. The nurse palpates the precordium and carotid pulses, and percusses the chest to determine the cardiac borders.

48. The nurse then auscultates the heart in five areas with the diaphragm and the bell of the stethoscope. The nurse also auscultates the carotid arteries and apical pulse.

49. The nurse uses standard precautions during the assessment.

50. Abnormal findings in the cardiovascular system include or may indicate cardiac murmurs, diseases of the myocardium, dysfunctional pumping capacity, valvular heart disease, septal defects, congenital heart disease, and electrical rhythm disturbances.

51. Abnormal findings during physical assessment include diaphoresis, pallor, jugular vein distention, liver congestion, peripheral edema, adventitious breath sounds, signs of decreased oxygen profusion, bradycardia, tachycardia, cardiac murmurs, and other abnormal findings.

52. Patient cues and physical assessment provide information related to cardiovascular dysfunction. This may include valvular disease such as mitral stenosis, mitral regurgitation, aortic stenosis, pulmonic stenosis, aortic regurgitation; septal defects, including ventricular septal defect or atrial septal defect; or congenital heart disorders including coarctation of the aorta, patent ductus arteriosus, and tetralogy of Fallot.

53. Both signs and symptoms of electrical rhythm disturbances may be found on physical assessment including heart block, atrial fibrillation, atrial flutter, symptomatic bradycardia or tachycardia, and in some cases more lethal cardiac dysrhythmias.

54. The nurse uses critical thinking and the nursing process to identify factors to be considered while collecting data related to the cardiovascular system.

55. The nurse collects data based on the focused interview, and clusters and categorizes the data to develop diagnoses related to the cardiovascular system.

56. The nurse prioritizes patient needs based on the data collected from the focused interview and from the physical assessment of the cardiovascular system.

57. In addition to developing diagnoses related to the patient’s current cardiovascular health status, the nurse provides education related to expected changes based on age, gender, physiological changes such as pregnancy in childbearing women, and psychosocial factors including stress and the environment.

58. The nurse develops both actual and potential diagnoses.

59. In the role of educator, the nurse teaches the patient the importance of cardiovascular health and educates the patient about diet, exercise, blood pressure control, and when appropriate, medications and smoking cessation.

60. In the role of educator, the nurse teaches the importance of blood pressure control and its link to other health conditions such as heart disease, heart failure, and chronic kidney disease.

61. The nurse also educates the patient on screening recommendations based on age, family history, and past medical history.

CHAPTER 20 PERIPHERAL VASCULAR SYSTEM

Learning Outcomes 1. Identify the anatomy and physiology of the peripheral vascular and lymphatic systems.

• Suggested Classroom Activity: Ask students to discuss the anatomy and physiology of both the peripheral vascular and lymphatic systems in terms of locations and functions.

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Suggested Clinical Activity: Assign students to patients and instruct students to assess and document peripheral pulses on their assigned patient noting any deficits.

2. Develop questions that guide the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct a peripheral vascular system focused interview on each other.

•

Suggested Clinical Activity: Instruct students to conduct a peripheral vascular system focused interview on an assigned patient.

3. Explain patient preparation for assessment of the peripheral vascular system.

• Suggested Classroom Activity: Ask students to work in pairs and practice explaining preparation for assessment of the peripheral vascular system.

•

Suggested Clinical Activity: Assign students to patients and instruct students to explain to their patients preparation for assessment of the peripheral vascular system.

4. Outline the techniques used for assessment of the peripheral vascular system.

Suggested Classroom Activity: Ask students to work in pairs and practice the technique used for assessment of the peripheral vascular system.

•

Suggested Clinical Activity: Assign students to patients and instruct students to outline for their assigned patient the technique used for assessment of the peripheral vascular system.

5. Differentiate normal from abnormal findings in the physical assessment of the peripheral vascular system.

• Suggested Classroom Activity: Ask students to discuss abnormal findings on physical assessment of the peripheral vascular system<CORE> as documented in the text</CORE>.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to conduct a peripheral vascular system assessment on their assigned patient documenting any abnormalities found during the assessment.

6. Describe the developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the peripheral vascular system.

• Suggested Classroom Activity: Ask students to discuss developmental, psychosocial, cultural, and environmental factors that affect the peripheral vascular system.

•

Suggested Clinical Activity: Assign students to patients. Instruct students to review their assigned patients’ charts and perform physical assessments with attention to the peripheral vascular system. Instruct students to note any developmental, psychosocial, cultural, and environmental factors that contribute to their patients’ primary peripheral vascular diagnosis and that may also contribute to the patient’s recovery.

7. Relate peripheral vascular health to Healthy People 2020 objectives.

Suggested Classroom Activity: Ask students to discuss Healthy People 2020 objectives as they relate to the peripheral vascular system.

•

Suggested Clinical Activity: Ask students to discuss with the nurse caring for a patient with a peripheral vascular system health problem his or her perception and integration of Healthy People 2020 objectives related to peripheral vascular disease in patient care.

8. Apply critical thinking to the physical assessment of the peripheral vascular system.

• Suggested Classroom Activity: Ask students to discuss the importance of critical care thinking in managing patients with peripheral vascular health problems.

•

Suggested Clinical Activity: Assign students to a patient with a peripheral vascular health problem. Ask each student to utilize critical thinking and develop three nursing diagnoses while prioritizing his or her patient’s needs.

Key Concepts

1. The peripheral vascular system is made up of the blood vessels of the body that together with the heart and lymphatic vessels make up the body’s circulatory system.

2. Arteries of the peripheral vascular system receive oxygen-rich blood from the heart and carry blood into organs and tissues of the body.

3. The heart produces a high-pressure waveform pulse that causes arteries to expand and contract.

4. The pulse can be felt at certain points in the body including the brachial artery, the radial and ulna arteries, the femoral artery, the popliteal artery, the anterior tibial artery, the posterior tibial artery, and the dorsalis pedis artery.

5. Veins deliver deoxygenated blood from the body’s periphery back to the heart.

6. Contraction of skeletal muscles during activities such as walking and pressure changes during the respiratory cycle assist in venous return of deoxygenated blood to the heart. Valves within veins prevent backflow of deoxygenated blood.

7. Problems with the lumen or valves of the lower extremities can lead to venous stasis or pooling of blood in the veins of the lower extremities.

8. Capillaries are the smallest vessels of the circulatory system and are the location of gas and nutrient exchange between the arterial and venous systems.

9. The lymphatic system consists of a vast network of vessels, fluids, various tissues, and organs throughout the body. Lymphatic vessels transport escaped fluid back into the vascular system.

10. Objectives of Healthy People 2020 related to peripheral vascular health include increasing the proportion of adults who have had their blood pressure measured

within the preceding 2 years and can articulate whether their blood pressure was normal or high.

11. Healthy People 2020 aims to reduce the proportions of individuals in the general population diagnosed with hypertension.

12. Healthy People 2020 aims to reduce the proportion of adults with elevated cholesterol levels.

13. Healthy People 2020 provides initiatives to increase the proportion of adults with hypertension who take prescribed medications in order to lower their blood pressure.

14. Healthy People 2020 provides initiatives to increase the proportion of adults with hypertension whose blood pressure is under control.

15. The nurse identifies factors that influence physical assessment of the peripheral vascular system including age, developmental level, race, ethnicity, work history, living conditions, and socioeconomic status.

16. All children 3 years of age and older should have their blood pressure evaluated during a well-child examination.

17. The nurse must recall that the pulse of a child increases if the child has a fever.

18. Blood pressure should be monitored carefully and consistently throughout pregnancy to eliminate the risk of unchecked pregnancy-induced hypertension.

19. Pressure from the expanding uterus on the lower extremities can obstruct venous return and lead to episodes of hypotension when the female is lying on her back and may also contribute to lower extremity edema, varicosities of the legs, and hemorrhoids.

20. The aging process causes arteriosclerosis or calcification of the walls of the blood vessels. This is a major contributor to increases in blood pressure in older adults.

21. Most hypertension is asymptomatic, but severe hypertension may produce headaches, epistaxis, shortness of breath, or chest pain.

22. Stress is among the factors that contribute to the development of hypertension.

23. Work-related stress is associated with hypertension.

24. Stress can also result from the rigors of everyday life in a complex and highintensity world.

25. African Americans have greater incidences of hypertension compared to Caucasians or Hispanics.

26. Smoking is a risk factor for hypertension and for peripheral vascular disease.

27. The focused interview for the peripheral vascular system concerns information related to the structures and functions of that system.

28. The nurse must be prepared to observe the patient for cues related to the function of the peripheral vascular system.

29. Follow-up questions are required to elicit further details and clarify data provided by the patient during the focused interview.

30. The focused interview guides the physical assessment of the peripheral vascular system.

31. The nurse may use the acronym OLDCART & ICE in order to elicit pertinent information regarding the peripheral vascular system from the patient.

32. Physical assessment of the peripheral vascular and lymphatic systems requires the use of inspection, palpation, auscultation, and assessment of the patient’s blood pressure.

33. Through these techniques, the nurse acquires information related to the patient’s circulatory system.

34. Physical assessment of the peripheral vascular and lymphatic systems proceeds in an organized pattern.

35. Blood pressure is assessed in the upper as well as lower extremities.

36. The nurse proceeds with a cephalocaudal pattern for assessment of the vascular and lymphatic system, beginning with the carotid arteries and following through to the lower extremities.

37. Additional assessment techniques include the Allen test and the manual compression tests.

38. In preparation for assessment of the peripheral vascular system, the patient should don an examination gown but keep undergarments in place.

39. Jewelry, watches, and other items that may interfere with the physical assessment should be removed.

40. Socks and stockings should be removed to accommodate full assessment of the peripheral vascular system.

41. The nurse explains to the patient the purpose of the assessment and provides clear instructions throughout the examination.

42. The nurse provides an environment that is warm, comfortable, and provides the patient with privacy during the assessment.

43. The nurse uses standard precautions during the examination.

44. Interpretation of data from health assessment is dependent on the ability to differentiate normal from abnormal findings.

45. Abnormal findings during the physical assessment of the peripheral vascular system may be based on cues and responses to follow-up questions from the patient during the focused examination.

46. It is essential for the nurse to be cognizant of normal findings in order to ascertain abnormal findings in assessing the peripheral vascular system.

47. The nurse must consider age, gender, environment, health practices, and past and current problems in differentiating normal from abnormal findings during physical assessment of the peripheral vascular system.

48. Abnormal findings on assessment of the peripheral vascular system include alterations in pulses, signs of claudication and arterial insufficiency, arterial aneurysm, venous insufficiency, varicose veins, Raynaud’s disease, deep venous thrombosis (DVT), lymphedema, and several other conditions.

49. The nurse uses critical thinking and the nursing process to identify factors to be considered while collecting data related to the peripheral vascular system.

50. The nurse collects data based on the focused interview, and clusters and categorizes the data to develop diagnoses related to the peripheral vascular system.

51. The nurse prioritizes patient needs based on the data collected from the focused interview and from the physical assessment of the peripheral vascular system.

52. In addition to developing diagnoses related to the patient’s current peripheral vascular health status, the nurse provides education related to expected changes based on age, lifespan considerations, and psychosocial factors including stress, and provides recommendations based on data related to the home and work environment as appropriate.

53. The nurse, in the role of educator, teaches the patient the importance of monitoring blood pressure, blood pressure control, and cholesterol control, and educates the patient about diet, exercise, and, when appropriate, taking medications as prescribed.

CHAPTER 21 ABDOMEN

Learning Outcomes 1. Describe the anatomy and physiology of the abdomen.

Suggested Classroom Activity: Using a simulation model, have students review the anatomy and physiology of the abdomen with attention to the digestive system.

•

Suggested Clinical Activity: Instruct each student to conduct an abdominal assessment on an assigned patient.

2. Identify landmarks that guide assessment of the abdomen.

• Suggested Classroom Activity: Ask students to practice finding the landmarks necessary for assessing the abdomen using a mapping technique.

•

Suggested Clinical Activity: Instruct students to locate the landmarks necessary for assessing the abdomen while examining an assigned patient.

3. Develop questions to be used when completing the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct a focused interview of the abdomen on each other.

•

Suggested Clinical Activity: Instruct students to conduct focused interviews related to the abdomen on assigned patients.

4. Explain patient preparation for assessment of the abdomen.

• Suggested Classroom Activity: Have students work in pairs and review preparing a patient for assessment of the abdomen.

•

Suggested Clinical Activity: Assign students to patients who will undergo an assessment of the abdomen. Instruct students to prepare patients for the assessment.

5. Differentiate normal from abnormal findings in the physical assessment of the abdomen.

• Suggested Classroom Activity: Ask students to discuss possible abnormal abdominal findings on physical assessment of the abdomen as documented in the text.

•

Suggested Clinical Activity: Assign each student to a patient with a known gastric or abdominal system health problem. Instruct students to conduct abdominal assessments on assigned patients and compare findings to documentation in assigned patients’ records.

6. Describe the developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the abdomen.

• Suggested Classroom Activity: Ask students to discuss developmental, psychosocial, cultural, and environmental factors that affect abdominal and digestive health.

•

Suggested Clinical Activity: Assign students to patients with abdominal or digestive health problems. Ask students to interview their assigned patients and to review patients’ medical records with attention to the role cultural, psychosocial, and environmental factors play in development of the patients’ primary diagnosis related to the abdomen and to patients’ recovery.

7. Describe the variation in techniques required for assessment of the abdomen.

• Suggested Classroom Activity: Working in pairs, have students review the technique for conducting an abdominal assessment.

•

Suggested Clinical Activity: Assign each student to a nurse caring for a patient with an abdominal health problem. Instruct students to observe physical assessment of the nurse’s assigned patient either by the nurse or by a physician. Instruct each student to document their observation and compare it to the notes documented by the nurse or the physician in the patient’s chart. Ask each student to compare the differences between his or her notes and the notes of the nurse or physician.

8. Relate Healthy People 2020 objectives to issues of the abdomen and gastrointestinal system.

• Suggested Classroom Activity: Ask students to discuss the objectives of Healthy People 2020 as they relate to abdominal and digestive health.

•

Suggested Clinical Activity: Instruct students to discuss with a nurse caring for patients with abdominal or digestive health problems the nurse’s perception and integration of Healthy People 2020 objectives related to digestive health in nursing care.

9. Apply critical thinking to assessment of the abdomen.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in caring for patients with abdominal or digestive health problems.

•

Suggested Clinical Activity: Assign students to patients with an abdominal or digestive health problem. Instruct each student to utilize critical thinking and develop three nursing diagnoses while prioritizing his or her patient’s needs.

Key Concepts

1. The abdomen is the largest cavity of the body and contains many organs and structures that belong to various systems of the body.

2. The primary focus of the abdomen involves the gastrointestinal system along with abdominal structures of other systems.

3. The abdomen contains the alimentary canal, the continuous hollow tube extending from the mouth to the anus that includes the esophagus, stomach, small intestines, and large intestines.

4. Accessory digestive organs within the abdomen include the liver, gallbladder, and pancreas.

5. Other related structures include the peritoneum, the muscles of the abdominal wall, the aorta, kidneys, ureters, bladder, spleen, and reproductive organs.

6. Mapping is the process of dividing the abdomen into quadrants or regions for the purpose of examination.

7. The abdomen is divided into four quadrants extending from the midsternal line from the xiphoid process through the umbilicus to the pubic bone intersecting with a horizontal line perpendicular to the first line through the umbilicus.

8. The four quadrants of the abdomen are the right upper quadrant (RUQ), right lower quadrant (RLQ), left upper quadrant (LUQ), and left lower quadrant (LLQ).

9. A second mapping method divides the abdomen into nine regions.

10. Objectives of Healthy People 2020 related to the abdomen and digestive health promote reduction in incidences of invasive colorectal cancer, hepatitis A, hepatitis B, and new hepatitis C infections.

11. Healthy People 2020 objectives promote initiatives to increase the proportion of individuals who are aware they have hepatitis C infections.

12. Healthy People 2020 objectives include increasing the proportion of consumers who follow key food safety practices, and reducing infections caused by key pathogens commonly transmitted through food.

13. The abdomen of the newborn is round. Toddlers have a characteristic potbelly abdominal appearance with abdominal breathing as the norm until approximately age 6.

14. Constipation, flatulence, hemorrhoids, and frequent voiding are common problems resulting from the displacement of abdominal organs and the pressure of the uterus on various organs during pregnancy.

15. This skin of the abdomen undergoes changes in color and develops striations in the pregnant female.

16. The digestive system of older adults undergoes characteristic changes. There is a gradual decrease in secretions of saliva and digestive enzymes and a decrease in the rate of peristalsis, intestinal absorption, and intestinal activity.

Constipation is a common problem for older adults.

17. The appearance of the abdomen changes with age. The abdomen may become more rounded or protuberant due to an increase in deposits of adipose tissue.

18. Health issues such as gastritis, gastric or duodenal ulcers, and ulcerative colitis are gastric and abdominal health problems associated with stress.

19. Culture, customs, family, and religious practices influence foods patients choose to eat.

20. Patients’ financial security impact their eating habits.

21. Focused interviews for assessment of the abdomen concern data related to the structures and functions of the organs within the abdomen.

22. Subjective data related to the status and functions of the structures within the abdomen are gathered during the focused interview.

23. The nurse observes the patient and listens for cues related to the function of organs and systems within the abdomen.

24. The focused interview guides the physical assessment of the abdomen.

25. The nurse considers the patient’s age, gender, race, culture, environment, health practices, past and current problems, and therapies when framing questions and using techniques to elicit information.

26. The nurse may utilize the acronym OLDCART & ICE to elicit information related to the structure and function of organs within the abdomen.

27. The nurse prepares the patient for assessment of the abdomen by providing an environment that is warm, comfortable, and private.

28. The nurse provides the patient with an explanation of the examination and what is to be expected.

29. The nurse provides specific directions during assessment of the abdomen giving the patient clear and precise directions.

30. Physical assessment of the abdomen follows an organized pattern beginning with patient survey and followed by inspection, auscultation, percussion, and palpation of the abdomen. This order differs from that of physical assessment of other systems.

31. The nurse pays attention to nonverbal cues that may indicate discomfort during the examination. The nurse notes facial gestures, legs flexed at the knees, and guarding with the hand as signs of pain or discomfort.

32. The nurse uses standard precautions during the examination.

33. When assessing the abdomen, the nurse performs auscultation after inspection.

The nurse delays percussion and palpation to avoid disturbing normal bowel sounds.

34. Abnormal findings in assessment of the abdomen may be detected by inspection, auscultation, percussion, and palpation and are often based on patients’ cues and complaints.

35. Abnormal findings related to the abdomen and digestive health include abdominal hernias that can lead to obstructive intestinal complications.

36. Additional abdominal abnormalities include ulcers, ascites, inflammatory and infectious processes, tumors, or cancers.

37. Accurate diagnoses of many abdominal and gastrointestinal problems require diagnostic studies in addition to the health history and physical assessment.

38. Diagnostic testing of the abdomen includes laboratory studies of blood, urine, and feces, and radiographic studies including magnetic resonance imaging (MRI) and CT scan as well as abdominal x-ray and ultrasound.

39. The nurse uses critical thinking and the nursing process to identify factors to be considered while collecting data related to the digestive system and abdominal health.

40. The nurse collects data based on the focused interview, and clusters and categorizes the data to develop diagnoses related to the digestive system.

41. The nurse prioritizes patient’s needs based on the data collected from the focused interview and from the physical assessment of the abdomen.

42. In addition to developing diagnoses related to the patient’s current digestive health status, the nurse provides education related to expected changes based on age, physiological changes such as aging and pregnancy, and psychosocial factors including stress and the environment.

43. The nurse, in the role of educator, teaches the patient the importance of digestive health and educates the patient about diet, gastric function, and screening recommendations based on age, family history, and past medical history.

CHAPTER 22 URINARY SYSTEM

Learning Outcomes 1. Describe the anatomy and physiology of the urinary system.

Suggested Classroom Activity: Using a simulation model, have students review the anatomy and physiology of the urinary system.

•

Suggested Clinical Activity: Instruct students to conduct a urinary system assessment on either a male or female patient.

2. Identify landmarks that guide assessment of the urinary system.

• Suggested Classroom Activity: Ask students to practice finding the landmarks necessary for palpating the kidneys and the bladder.

•

Suggested Clinical Activity: Ask students to locate the landmarks necessary for palpating the kidneys and the bladder on a patient during an examination of the urinary system.

3. Develop questions to be used when completing the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct a urinary system focused interview on each other.

•

Suggested Clinical Activity: Instruct students to conduct a urinary system focused interview on a patient as part of a physical assessment.

4. Explain patient preparation for assessment of the urinary system.

• Suggested Classroom Activity: Have students work in pairs and review preparing a patient for a urinary system assessment.

•

Suggested Clinical Activity: Assign students to patients who will undergo a urinary system assessment. Instruct students to prepare patients for the assessment.

5. Outline the techniques required for assessment of the urinary system.

• Suggested Classroom Activity: Working in pairs, have students review the technique for conducting a urinary system assessment.

•

Suggested Clinical Activity: Assign each student to a nurse caring for a patient with a urinary health problem. Have the students document their observations of the assessment performed by the nurse. Ask each student to compare the differences between his or her notes and the nurse’s notes.

6. Differentiate normal from abnormal findings in the physical assessment of the urinary system.

• Suggested Classroom Activity: Ask students to discuss possible abnormal urinary system findings on physical assessment<CORE> as documented in the text</CORE>.

•

Suggested Clinical Activity: Assign students to patients with a known urinary system health problem. Instruct students to conduct a urinary system assessment on their assigned patient and compare findings with documentation in the patient’s record.

7. Identify the developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the urinary system.

• Suggested Classroom Activity: Ask students to discuss developmental, psychosocial, cultural, and environmental factors that affect the urinary system or assessment of the urinary system.

•

Suggested Clinical Activity: Assign students to patients with urinary system health problems. Ask students to interview their assigned patients and review patients’ medical records with attention to the role of cultural, psychosocial, and environmental factors play in development of patients’ primary diagnosis related to the urinary system and to the patients’ recovery.

8. Relate Healthy People 2020 objectives to issues of the urinary system.

• Suggested Classroom Activity: Ask students to discuss the objectives of Healthy People 2020 as they relate to the urinary system and urinary system health.

•

Suggested Clinical Activity: Ask students to discuss with a nurse caring for patients with a urinary system health problem how the nurse perceives and incorporates the objectives of Healthy People 2020 into nursing care.

9. Apply critical thinking to assessment of the urinary system.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in managing patients with urinary system health problems.

Suggested Clinical Activity: Assign students to patients with urinary health problems. Ask each student to utilize critical thinking and develop three nursing diagnoses while prioritizing his or her patient’s needs.

Key Concepts

1. The kidneys are bean-shaped organs located in the retroperitoneal space on either side of the vertebral column. The right kidney is displaced downward by the liver and sits slightly lower than the left kidney.

2. The inner portion of the kidney is called the renal medulla. It is composed of structures called pyramids and calyces. Calyces are structures that collect and transport urine to the renal pelvis.

3. The outer portion of the kidney is called the renal cortex. The renal cortex is composed of over 1 million nephrons that form urine.

4. Each nephron has a renal corpuscle that consists of a tuft of capillaries called the glomerulus that filter blood.

5. The major functions of the kidneys are eliminating nitrogenous waste products, toxins, excess ions, and drugs through urine; regulating volume and chemical makeup of the blood; maintaining balance between water, salts, acids, and bases; producing renin, an enzyme that assists in regulating blood pressure; producing erythropoietin, a hormone that stimulates production of red blood cells in bone marrow; and assisting in the metabolism of vitamin D. 6. Kidneys receive their oxygen and nutrient supply from the renal arteries and require 25% of the cardiac output. The major function of the renal arteries is providing a rich supply of blood to the kidneys.

7. The ureters, urinary bladder, and urethra make up the other functional units of the urinary system.

8. The major function of the ureters is transportation of urine from the kidneys to the urinary bladder.

9. The major function of the urinary bladder is to store urine temporarily and to contract to release urine during micturition.

10. The major function of the urethra is providing a passage for eliminating urine.

11. The nurse uses three landmarks to locate and palpate the kidneys and urinary bladder: the costovertebral angle, the rectus abdominis muscle, and the symphysis pubis.

12. The costovertebral angle is the area of the lower back formed by the vertebral column and the downward curve of the last posterior rib.

13. The symphysis pubis is the joint formed by the union of the two pubic bones by cartilage at the midline of the body.

14. The bladder is cradled under the symphysis pubis. When the bladder is full, the nurse is able to palpate it as it rises above the symphysis pubis.

15. Fluid and electrolyte balance in infants and children is fragile. Illnesses that cause dehydration, loss of fluids, or lack of fluid intake may rapidly lead to metabolic acidosis and fluid imbalance. Persistent fluid and electrolyte imbalances may impair the child’s growth and development.

16. Cryptorchidism is the failure of one or both testicles to descend through the inguinal canal during the final stages of fetal development. Males with undescended testicles should be referred for surgical evaluation by 9 to 12 months of age.

17. Cryptorchidism carries an increased risk of testicular cancer.

18. Infant females may have a bloody vaginal discharge during the first 2 weeks of life due to exposure to maternal estrogen and progesterone.

19. Labial adhesions are the result of decreased estrogen levels in preadolescent females and are due to labial and genital atrophy. Labial adhesions are of medical concern if there is blockage of urinary flow or if they result in recurrent urinary tract infections.

20. The presence of a diaper rash is a clue that the nurse should explore a family’s hygiene practices.

21. Bedwetting is a difficult problem for children and their families, and may influence the child’s relationship with the family.

22. During the first and third trimesters of pregnancy, the pregnant female experiences an increase in urinary frequency due to the growing fetus and pressure against the bladder.

23. Major changes in both male and female older adults include urinary retention leading to an increase in urinary infections; involuntary bladder contractions resulting in urgency, frequency, and incontinence; decreased bladder capacity causing frequent voiding; and weakening of the urinary sphincter causing urgency and incontinence.

24. Patients suffering from incontinence are at increased risk for social isolation, selfesteem disturbance, and other psychosocial problems.

25. For patients with obesity, incontinence in combination with decreased mobility may result in problems with hygiene, leading to odor, increased risk of urinary infection, and skin irritation.

26. Urinary tract infections in females may be the result of sexual trauma, sexual intercourse with a new partner, or coital frequency.

27. The nurse should consider the possibility of sexual abuse in a child or adolescent who presents with a urinary tract infection.

28. Patients with hypertension or diabetes are especially vulnerable to kidney damage and require a strict medication and diet regimen. Hispanics and African

Americans experience higher rates of hypertension and diabetes than Caucasians and are at greater risk for kidney disease.

29. Chronic kidney disease is one of the major topics of Healthy People 2020.

Objectives of Healthy People 2020 related to chronic kidney disease aim to reduce the number of new cases of chronic kidney disease and the many complications, disabilities, and deaths associated with this disease as well as the cost of treatment.

30. Healthy People 2020 objectives promote reducing end-stage kidney disease, identifying individuals who are at risk for end-stage renal disease, and promoting preventive measures.

31. Healthy People 2020 objectives seek to increase awareness of chronic kidney disease in patients who have impaired renal function, improve cardiovascular care in people with chronic kidney disease, increase the proportion of individuals with chronic kidney disease who receive care from a nephrologist, improve vascular access for patients on hemodialysis, and increase the proportion of patients with chronic kidney disease who receive transplants.

32. Initiatives in Healthy People 2020 seek to reduce kidney failure due to diabetes.

33. The focus of the interview for the urinary system concerns data related to the structures and functions of the urinary system.

34. The nurse observes the patient and listens for cues related to the functions of the urinary system.

35. Discussion of the urinary system and its functions may be difficult for some patients because it is often considered a private matter.

36. The focused interview guides the physical assessment of the urinary system.

37. The nurse considers age, gender, race, culture, environment, health practices, past and current problems, and therapies when framing questions and using techniques to elicit information during the focused interview.

38. The nurse may utilize the acronym OLDCART & ICE in order to elicit information from the patient regarding the urinary system.

39. The nurse provides the patient with an examination area that is warm, comfortable, and private.

40. The nurse explains to the patient the purpose of the examination.

41. The nurse instructs the patient to empty the bladder before the examination and collect a urine specimen at that time.

42. The nurse provides clear instructions for specimen collection and provides privacy.

43. The nurse uses appropriate draping to maintain the dignity of the patient.

44. The nurse explains each step of the assessment and instructs the patient to report any discomfort or difficulties.

45. The nurse uses standard precautions during the assessment of the urinary system.

46. Physical assessment of the urinary system includes the use of inspection, palpation, percussion, and auscultation.

47. Knowledge of normal parameters and expected findings on physical assessment is essential in determining the meaning of data as the nurse performs a physical assessment.

48. The physical assessment of the urinary system follows an organized pattern. It begins with a survey of the patient’s general appearance followed by inspection of the abdomen.

49. The renal arteries are auscultated and the costovertebral angles and flank are inspected, palpated, and percussed.

50. The kidneys are palpated.

51. Bladder fullness is determined by palpation and percussion of the lower abdomen.

52. Alterations of the urinary system include bladder cancer, kidney and urinary tract infections, calculi, tumors, renal failure, and changes in urinary elimination.

53. Information and cues from the focused interview aid in determining alterations in the urinary system.

54. During physical assessment, lower extremity edema and palpation of a pelvic mass raise suspicion of bladder cancer or renal tumor.

55. Additional alterations in the urinary system include changes in urinary elimination such as dysreflexia, incontinence, and urinary retention.

56. The nurse uses critical thinking and the nursing process to identify factors to be considered while collecting data related to the urinary system.

57. The nurse collects data based on the focused interview, and clusters and categorizes the data to develop diagnoses related to the urinary system.

58. The nurse prioritizes patient needs based on the data collected from the focused interview and from the physical assessment of the urinary system.

59. In addition to developing diagnoses related to the patient’s current urinary system health status, the nurse provides education related to expected changes based on age, physiological changes such as aging and pregnancy, and psychosocial factors including stress and the environment.

60. The nurse develops both actual and potential diagnoses.

61. In the role of educator, the nurse teaches the patient the importance of urinary system health and educates the patient about diet, renal function, and screening recommendations based on age, family history, and past medical history.

62. In the role of educator, the nurse teaches the importance of blood pressure control, glycemic control and their link to chronic kidney disease.

CHAPTER 23 MALE REPRODUCTIVE SYSTEM

Learning Outcomes 1. Describe the anatomy and physiology of the male reproductive system.

• Suggested Classroom Activity: Using a simulation model, have students review the anatomy and physiology of the male reproductive system.

•

Suggested Clinical Activity: Instruct students to review the anatomy and physiology of the male reproductive system with an assigned male patient.

2. Develop questions to be used when completing the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct a male reproductive system focused interview on each other.

•

Suggested Clinical Activity: Assign each student to a nurse caring for a male patient with a reproductive health problem. Ask students to conduct a male reproductive system focused interview with the patient.

3. Describe techniques required for assessment of the male reproductive system.

• Suggested Classroom Activity: Working in pairs, have students review the technique for conducting a male reproductive system assessment.

•

Suggested Clinical Activity: Assign each student to a nurse caring for a male patient with a reproductive health problem. Instruct students to observe physical assessment of the patient either by the nurse or by a physician.

4. Differentiate normal from abnormal findings in the physical assessment of the male reproductive system.

• Suggested Classroom Activity: Ask students to discuss possible abnormal male reproductive health findings on physical assessment<CORE> as documented in the text</CORE>.

•

Suggested Clinical Activity: Assign students to male patients with reproductive health problems. Instruct students to review the charts of their assigned patients and discuss with patients physical assessment findings that contributed to their diagnosis.

5. Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the male reproductive system.

• Suggested Classroom Activity: Ask students to discuss developmental,

psychosocial, cultural, and environmental factors that affect the male reproductive system.

•

Suggested Clinical Activity: Assign students to patients with male reproductive health problems. Ask students to interview their assigned patient and to review the patient’s medical record with attention to the role of cultural, psychosocial, and environmental factors play in development of the patient’s diagnosis and in the patient’s recovery.

6. Discuss the objectives of the male reproductive system as represented in Healthy People 2020.

• Suggested Classroom Activity: Ask students to discuss the objectives of Healthy People 2020 as they relate to male reproductive health.

•

Suggested Clinical Activity: Ask students to discuss with a nurse caring for male patients with reproductive health problems the nurse’s perception and integration of the objectives of Healthy People 2020 related to male reproductive health into nursing care.

7. Apply critical thinking to the physical assessment of the male reproductive system.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in managing male patients with reproductive health problems.

•

Suggested Clinical Activity: Assign students to patients with male reproductive health problems. Ask each student to utilize critical thinking and develop three nursing diagnoses while prioritizing his or her patient’s needs.

Key Concepts

1. The male reproductive system is divided anatomically into external and internal genital organs and accessory glands including the seminal vesicles, the prostate gland, and the bulbourethral glands.

2. The penis and scrotum, the two external organs, are easily inspected and palpated. The major functions of the penis are to serve as an exit for urine and as a passageway for sperm to exit and be deposited into the vagina during sexual intercourse.

3. The internal organs include the testes, spermatic cord, duct system, accessory glands, and inguinal and perianal areas. Not all of the internal structures are palpable.

4. The functions of the male reproductive system are manufacturing and protecting sperm for fertilization, transporting sperm to the female vagina, regulating hormonal production and secretion of male sex hormones, and providing sexual pleasure.

5. The scrotum houses the testes, which produce sperm, a process called spermatogenesis. A vertical septum within the scrotum divides it into sections, each containing a testis, epididymis, vas deferens, and spermatic cord as well as other functional structures.

6. The testes manufacture sperm and are the primary male sex organs.

7. The spermatic cord is composed of fibrous connective tissue. Its purpose is to form a protective sheath around the nerves, blood vessels, lymphatic structures, and muscle fibers associated with the scrotum.

8. The duct system plays a crucial role in the transportation of sperm. The three structures that comprise the duct system are the epididymis, the ductus deferens, and the urethra.

9. Objectives of Healthy People 2020 related to the male reproductive system include improving reproductive health among individuals in the United States by reducing the incidence and prevalence of sexual transmitted infections.

10. For males, goals of this initiative target effective implementation of screening and preventive measures related to infectious diseases such as chlamydia, syphilis, and gonorrhea.

11. Significant initiatives of Healthy People 2020 are to decrease the transmission of human immunodeficiency virus (HIV) infections, prevent the development of acquired immunodeficiency syndrome (AIDS), and decreased HIV-related deaths.

12. Other initiatives of Healthy People 2020 related to male reproductive health include reduction in the prostate cancer death rate and reduction of the proportion of men who have unprotected anal sex.

13. Accurate interpretation of physical findings during physical assessment is dependent on the nurse’s knowledge of expected variations across the life span.

14. Ambiguity of a male newborn’s genitals requires referral to genetic counseling.

15. Assessment of newborn male genitalia should reveal the urethral meatus at the center of the glans. Alteration in location may indicate hypospadias or epispadias.

16. The nurse is aware that for the male child, the foreskin may not be retractable until age 2 or 3. After the age of 3, foreskin that remains tight indicates phimosis.

17. Foreskin should not be forcibly retracted in infants and toddlers.

18. The onset of puberty in the male child occurs between 10 and 15 years of age.

19. Occurrences such as unexpected erections and nocturnal emissions may be of concern to the young male. Open, supportive communication is essential at this time.

20. Adolescents require counseling on relationships, birth control, protection against sexually transmitted infections, and delaying sexual activity.

21. In the older male, testosterone decreases resulting in diminished libido. A decrease in sexual drive may contribute to the patient’s withdrawing from sexual experiences and relationships.

22. Issues such as fatigue, depression, and stress can decrease sexual drive in the male patient at any age.

23. Past or recent trauma, physical assault, and sexual assault may have a significant impact on a patient’s ability to enjoy a sexual relationship.

24. Sexual, physical, or verbal abuse among family members may lead to significant sexual dysfunction.

25. Caring and sensitive teaching are necessary to help patients understand that variations in penis size are normal and that there is little correlation between penis size and partner sexual satisfaction.

26. Cultural considerations for the male patient include cultural and religious beliefs related to circumcision, and patient’s preference for a same-gender examiner.

27. Environmental considerations for the male patient include testicular cancer, which is more common in males between the ages of 20 and 34 compared to other age groups. Testicular cancer is most common among White males.

28. Prostate cancer is most common in African American males and in Caribbean males of African ancestry. Signs of prostate cancer are not usually noticeable until the advanced stages of the disease.

29. The focus of the interview for the male reproductive system concerns data related to the structures and functions of the system.

30. The nurse observes the patient and listens for cues related to the function of the reproductive system noting that because of the dual functions of some of the male reproductive structures, data gathered during the interview will relate to both the urinary system and the reproductive system.

31. Discussion of the reproductive system and its functions may be difficult for some patients because it is often considered a private matter.

32. The focused interview guides the physical assessment of the male reproductive system.

33. The nurse considers age, culture, environment, health practices, past and current problems, and therapies when framing questions and using techniques to elicit information during the focused interview.

34. The nurse may utilize the acronym OLDCART & ICE in order to elicit information from the male patient regarding the reproductive system.

35. Nurses need to understand their own feelings and comfort with various aspects of sexuality in order to gather data efficiently. The nurse must put aside personal beliefs and values about sexual practices and focus on a culturally competent and nonjudgmental manner of gathering data to determine the health status of the patient.

36. The nurse provides the patient with an environment that is warm, comfortable, and private.

37. The nurse explains each step of the procedure to the patient and provides specific instructions about what the patient may expect during the examination.

38. The nurse uses standard precautions during the examination.

39. Physical assessment of the male reproductive system follows an organized pattern and begins with inspection and palpation of the external genitalia.

40. After inspection, the nurse palpates the bulbourethral and prostate glands via rectal examination.

41. The nurse examines stool for occult blood.

42. The nurse must be cognizant of normal findings in examination of the male reproductive system in order to ascertain abnormal findings.

43. Abnormal findings of the male reproductive system may include direct, indirect, and femoral hernias.

44. Reproductive dysfunctions may involve disorders of the penis, abnormalities of the scrotum, and problems in the perianal area.

45. Abnormal findings on examination of the male reproductive system may include hypospadias; Peyronie’s disease; carcinoma of the penis; and signs of sexually transmitted infections including human papilloma virus (HPV), genital herpes, and syphilitic chancre.

46. Abnormalities of the scrotum may include hydrocele, scrotal hernia, orchitis, and testicular tumor, among several other possible abnormal findings.

47. The nurse uses critical thinking and the nursing process to identify factors to be considered while collecting data related to the male reproductive system.

48. The nurse collects data based on the focused interview, and clusters and categorizes the data to develop diagnoses related to the male reproductive system.

49. The nurse prioritizes patient needs based on the data collected from the focused interview and from the physical assessment of the male reproductive system.

50. In addition to developing diagnoses related to the patient’s current reproductive health status, the nurse provides education related to expected changes based on age, development, physiological changes, environmental, and psychosocial factors.

51. The nurse develops both actual and potential diagnoses.

52. In the role of educator, the nurse teaches the patient the importance of reproductive health and educates the patient about general health, prostate screening, protected sexual intercourse, HIV and other sexually transmitted infections, and the importance of regular testicular examinations.

CHAPTER 24 FEMALE REPRODUCTIVE SYSTEM

Learning Outcomes 1. Describe the anatomy and physiology of the female reproductive system.

• Suggested Classroom Activity: Using a simulation model, have students review the anatomy and physiology of the female reproductive system.

•

Suggested Clinical Activity: Ask each student to review with a gynecological patient the anatomy and physiology of the female reproductive system.

2. Explain patient preparation for the assessment of the female reproductive system.

• Suggested Classroom Activity: Ask students to work in pairs and review patient preparation for assessment of the female reproductive system.

•

Suggested Clinical Activity: Assign each student to a nurse who will be performing an assessment on a gynecological patient. Ask each student to prepare a patient for the physical assessment.

3. Develop questions to be used when conducting the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct a female reproductive system focused interview on each other.

•

Suggested Clinical Activity: Assign each student to a nurse caring for gynecological patients. Ask students to conduct a female reproductive system focused interview on a patient.

4. Describe techniques required for assessment of the female reproductive system.

• Suggested Classroom Activity: Working in pairs, have students review the technique for conducting a female reproductive system assessment.

•

Suggested Clinical Activity: Assign each student to a nurse caring for gynecological patients. Instruct students to observe physical assessment of the patient performed by either the nurse or by a physician.

5. Differentiate normal from abnormal findings in the physical assessment of the female reproductive system.

• Suggested Classroom Activity: Ask students to discuss possible abnormal gynecological findings on physical assessment<CORE> as documented in the text</CORE>.

•

Suggested Clinical Activity: Assign students to gynecological patients. Instruct students to review the chart of their assigned patient and discuss with the patient physical assessment findings that contributed to the patient’s primary diagnosis.

6. Describe developmental, psychosocial, cultural, and environmental variations in assessment techniques and findings of the female reproductive system.

• Suggested Classroom Activity: Ask students to discuss developmental, psychosocial, cultural, and environmental factors that affect the female reproductive system.

•

Suggested Clinical Activity: Assign students to gynecological patients. Instruct each student to interview his or her assigned patient and review the patient’s medical record with attention to the roles of cultural, psychosocial, and environmental factors play in development of the patient’s diagnosis and in the patient’s recovery.

7. Discuss the objectives related to women’s health as stated in Healthy People 2020.

• Suggested Classroom Activity: Ask students to discuss the objectives of Healthy People 2020 as they relate to female reproductive health.

•

Suggested Clinical Activity: Instruct students to discuss with a nurse caring for gynecological patients the nurse’s perception and integration of Healthy People 2020 objectives related to female reproductive health in nursing care.

8. Apply critical thinking to the physical assessment of the female reproductive system.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in managing patients with gynecological health problems.

•

Suggested Clinical Activity: Assign students to patients with gynecological health problems. Ask each student to utilize critical thinking and develop three nursing diagnoses while prioritizing his or her patient’s needs.

Key Concepts

1. The female reproductive system is unique in that it experiences cyclic changes in direct response to hormonal levels of estrogen and progesterone during the childbearing years.

2. The functions of the female reproductive system are to manufacture and protect ova for fertilization, transport the fertilized ovum for implantation and embryonic/fetal development, regulate hormonal production and secretion of several sex hormones, and provide sexual stimulation and pleasure.

3. The external genitalia of the female reproductive system include the mons pubis, labia majora and labia minora, Skene’s and Bartholin’s glands, clitoris, and perianal area.

4. Internal female reproductive organs include the vagina, the uterus, uterine or fallopian tubes, and the ovaries.

5. The major functions of the vagina are to serve as the female organ for copulation, function as the birth canal, and function as the channel for the exit of menstrual flow.

6. The major functions of the uterus are to serve as the site for implantation of the fertilized ovum and function as a protective sac for the developing embryo and fetus.

7. The uterine or fallopian tubes serve as the site of fertilization and provide a passageway for unfertilized and fertilized ova to travel to the uterus.

8. The major functions of the ovaries are to produce ova for fertilization by sperm and to produce estrogen and progesterone.

9. Reproductive system diseases and disorders significantly impact female health and wellness. Objectives of Healthy People 2020 related to the female reproductive system include improving reproductive health among individuals in the United States by reducing the incidence and prevalence of sexual transmitted infections.

10. For both men and women, goals of this national initiative target effective implementation of screening and preventive measures related to infectious diseases such as chlamydia, syphilis, and gonorrhea.

11. The Healthy People 2020 initiatives related to female reproductive health focus on reducing the disease transmission rate of human immunodeficiency virus (HIV) infections and preventing the development of acquired immunodeficiency syndrome (AIDS) and HIV-related deaths.

12. Pelvic inflammatory disease and invasive uterine cervical cancer are additional topics of concern in Healthy People 2020 related to female reproductive health.

13. The nurse is cognizant of developmental changes of the female patient across the life span beginning at birth. Bloody and mucoid vaginal discharge is commonly seen in newborns due to maternal estrogen and progesterone.

14. Female children reach puberty a few years before male children and exhibit changes in breasts and the beginning of menstruation.

15. It is essential to assess for sexual molestation of female children. The nurse looks for signs of depression, eating disorders, and bruising, swelling, and inflammation of the vaginal, perineal, and anal areas among other signs.

16. Pregnancy brings a multitude of changes to the female reproductive organs. The uterus, cervix, ovaries, and vagina undergo significant structural changes related to pregnancy and the influence of hormones.

17. Reproductive ability in the female usually peaks in the late 20s. Over time, estrogen levels decline as females approach menopause.

18. Sexual organs atrophy as the female progresses in age. A decrease in sexual drive may contribute to patients withdrawing from sexual experiences and relationships despite the fact that older adults can achieve sexual gratification and participate in satisfying sexual relationships.

19. Chronic or acute illness, medications, loss of a spouse or significant other, and other factors influence the sexual drive of the older female patient. Depression and stress can decrease the sexual drive in a patient of any age.

20. The nurse should be aware of the patient’s cultural practices and beliefs related to sexual practices and activity.

21. A history of sexually transmitted infections in children indicates sexual abuse.

22. The risk for cervical cancer increases in females who participate in early and frequent sexual activity and have a history of many sexual partners.

23. Obesity is a risk factor for uterine cancer.

24. The focus of the interview for the female reproductive system concerns data related to the structures and functions of the system.

25. The nurse observes the patient and listens for cues related to the function of the reproductive system.

26. Discussion of the reproductive system and its functions may be difficult for some patients because it is often considered a private matter.

27. The focused interview guides the physical assessment of the female reproductive system.

28. The nurse considers age, culture, environment, health practices, past and current problems, and therapies when framing questions and using techniques to elicit information during the focused interview.

29. The nurse may utilize the acronym OLDCART & ICE in order to elicit information from the patient regarding the reproductive system.

30. Nurses need to understand their own feelings and comfort with various aspects of sexuality in order to gather data efficiently. The nurse must put aside personal beliefs and values about sexual practices and focus on a culturally competent and nonjudgmental manner of gathering data to determine the health status of the female patient.

31. The nurse explores and remedies cultural and language issues prior to beginning the physical assessment.

32. The nurse provides the patient with a warm, comfortable, and private environment.

33. The nurse instructs the patient to void and empty bowels prior to the assessment.

34. The nurse uses appropriate draping to maintain the patient’s privacy and dignity.

35. The nurse determines if the patient has had this kind of assessment previously. If not, booklets with diagrams are helpful before proceeding. It is helpful to show the patient pictures of equipment and of the bimanual assessment.

36. The nurse uses an unhurried, deliberate manner during the assessment and asks the patient how she is doing as the assessment proceeds.

37. The nurse uses standard precautions.

38. Physical assessment of the female reproductive system includes the techniques of inspection and palpation.

39. The speculum is used to visualize the vagina and cervix as part of inspection.

40. During each of the procedures, the nurse gathers data related to the health and function of the reproductive system.

41. Knowledge of normal or expected findings is essential in determining the meaning of the data as the nurse conducts the physical assessment.

42. Physical assessment of the female reproductive system follows an organized pattern. The assessment of the female reproductive system begins with inspection of the external genitalia and perianal area, followed by palpation of the vagina and glands, the speculum examination, and specimen collection.

43. The next step is palpation of the cervix, fornices, uterus, Fallopian tubes, and ovaries.

44. The assessment ends with the rectovaginal examination.

45. An internal pelvic exam is not recommended for healthy, asymptomatic females below the age of 21.

46. Annual pelvic examination, both internal and external, should be performed on all patients ages 21 and older.

47. Abnormal findings from assessment of the female reproductive system include but are not limited to problems with the external genitalia, perianal area, cervix, internal reproductive organs, and inflammatory processes.

48. Abnormal findings of the external genitalia may include but are not limited to pediculosis pubis, herpes simplex, syphilitic lesions, and genital warts or human papilloma virus (HPV), as well as signs of other sexually transmitted infections.

49. Abnormal findings of the cervix may include abscesses of Bartholin’s gland; cyanosis, a sign of congestive heart failure; polyps; and carcinoma.

50. Abnormal findings of the internal reproductive organs may include fibroids, ovarian cancer, and ovarian cysts.

51. The nurse uses critical thinking and the nursing process to identify factors to be considered while collecting data related to the female reproductive system.

52. The nurse collects data based on the focused interview and physical assessment, and clusters and categorizes the data to develop diagnoses related to the female reproductive system.

53. The nurse prioritizes patient needs based on data collected from the focused interview and from the physical assessment of the female reproductive system.

54. In addition to developing diagnoses related to the patient’s current reproductive health status, the nurse provides education related to expected changes based on age, development, pregnancy, physiological changes, and environmental and psychosocial factors.

55. The nurse develops both actual and potential diagnoses.

56. In the role of educator, the nurse teaches the patient the importance of reproductive health and educates the patient about general health, cancer screening, protected sexual intercourse, HIV and other sexually transmitted infections, annual Pap smear and gynecological examination, birth control, and family planning as appropriate.

CHAPTER 25 MUSCULOSKELETAL SYSTEM

Learning Outcomes 1. Describe the anatomy and physiology of the bones, muscles, and joints.

• Suggested Classroom Activity: Using a simulation model, have students review the anatomy of the musculoskeletal system while discussing physiology of the system.

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Suggested Clinical Activity: Instruct each student to conduct a musculoskeletal assessment on an assigned patient.

2. Discuss the directional movements of the joints.

• Suggested Classroom Activity: Using a simulation model, have students review different types of joint movement.

•

Suggested Clinical Activity: Instruct each student to conduct a musculoskeletal assessment on a patient with attention to joint movement, noting any limitations.

3. Develop questions to be used when completing the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct musculoskeletal system focused interviews on each other.

•

Suggested Clinical Activity: Instruct students to conduct a musculoskeletal focused interview on an assigned patient.

4. Outline techniques used for assessment of the musculoskeletal system.

• Suggested Classroom Activity: Working in pairs, have students review the technique for conducting a complete musculoskeletal assessment.

•

Suggested Clinical Activity: Assign each student to a nurse caring for a patient with an orthopedic deficit. Instruct each student to perform a physical assessment on the assigned patient within the limits of the patient’s condition. Have students document and compare their physical assessment findings to those of the primary nurse.

5. Differentiate normal from abnormal findings of the musculoskeletal system.

• Suggested Classroom Activity: Ask students to discuss possible abnormal musculoskeletal findings on physical assessment<CORE> as documented in the text</CORE>.

•

Suggested Clinical Activity: Assign students to patients with known musculoskeletal or orthopedic conditions. Instruct students to conduct a musculoskeletal assessment based on the patient’s deficits and compare the findings to documentation in the patient’s record.

6. Describe the developmental, cultural, psychosocial, and environmental variations in assessment findings of the musculoskeletal system.

• Suggested Classroom Activity: Ask students to discuss the role of developmental, cultural, psychosocial, and environmental factors in musculoskeletal health problems.

•

Suggested Clinical Activity: Assign students to patients with musculoskeletal health problems. Instruct each student to interview his or her assigned patient and to review the patient’s medical record with attention to the roles of cultural, psychosocial, and environmental factors play in the patient’s illness or injury and in the patient’s recovery.

7. Relate musculoskeletal health to Healthy People 2020 objectives.

• Suggested Classroom Activity: Ask students to discuss the objectives of Healthy People 2020 as they relate to the musculoskeletal system and musculoskeletal health.

•

Suggested Clinical Activity: Instruct students to discuss with a nurse caring for patients with musculoskeletal illness or injury the nurse’s perception and integration of Healthy People 2020 objectives related to musculoskeletal health into nursing care.

8. Apply critical thinking to the physical assessment of the musculoskeletal system.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in managing patients with musculoskeletal deficits.

•

Suggested Clinical Activity: Assign students to patients with known musculoskeletal deficits. Ask each student to utilize critical thinking and develop three nursing diagnoses while prioritizing his or her patient’s needs.

Key Concepts

1. The musculoskeletal system consists of bones, skeletal muscles, and joints.

2. Bones support and provide a framework for soft tissue and organs of the body.

3. Bones are classified according to their shape and their composition.

4. Bones are composed of osseous tissue arranged in either dense, smooth, compact structure, or cancellous, spongy structures with many small open spaces.

5. Major functions of bones include providing a framework for the body, protecting structures, acting as levers for movement, storing fat and minerals, and producing blood cells.

6. Generally, skeletal muscles are voluntary and are under an individual’s conscious control.

7. The major functions of skeletal muscles include providing for movement and maintaining posture, and helping maintain body heat.

8. A joint is the point at which two or more bones in the body meet.

9. Joints may be classified structurally as fibrous, cartilaginous, or synovial (bones separated by a fluid-filled joint).

10. During assessment of the musculoskeletal system, the nurse assesses joints with attention to range of motion and surrounding structures including muscles, ligaments, tendons, and bursae.

11. Joint movements are described by a selection of specific terms that illustrate the ability of joints to move appropriately and in accordance with their function.

12. Terms that describe joint movement include gliding, flexion, extension, hyperextension, dorsiflexion, abduction, adduction, circumduction, rotation, supination and pronation, inversion and eversion, protraction and retraction, elevation and depression, and opposition.

13. Healthy People 2020 objectives related to musculoskeletal health include prevention of illness and disability due to musculoskeletal disorders such as arthritis, osteoporosis, and chronic back conditions.

14. Healthy People 2020 objectives related to the musculoskeletal system and musculoskeletal health include reduction of joint pain among adults diagnosed with arthritis and reduction in the proportion of adults diagnosed with arthritis who experience a limitation in activity due to arthritic-type symptoms.

15. Other objectives in Healthy People 2020 that relate to musculoskeletal health include reduction in the proportion of adults diagnosed with arthritis who report

serious psychological distress as well as reduction on the impact of employment of individuals diagnosed with arthritis.

16. The Healthy People 2020 initiative also seeks to reduce the proportion of adults with osteoporosis, reduce the incidence of hip fractures among older adults, and reduce activity limitations of individuals due to chronic back conditions.

17. Accurate interpretation of assessment findings by the nurse requires knowledge of the variations in anatomy and physiology that occur with growth and development.

18. Fetal positioning in the delivery process may cause musculoskeletal anomalies in infants including tibial torsion and metatarsus adduction. Such anomalies correct themselves as children grow and begin to walk.

19. The nurse assesses the newborn’s spine for tufts of hair, cysts, or masses that may indicate abnormalities such as spina bifida or congenital neural tube defects.

Infants are assessed for congenital hip dislocation, shoulder muscle weakness, and unequal leg length throughout the first year of life.

20. Children are assessed for musculoskeletal alterations including subluxation, irregular gait, and movements or positioning that may stress bones or joints such as reversed tailor position.

21. Estrogen and other hormones soften the cartilage in the pelvis and increase mobility of joints during pregnancy. As the pregnancy progresses lordosis compensates for the enlarging fetus. The pregnant female’s center of gravity shifts forward, pushing her weight farther back on her lower extremities. This causes lower back pain, a common complaint during late pregnancy.

22. As individual’s age, physiological changes take place in bones, muscles, connective tissue, and joints affecting the individual’s mobility and endurance.

Older adults with chronic illnesses or who take medications have an increased risk of decreased bone density. As adults age, bone resorption occurs more rapidly than new bone growth, resulting in the loss of bone density that is typical of osteoporosis.

23. Age-associated changes in the vertebral column may cause a shift in the individual’s center of gravity that may put older adults at increased risk for falls.

Normal degenerative changes that occur from aging and use are referred to as osteoarthritis.

24. Psychosocial problems such as anxiety, depression, fear, altered body image, or disturbances in self-esteem may promote inactivity and isolation that may lead to musculoskeletal degeneration.

25. A well-balanced diet and regular exercise help to slow the progression of decreasing muscular tone and musculoskeletal changes.

26. The focus of the interview for the musculoskeletal system concerns data related to the structures and functions of bones, joints, muscles and related structures.

27. The nurse observes the patient and listens for cues related to the function of the musculoskeletal system.

28. The nurse considers age, culture, environment, health practices, past and current problems, and therapies when framing questions and using techniques to elicit information during the focused interview.

29. The nurse may utilize the acronym OLDCART & ICE in order to elicit information from the patient regarding the musculoskeletal system.

30. Age and agility influence the patient’s ability to participate in the musculoskeletal assessment.

31. The nurse demonstrates the movements expected of the patient during the assessment and avoids pushing joints beyond their normal range of motion during the assessment.

32. The nurse uses an organized and orderly approach such as head to toe, and proximal to distal, and compares the sides of the body for symmetry.

33. Physical assessment of the musculoskeletal system requires the use of inspection and palpation.

34. During each of the procedures, the nurse gathers data related to the patient’s skeletal system, joints, musculature, strength, and mobility.

35. Knowledge of normal or expected findings is essential in determining the meaning of the data as the nurse conducts the physical assessment.

36. Physical assessment of the musculoskeletal system follows an organized pattern. It begins with a patient survey and proceeds in cephalocaudal direction to include inspection; palpation; assessment of range of motion of each joint; and an assessment of muscle size, symmetry, and strength.

37. Abnormal findings of the musculoskeletal system include joint disorders, inflammatory disorders, abnormalities of the spine, and trauma-induced disorders.

38. Inflammatory muscular disorders include osteoarthritis, rheumatoid arthritis, scleroderma, fibromyalgia, gout, and tendinitis among several other inflammatory conditions.

39. Traumatic muscular skeletal injuries include joint sprain, muscle strain, bone dislocation, and fractures.

40. Common joint disorders include but are not limited to temporomandibular joint syndrome, rotator cuffs tears, bursitis, joint effusion, carpal tunnel syndrome, ulnar deviation, and rheumatoid nodules.

41. Spinal abnormalities that may be found on exam include kyphosis, scoliosis, and lordosis.

42. The nurse uses critical thinking and the nursing process to identify factors to be considered while collecting data related to the musculoskeletal system.

43. The nurse collects data based on the focused interview and physical assessment, and clusters and categorizes the data to develop diagnoses related to the musculoskeletal system.

44. The nurse prioritizes patient needs based on data collected from the focused interview and from the physical assessment of the musculoskeletal system.

45. In addition to developing diagnoses related to the patient’s current musculoskeletal health status, the nurse provides education related to expected changes based on age, gender, developmental stage, pregnancy when appropriate, physiological changes, and environmental and psychosocial factors.

46. The nurse develops both actual and potential diagnoses.

47. In the role of educator, the nurse teaches the patient the importance of general health and educates the patient about the role of diet, exercise, activity and safety in accordance with the initiatives of Healthy People 2020 related to musculoskeletal health.

CHAPTER 26 NEUROLOGICAL SYSTEM

Learning Outcomes 1. Describe the anatomy and physiology of the neurological system.

• Suggested Classroom Activity: Using a simulation model, have students review the anatomy of the central nervous system and peripheral nervous system while discussing physiology of the nervous system.

•

Suggested Clinical Activity: Ask each student to conduct a neurological assessment of the central and peripheral nervous systems on a patient who does not have neurological deficits.

2. Develop questions to be used when completing the focused interview.

• Suggested Classroom Activity: Ask students to work in pairs and conduct neurological system focused interviews on each other.

•

Suggested Clinical Activity: Ask students to conduct a neurological system focused interview on a patient who does not have known neurological deficits.

3. Describe the techniques required for assessment of the neurological system.

• Suggested Classroom Activity: Working in pairs, have students review the technique for conducting a neurological assessment.

•

Suggested Clinical Activity: Assign each student to a nurse caring for a patient with known neurological deficits. Have the student observe physical assessment of the patient either by the nurse or by a physician. Have the student document his or her observations and compare them to the notes documented by the nurse or the physician in the patient’s chart. Ask the student to compare the differences between the notes.

4. Differentiate normal from abnormal findings in the physical assessment of the neurological system.

• Suggested Classroom Activity: Ask students to discuss possible abnormal neurological findings on physical assessment<CORE> as documented in the text</CORE>.

•

Suggested Clinical Activity: Assign students to patients with known neurological deficits. Instruct the student to conduct a neurological physical assessment based on their assigned patient’s deficits and compare the findings to documentation in the patient’s record noting whether there has been any improvement in the recorded deficit.

5. Describe developmental, cultural, psychosocial, and environmental variations in assessment techniques and findings of the neurological system.

• Suggested Classroom Activity: Ask students to discuss environmental factors that may affect the neurological system.

•

Suggested Clinical Activity: Assign students to patients with neurological deficits.

Ask each student to interview his or her assigned patient and review the patient’s medical record with attention to the roles cultural, psychosocial, and environmental factors play in development of the patient’s neurological deficit and the patient’s recovery.

6. Discuss the objectives regarding neurological health as stated in Healthy People 2020.

• Suggested Classroom Activity: Ask students to discuss the objectives of Healthy People 2020 as they relate to the neurological system and neurological health.

•

Suggested Clinical Activity: Assign students to nurses caring for patients with neurological deficits. Ask students to discuss with the assigned nurse how he or she perceives and incorporates the objectives of Healthy People 2020 into nursing care.

7. Apply critical thinking to the physical assessment of the neurological system.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking in managing patients with neurological deficits.

Suggested Clinical Activity: Assign students to patients with known neurological deficits. Ask each student to utilize critical thinking and develop three nursing diagnoses prioritizing his or her patient’s needs.

Key Concepts

1. The neurological system is highly integrated and complex. It is divided into the central nervous system (CNS) and the peripheral nervous system (PNS).

2. The central nervous system consists of the brain and the spinal cords; the peripheral nervous system consists of the cranial nerves and spinal nerves.

3. The brain is the largest portion of the central nervous system and is protected by the meninges, the cerebrospinal fluid, and the bony structure of the skull.

Structures of the brain include the cerebrum, diencephalon, the cerebellum, and the brainstem.

4. The cerebrum consists of the frontal, parietal, occipital, and temporal lobes, and its outermost layer, the cerebral cortex.

5. The diencephalon houses the thalamus, the hypothalamus, and the epithalamus.

6. The cerebellum is located below the cerebrum and behind the brainstem.

7. The brainstem contains the midbrain, ponds, and medulla oblongata. The brainstem is located between the cerebrum and the spinal cord.

8. The spinal cord is a continuation of the medulla oblongata and is protected by the meninges, cerebrospinal fluid, and bony vertebrae.

9. The peripheral nervous system includes the 12 pairs of cranial nerves that take impulses to and from the brain, and the paired spinal nerves that transmit impulses to and from the spinal cord.

10. Growth of the nervous system is very rapid during fetal development. The neonate has several primitive reflexes at birth including but not limited to sucking, stepping, the Moro reflex, and the Babinski reflex.

11. Primitive reflexes begin to disappear at approximately 1 month of age.

12. As children grow, it is important for the nurse to assess for fine and gross motor skills, language, and personal–social skills in order to recognize developmental delays, learning disabilities, neurological conditions, and attention deficit disorder.

13. In the pregnant female, as the uterus grows to accommodate the fetus, pressure may be placed on nerves in the pelvic cavity, producing neurological changes.

14. Changes in the lumbar curvature during pregnancy can place pressure on the roots of nerves, causing sensory changes to the lower extremities. These changes are reversible following relief of pressure and postural changes.

15. Hyperactive reflexes may indicate pregnancy-induced hypertension (PIH) in the pregnant female.

16. Many neurological changes occur with age. In the older adult, reflexes are diminished or disappear, and coordination weakens. The senses—hearing, vision, smell, taste, and touch—are also not as acute as they were in earlier years.

17. Changes in nervous system functioning may alter an individual’s ability to control body movements, speech, and elimination patterns and the ability to engage in activities of daily living.

18. Neurological changes affect individuals’ psychosocial health and their selfesteem because they are no longer able to function as they did previously.

19. Psychosocial considerations include stress related to neurological changes in older adults such as forgetfulness, confusion, inability to concentrate, sleeplessness, and development of tremors.

20. Chronic stress related to neurological changes may contribute to clinical depression in some patients.

21. Environmental considerations that affect the neurological system include exposure to toxins such as carbon monoxide, manganese, and mercury.

22. Cultural considerations include genetically transferred neurological disorders, such as Huntington’s disease, and the increased prevalence of certain conditions in certain ethnic groups. For example, there is a greater prevalence of Alzheimer’s disease among individuals of African American and Hispanic descent.

23. Factors related to patients’ occupation, environment, and genetic background contribute to neurological health. These are among the considerations regarding neurological health as described in Healthy People 2020.

24. Healthy People 2020 objectives related to neurological health seek to increase the proportion of persons with diagnosed Alzheimer’s disease and other dementias, or their caregivers, who are aware of the diagnosis.

25. Healthy People 2020 objectives also seek to reduce the proportion of preventable hospitalizations in persons diagnosed with Alzheimer’s disease and other dementias.

26. The focused interview for the neurological system concerns data related to the structures and functions of that system.

27. The nurse observes the patient and listens for cues related to the functions of the neurological system during the focused interview.

28. The focused interview guides the physical assessment of the neurological system.

29. The nurse considers age, gender, race, culture, environment, health practices, past and current problems, and therapies when framing questions and using techniques to elicit information during the focused interview.

30. The nurse may utilize the acronym OLDCART & ICE in order to elicit information from the patient regarding the neurological system.

31. The nurse begins to gather data about the neurological system during the initial nurse–patient interaction. As the nurse meets the patient, he or she makes an assessment regarding the patient’s general appearance, personal hygiene, and the patient’s ability to walk and sit down.

32. Physical assessment of the neurological system proceeds in a cephalocaudal and distal-to-proximal pattern and includes comparison of corresponding body parts.

33. Several assessments may occur at one time during examination of the neurological system.

34. The nurse provides the patient with specific information about what is expected of the patient during the examination. The nurse explains and demonstrates the purposes and uses of equipment that will be used during the assessment.

35. The nurse uses standard precautions.

36. Physical assessment of the neurological system requires the use of inspection, palpation, auscultation, and special equipment and procedures to test the function of the system.

37. Physical assessment of the neurological system follows an organized pattern that begins with assessment of the patient’s mental status and proceeds to assessment of cranial nerves, motor and sensory function, reflexes, and auscultation of carotid arteries. Assessment proceeds in a cephalocaudal manner.

38. The nurse assesses patients distal to proximal, and moves from gross motor function to fine motor function, always comparing corresponding body parts.

More than one technique may be used to assess one function.

39. Problems commonly associated with the neurological system include changes in motor function, including gait and movement; seizures; spinal cord injury; traumatic brain injury; infection; degenerative disorders; and cranial nerve dysfunction.

40. The nurse may observe problems with motor function that affect ambulation during the neurological assessment. Examples include an ataxic gait, scissors gait, steppage gate, or festination gate.

41. The nurse observes for other motor dysfunctions including tics, tremors, athetoid movement, myoclonus, and fasciculation.

42. Findings indicative of cranial nerve dysfunction include but are not limited to unilateral or bilateral anosmia, optic atrophy and visual field defects, diplopia and convergent strabismus, tinnitus, loss of gag reflex, loss of voice, and Bell’s palsy among several other cranial nerve dysfunctions.

43. Symptoms indicative of several other neurological dysfunctions may be evident on physical assessment including evidence of traumatic brain injury, meningitis, myelitis, brain abscess, Lyme disease, Parkinson’s disease, myasthenia gravis, and several other neurological disorders.

44. The nurse uses critical thinking and the nursing process to identify factors to be considered while collecting data related to the neurological system.

45. The nurse collects data based on the focused interview, and clusters and categorizes the data to develop diagnoses related to the neurological system.

46. The nurse prioritizes a patient’s needs based on this collection of data from the focused interview and from the physical assessment of the neurological system.

47. In addition to developing diagnoses related to the patient’s current neurological health status, the nurse provides education related to expected changes based on age, developmental stage, pregnancy, physiological changes, and environmental and psychosocial factors.

48. The nurse develops both actual and potential diagnoses.

49. In the role of educator, the nurse teaches the patient the importance of neurological health and educates the patient about general health, helmet safety, stroke prevention, and familial history as appropriate.

1 CHAPTER 27 THE PREGNANT FEMALE

Learning Outcomes 1. Describe the anatomy and physiology specific to assessment of the pregnant and postpartum female.

• Suggested Classroom Activity: Ask each student to select and discuss one of the three major functions of anatomical and physiological changes during the 40 weeks of pregnancy: • Maintaining normal maternal physiological function • Meeting maternal metabolic needs as the patient adapts to pregnancy • Meeting the growth and development needs of the fetus •

Suggested Clinical Activity: Ask each student to discuss with a selected pregnant female any physical changes that have caused discomfort during the patient’s pregnancy. Have the student develop an informal teaching module to explain the physiological source of the patient’s discomfort and what can be done to alleviate the discomfort.

2. Illustrate the anatomical and physiological variations in body systems that guide assessment in pregnancy and postpartum.

• Suggested Classroom Activity: Using a simulation model, ask students to determine the gestational age of a fetus and to discuss physiological changes in the pregnant woman at various stages of gestation.

•

Suggested Clinical Activity: Assign each student to a pregnant client. Instruct the student to assess the patient with respect to the size of the uterus and discuss with the client the physiological changes associated with the current stage of pregnancy and anticipated changes as the pregnancy continues.

3. Practice questions used when completing the focused interview.

• Suggested Classroom Activity: Have students work in pairs with one student as the nurse and the other student as a first-time pregnant female. Ask students to role-play the complete first prenatal visit. At the end of the interview, have students review positive aspects as well as challenges associated with the first interview with a pregnant female.

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•

Suggested Clinical Activity: Assign each student to a nurse who will be interviewing a pregnant patient at the first prenatal visit. Ask the student to observe the encounter and later write or discuss the differences observed between the actual encounter and the information in the text related to the initial prenatal visit.

4. Demonstrate the techniques used in the assessment of the pregnant and postpartum female.

• Suggested Classroom Activity: Ask students to work in pairs with one student as the postpartum female and the other student as the nurse. Instruct the “nurse” to conduct a focused interview with the postpartum female.

•

Suggested Clinical Activity: Assign each student to a nurse who will be interviewing a female at her first postpartum visit. Ask the student to observe the encounter and write or discuss the differences observed between the actual encounter and the information in the text related to the first postpartum visit.

5. Differentiate normal from abnormal findings in the focused interview and physical assessment of the pregnant female.

• Suggested Classroom Activity: Ask students to identify potential complications of pregnancy.

•

Suggested Clinical Activity: Ask students to review the chart of a pregnant female patient who has been hospitalized with complications related to pregnancy. Instruct students to use the nursing process to develop a plan of care based on the patient’s primary diagnosis for hospitalization related to complications of the pregnancy.

6. Teach patients about health promotion and education topics related to care of the pregnant female.

• Suggested Classroom Activity: Ask students to identify common health promotion needs in uncomplicated pregnancies.

•

Suggested Clinical Activity: Assign each student to a pregnant patient and have the student conduct a focused interview related to the pregnancy. Ask the student to identify any health promotion and educational needs of the client. Ask the student to prioritize a teaching need and develop a teaching plan specifically for that client.

7. Relate the objectives in Healthy People 2020 to the pregnant female.

Suggested Classroom Activity: Ask students to review the objectives of Healthy People 2020 and discuss the objectives that relate to pregnant females and maternal health.

3 Suggested Clinical Activity: Assign each student to a nurse caring for pregnant women. Ask each student to discuss with the nurse the nurse’s perception and integration of Healthy People 2020 objectives into patient care of pregnant females.

8. Apply critical thinking to the physical assessment of the pregnant and postpartum female.

• Suggested Classroom Activity: Ask students to discuss the importance of critical thinking to the physical assessment of the pregnant and postpartum female.

•

Suggested Clinical Activity: Assign each student to a nurse caring for a postpartum patient. Instruct the student to observe the nurse as the patient is interviewed and a physical assessment conducted. Based on the physical assessment and the interview, ask the student to use critical thinking to develop actual and potential nursing diagnoses.

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Key Concepts

1. The anatomical and physiological changes during the 40 weeks of pregnancy serve three important functions: Maintain normal maternal physiological function, meet maternal metabolic needs as the patient adapts to pregnancy, and meet the growth and development needs of the fetus.

2. The physiological and anatomical changes in pregnancy are due to hormones secreted by the fetus and placenta, and the mechanical effects of the growing fetus.

3. The placenta, in conjunction with the fetus and maternal uterine lining, produces hormones such as human chorionic gonadotropin (hCG), estrogen, progesterone, relaxin, prolactin, and others.

4. The uterus is profoundly transformed in pregnancy, increasing in both size and in capacity. The growing uterus can be palpated in the abdomen by about 10 to 12 weeks of pregnancy.

5. Early in pregnancy the uterus retains its nonpregnant pear shape but becomes more globular by 12 weeks.

6. Bimanual palpation is used to assess the size of the uterus during the early weeks of pregnancy.

7. The early sizes of the uterus can be compared to fruits: 6 weeks, a lemon; 8 weeks, a small orange; 10 weeks, a large orange; and 12 weeks, a grapefruit.

8. The cervix, or opening of the uterus, develops a protective mucous plug during pregnancy due to the actions of progesterone. Near the end of pregnancy, the cervix ripens or softens, and effaces or thins in preparation for labor. Progressive dilation or opening of the cervix does not usually occur until the onset of active labor.

9. Externally the labia majora, labia minora, clitoris, and vaginal introitus enlarge because of hypertrophy and increased vascularity during pregnancy.

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10. One of the first symptoms of pregnancy is breast tenderness, enlargement, and tingling sensation. Changes in the breasts are attributed to the influence of estrogen and progesterone.

11. Respiratory changes include a slight increase in respiratory rate, a lower threshold for carbon dioxide, decreased airway resistance, increased tidal volume and inspiratory capacity, and decreased expiratory volume. Oxygen consumption in the pregnant female increases by 20% to 60%.

12. Cardiovascular and hematological changes during pregnancy include an increase in sodium retention and total body water, and an increase in plasma volume. There is also a 25% to 33% increase in red blood cells and an overall decrease in hemoglobin and hematocrit caused by a plasma volume increase that outpaces red blood cell production.

13. The growing uterus can be palpated in the abdomen by about 10 to 12 weeks at which time the top of the uterus, the fundus, is slightly above the symphysis pubis. It is during this time the female begins “to show” externally at approximately 14 to 16 weeks.

14. At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus.

15. Between 20 and 22 weeks, the fundus reaches the umbilicus. Fundal height continues to increase until 38 weeks.

16. Several key objectives of Healthy People 2020 address the pregnant female and maternal and infant health.

17. Objectives of Healthy People 2020 include initiatives to increase the proportion of intended pregnancies; increase the proportion of pregnant women who receive early and adequate prenatal care; increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant women; and increase the proportion of women who choose to breast-feed newborns and infants.

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18. Objectives of Healthy People 2020 also seek to reduce the proportion of females who experience pregnancy despite the use of reversible contraceptive methods, reduce the incidence of perinatal acquired HIV and AIDS cases, reduce the rate of maternal and infant mortality, reduce maternal illness and complications due to pregnancy, reduce cesarean births among low-risk women, reduce preterm births, reduce the occurrence of fetal alcohol syndrome (FAS), and reduce iron deficiency among pregnant females.

19. Other Healthy People 2020 objectives related to pregnancy and maternal health include increasing the proportion of adolescents ages 17 years and younger who have never had sexual intercourse, and increasing the proportion of adolescents who talk to a parent or guardian about reproductive health topics before the age of 18.

20. At the first prenatal visit, a very thorough interview is conducted. Important information that may dramatically affect the health of the fetus and mother should be obtained. The quality of the relationship with the patient for the entire pregnancy begins with this visit. The environment for the interview should be comfortable, quiet, private, and relaxing.

21. For the purposes of identification, statistics, billing, and record keeping, demographic information should be collected.

22. Prior to beginning the interview, confirmation of pregnancy is required either by urine or serum testing, and by associated signs and symptoms of pregnancy.

23. Once pregnancy is confirmed, the nurse calculates the estimated date of birth and the patient’s gestational weeks.

24. The nurse obtains the patient’s obstetrical and gynecological history as well as the patient’s reaction to the pregnancy.

25. The nurse completes a health history including past medical and surgical history as well as the patient’s family history. The nurse elicits information regarding familial and genetic risk factors.

7 26. The nurse elicits information related to the pregnant female’s lifestyle, social health practices, nutrition, and exercise history.

27. The nurse elicits a 24-hour dietary recall including water, vitamins, and supplements in order to perform a nutritional assessment that includes anthropometric measurements.

28. Prenatal visits present excellent opportunities for health promotion and education for the pregnant female.

29. The nurse develops a teaching schedule with health promotion topics from the initial prenatal visit until a few weeks prior to delivery.

30. Education topics for the pregnant female include but are not limited to lifespan considerations, cultural considerations, behavioral considerations, and environmental considerations.

31. Specific lifespan considerations include vomiting, breast tenderness, urinary frequency and urgency, leukorrhea, nasal stuffiness or nosebleeds, heartburn, ankle edema and varicose veins, hemorrhoids, constipation, backache, leg cramps, faintness or dizziness, and dyspnea.

32. Specific cultural considerations include recognizing language barriers, the patient’s cultural norms, and risks for disease processes during pregnancy.

33. Cultural considerations also include the increased infant mortality rate of African American mothers compared to non-Hispanic white mothers, and the increased risk of gestational diabetes in Hispanic women.

34. Specific behavioral considerations for pregnant females include adequate rest, positioning, appropriate clothing, adequate nutrition, adequate exercise, adequate travel precautions, substance abuse, sexual activity, and childbirth/parenting classes.

35. Specific environmental considerations include harmful workplace practices, harmful foods, and infectious diseases.

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36. To perform the physical assessment of the pregnant female, the nurse provides a warm, comfortable, and private environment.

37. The nurse asks the patient to empty her bladder and explains to the patient how to provide a clean-catch urine specimen.

38. The nurse explains the components and the general purpose of the physical assessment to the patient using pictures and showing equipment as necessary, and asks the patient if she has any special needs or questions about the exam.

39. The initial part of the physical exam requires the patient to be seated. She will later need to recline in a semi-Fowler’s position on the examination table. The patient will later be required to assume the lithotomy position and should be assisted by the nurse into this position.

40. During the assessment, the nurse maintains the patient’s dignity.

41. The side-lying position will be used to inspect the perineal and rectum of the postpartum patient.

42. The nurse uses standard precautions in assessing both the pregnant and postpartum female.

43. During the physical assessment of the pregnant female, the nurse inspects and palpates the abdomen and assesses fetal growth through fundal height assessment.

44. The nurse assesses fetal activity, fetal presentation, and fetal positioning during the physical assessment.

45. Based on abdominal palpation, the nurse estimates fetal weight and auscultates for fetal heart rate.

9 46. The nurse examines the external genitalia, and inspects the vagina and cervix followed by palpation of the pelvis, cervix, uterus, adnexa, and vagina during physical assessment.

47. The nurse also performs the rectovaginal exam and assesses the pelvic outlet.

48. During pregnancy and the postpartum period, the role of the nurse is to educate the patient, to prevent complications, and to assist in the screening process to detect possible complications, identify risk factors, and effectively implement treatments if complications develop.

49. Disease processes can result in abnormal assessment findings or abnormal laboratory results in the pregnant female. Common complications in pregnancy include the following: first trimester—spontaneous abortion, ectopic pregnancy, anemia, substance abuse, molar pregnancy/gestational trophoblastic disease, and mood disorders; second and third trimesters—premature dilation of cervix, preeclampsia, gestational diabetes, preterm labor, intrauterine growth restriction, and placenta abnormalities.

50. Common complications of the postpartum period include the following: hemorrhage, preeclampsia, subinvolution of the uterus, disseminated intravascular coagulation, deep venous thrombophlebitis, endometriosis, mastitis, and hematomas.

51. Additional complications during pregnancy include hypertension, gestational diabetes, and, although rare, heart failure.

52. Additional complications related to pregnancy and the postpartum period may be indicated by laboratory results.

53. The nurse uses critical thinking and the nursing process to identify factors to be considered while collecting data related to pregnancy at each prenatal visit.

54. The nurse collects data based on the initial interview and continues to gather data throughout the pregnancy. The nurse clusters and categorizes the data to develop diagnoses applicable to the pregnancy of each patient.

10 55. The nurse prioritizes patients’ learning needs based on data collection and from the physical assessment of the pregnant female at each prenatal visit.

56. In addition to developing diagnoses related to the patient’s current health status, the nurse provides education related to expected changes during the pregnancy.

The nurse considers the patient’s age, expected physiological changes, psychosocial factors including stress and the environment, and risk factors.

57. The nurse develops both actual and potential diagnoses.

58. In the role of educator, the nurse teaches the patient the importance of diet, nutrition, exercise, proper weight gain, blood pressure, and glucose control.

59. The nurse identifies learning needs in order to implement teaching plans for pregnant females.

CHAPTER 28 THE HOSPITALIZED PATIENT

Learning Outcomes 1. Differentiate the types of assessment carried out with the hospitalized patient.

• Suggested Classroom Activity: Have students work in pairs and review the components of both the rapid assessment and routine assessment.

•

Suggested Clinical Activity: Ask each student to discuss with a registered nurse the nurse’s method of conducting a rapid assessment.

2. Conduct a rapid and routine assessment of a hospitalized patient.

• Suggested Classroom Activity: Have student work in pairs. Ask each pair to develop a scenario in which one student conducts a rapid assessment and the other student conducts a routine assessment on the same patient with the same diagnosis.

Ask students to compare each assessment looking for possible important missed cues in the rapid assessment.

•

Suggested Clinical Activity: Ask each student to perform a rapid assessment on an assigned patient and discuss with the primary nurse the accuracy of the assessment.

Instruct the student to then complete a routine assessment on the same patient. Ask students to analyze missed cues that should have been picked up on the rapid assignment.

3. Apply knowledge and skills in the assessment of a hospitalized patient.

• Suggested Classroom Activity: Have students work in pairs and conduct a complete physical assessment on each other. Allow the student simulating the patient to provide cues regarding missed steps of the physical assessment.

•

Suggested Clinical Activity: Ask each student to conduct a complete physical assessment on a hospitalized patient within the limits of the patient’s condition.

4. Apply critical thinking to assessment of the hospitalized patient.

• Suggested Classroom Activity: Ask students to work in pairs as nurse-patient dyads.

Have one student complete a routine assessment of the “patient.” After completing the assessment, have each pair of students develop a plan of care with objectives that are attainable during the “patient’s” hospitalization.

•

Suggested Clinical Activity: Instruct each student to develop three potential diagnoses for an assigned patient and determine the patient’s educational needs beyond the patient’s primary physiological diagnosis or reason for hospitalization.

Key Concepts

1. The depth and breadth of assessment of the hospitalized patient varies with both the purpose of the assessment and the health status of the patient.

2. The nurse performs a more focused and limited assessment when a patient is in distress or if special circumstances are present.

3. Because the hospitalized patient undergoes frequent assessments, it is important for the nurse to communicate with the patient effectively regarding the type and purpose of each assessment.

4. A well-documented knowledge base regarding the patient assists the nurse in making decisions about assessment findings in relation to expected norms in each patient encounter.

5. The rapid assessment requires 1 minute or less to complete and is an initial assessment of each patient in a nursing assignment.

6. The rapid assessment facilitates the nurse’s ability to prioritize actions and interventions.

7. The rapid assessment allows the nurse to establish priorities alone or in collaboration with other providers.

8. Documented data from the rapid assessment establishes a baseline for ongoing patient interaction and care.

9. The rapid assessment is based on patient observation including the patient’s level of consciousness; signs of distress; skin color and respiratory effort; posture, facial expression, and symmetry; and the patient’s response to the nurse’s introduction ensuring speech clarity, and alertness.

10. The nurse assures the patient that he or she will be return shortly, providing the patient with a sense of security.

11. The routine or initial assessment is used to gather in-depth data regarding a patient for whom the nurse will be caring.

12. Data gathered in the initial assessment guides the direction of care and informs the nurse about the need for, the type, and the frequency of continuing assessments.

13. The nurse applies knowledge and skills specific to individual patient care.

14. Populations that require special consideration during hospitalizations include children, patients with communication barriers, and dying patients.

15. The nurse applies knowledge regarding age and developmental stage when caring for small children.

16. The nurse provides children with the opportunity to make choices regarding their care when possible.

17. Nurses must consider patients’ cultural, religious, and spiritual beliefs as part of their essential care.

18. The nurse makes every attempt to provide patients with limited English proficiency or communication disabilities with appropriate communication accommodations.

19. When patients with limited communication require assessment, the nurse must confirm that the patient understands the assessment procedures and the questions that will be asked before the assessment begins.

20. When possible, a staff member should be used as an interpreter for non–Englishspeaking patients.

21. Dying patients require both physical and emotional care. In some cases, the nurse must spend extra time with the dying patient and with the family to aid in this transition.

22. Nurses should assess the emotional state of family members and friends of dying patients and assess their need for emotional care and for information, especially if the patient is a child or if the death is unexpected.

23. Cultural beliefs about death and dying should be assessed and incorporated into nursing interventions related to a patient’s death.

24. The nurse utilizes critical thinking to determine whether a patient requires a routine or rapid assessment.

25. The nurse utilizes observation skills to determine the immediate needs of the patient.

26. The nurse determines special needs and requirements of patients based on age, developmental level, acuity of illness, and other considerations.

27. The nurse utilizes detailed assessment and develops accurate analysis of data to appropriately plan the care of each patient.

28. Analysis of data during rapid and routine assessments requires critical thinking and application of knowledge about health, illness, and factors that influence patients’ responses to changes in their lives.

29. Detailed assessment and accurate data analysis facilitate the nurse’s ability to develop care plans specific to each patient and to the patient’s needs.

CHAPTER 29 THE COMPLETE HEALTH ASSESSMENT

Learning Outcomes 1. Use professional communication skills to gather subjective data and a health history.

• Suggested Classroom Activity: Ask students to work in pairs and simulate a nurse– patient interaction. Ask one student to conduct a focused interview related to a body system or health issue of the other student. At the end of the interview, have the “patient” discuss the communication style of the interviewer focusing on professionalism and therapeutic styles and on asking questions to elicit information relative to the “patient’s” complaint.

•

Suggested Clinical Activity: Instruct students to interview an assigned patient and obtain subjective data related to each patient’s primary complaint or reason for hospitalization. Instruct students to obtain a complete health history.

2. Apply knowledge and skill in gathering objective data in a general survey and physical assessment of the patient.

• Suggested Classroom Activity: Ask students to work in pairs and perform a general survey and a complete physical assessment on each other. Have students assess each other’s work for thoroughness and efficiency in conducting a physical assessment.

•

Suggested Clinical Activity: Ask students to conduct a general survey and perform a complete physical assessment on their assigned patient within the limits of the patient’s ability.

3. Apply critical thinking to the complete health assessment.

• Suggested Classroom Activity: Ask students to work in pairs and perform a general survey and a complete physical assessment on each other. Ask each student to assess the other’s work for thoroughness. Based on the complete health assessment, ask each student to develop three nursing diagnoses that include educational objectives relevant to the nursing diagnoses.

•

Suggested Clinical Activity: Ask each student to develop three nursing diagnoses based on the complete health assessment of an assigned patient prioritizing the assigned patient’s education needs.

Key Concepts

1. The nurse uses effective communication to conduct a complete and detailed health history and health assessment.

2. Physical assessment should be carried out in an organized and effective manner.

3. The nurse plans sequential steps for performing the physical assessment: Gather the necessary equipment; review documentation forms; have pen, paper, or mobile device available to record data or reminder notes and points that require clarification; and provide orderly and concise documentation.

4. The nurse applies knowledge from the natural and behavioral sciences and from nursing to perform the physical assessment.

5. The physical assessment should be performed with efficiency and with accuracy.

6. Nurses utilize established physical assessment techniques and instruments to gather objective data in assessing a patient.

7. The nurse recognizes verbal and nonverbal patient cues and elicits additional information to build a complete database of information.

8. The nurse interprets and documents findings using appropriate terms and descriptions to share and collaborate with other providers.

9. Nurses utilize their senses and their skills to perform the physical assessment.

10. The physical assessment may be guided by cues obtained during the interview.

11. The nurse applies knowledge from the biological sciences, psychology, sociology, and other disciplines to assess the patient.

12. The nurse is cognizant of special considerations related to a patient’s age, developmental stage, gender, genetic makeup, religion, culture, occupation, socioeconomic status, emotional well-being, and other factors when conducting a physical assessment.

13. The nurse prioritizes and accommodates the patient’s needs, physical or emotional, when conducting the health assessment.

14. The nurse uses critical thinking and the nursing process to collect data and elicit additional relevant information during the health assessment.

15. The nurse develops a database of information from subjective and objective findings, organizes this data into clusters, and categories the data to develop actual and potential diagnoses.

16. The nurse utilizes the nursing process, and with the patient, determines goals and implements a plan of care that is evaluated and changed as needed.

17. The nurse prioritizes patients’ needs based on data collection from the interview and from the physical assessment.

18. In addition to developing diagnoses, the nurse provides education related to expected changes based on age and developmental stage, and provides developmentally appropriate interventions and recommendations.

AACN Essentials of Baccalaureate Nursing Education Essentials I. Liberal Education for Baccalaureate Generalist Nursing Practice 1. Integrate theories and concepts from liberal education into nursing practice 2. Synthesize theories and concepts from liberal education to build an understanding of the human experience 3. Use skills of inquiry, analysis, and information literacy to address practice issues 4. Use written, verbal, non-verbal and emerging technology methods to communicate effectively 5. Apply knowledge of social and cultural factors to the care of diverse populations 6. Engage in ethical reasoning and actions to provide leadership in promoting advocacy, collaboration and social justice as a socially responsible citizen 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making 8. Demonstrate tolerance for the ambiguity and unpredictability of the world and its effect on the healthcare system 9. Value the ideal of lifelong learning to support excellence in nursing practice II. Basic Organizational and Systems Leadership for Quality Care and Patient Safety 1. Apply leadership concepts, skills and decision making in the provision of high quality nursing care, healthcare team coordination and the oversight and accountability for care delivery in a variety of settings 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team 3. Demonstrate an awareness of complex organizational systems 4. Demonstrate a basic understanding of organizational structure, mission, vision, philosophy and values 5. Participate in quality and patient safety initiatives, recognizing that these are complex system issues, which involve individuals, families, groups, communities, populations and other members of the healthcare team 6. Apply concepts of quality and safety using structure, process and outcome measures to identify clinical questions and describe the process of changing current practice 7. Promote factors that create a culture of safety and caring 8. Promote achievement of safe and quality outcomes of care for diverse populations 9. Apply quality improvement processes to effectively implement patient safety initiatives and monitor performance measures, including nurse-sensitive indicators in the microsystem of care 10. Use improvement methods, based on data from the outcomes of care processes, to design and test changes to continuously improve the quality and safety of health care 11. Employ principles of quality improvement, healthcare policy, and cost-effectiveness to assist in the development and initiation of effective plans for the microsystem and/or system-wide practice improvements that will improve the quality of healthcare delivery 12. Participate in the development and implementation of imaginative and creative strategies to enable systems to change

III.

IV.

V.

Scholarship for Evidence-Based Practice 1. Explain the interrelationships among theory, practice and research 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice 3. Advocate for the protection of human subjects in the conduct of research 4. Evaluate the credibility of sources of information, including but not limited to databases and Internet resources 5. Participate in the process of retrieval, appraisal and synthesis of evidence in collaboration with other members of the healthcare team to improve patient outcomes 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care 7. Collaborate in the collection, documentation and dissemination of evidence 8. Acquire an understanding of the process for how nursing and related healthcare quality and safety measures are developed, validated, and endorsed 9. Describe mechanisms to resolve identified practice discrepancies between identified standards and practice that may adversely impact patient outcomes Information management and Application of Patient Care Technology 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice 2. Use telecommunication technologies to assist in effective communication in a variety of healthcare settings 3. Apply safeguards and decision making support tools embedded in patient care technologies and information systems to support a safe practice environment for both patients and healthcare workers 4. Understand the use of CIS (clinical information systems) systems to document interventions related to achieving nurse sensitive outcomes 5. Use standardized terminology in a care environment that reflects nursing’s unique contribution to patient outcomes 6. Evaluate data from all relevant sources, including technology, to inform the delivery of care 7. Recognize the role of information technology in improving patient care outcomes and creating a safe care environment 8. Uphold ethical standards related to data security, regulatory requirements, confidentiality and clients’ right to privacy 9. Apply patient-care technologies as appropriate to address the needs of a diverse patient population 10. Advocate for the use of new patient care technologies for safe, quality care 11. Recognize that redesign of workflow and care processes should precede implementation of care technology to facilitate nursing practice Healthcare Policy, Finance and Regulatory Environments 1. Demonstrate basic knowledge of healthcare policy, finance and regulatory environments; including local, state, national and global healthcare trends 2. Describe how health care is organized and financed, including the implications of business principles, such as patient and system cost factors 3. Compare the benefits and limitations of the major forms of reimbursement on the delivery of health care services

VI.

VII.

4. Examine legislative and regulatory processes relevant to the provision of health care 5. Describe state and national statues, rules and regulations that authorize and define professional nursing practice 6. Explore the impact of socio-cultural, economic, legal and political factors influencing healthcare delivery and practice 7. Examine the roles and responsibilities of the regulatory agencies and their effect on patient care quality, workplace safety and the scope of nursing and other health professionals’ practice 8. Discuss the implications of healthcare policy on issues of access, equity, affordability and social justice in healthcare delivery 9. Use an ethical framework to evaluate the impact of social policies on health care, especially for vulnerable populations 10. Articulate, through a nursing perspective, issues concerning healthcare delivery to decision makers within healthcare organizations and other policy arenas 11. Participate as a nursing professional in political processes and grassroots legislative efforts to influence healthcare policy 12. Advocate for consumers and the nursing profession Interprofessional Communication and Collaboration for Improving Patient Health Outcomes 1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education and licensure requirements) 2. Use inter-and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care 3. Incorporate effective communication techniques, including negotiation and conflict resolution to produce positive professional working relationships 4. Contribute the unique nursing perspective to interprofessional teams to optimize patient outcomes 5. Demonstrate appropriate teambuilding and collaborative strategies when working with interprofessional teams 6. Advocate for high quality and safe patient care as a member of the interprofessional team Clinical Prevention and Population Health 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities and populations 2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities and populations 4. Use behavioral change techniques to promote health and manage illness 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan 6. Use information and communication technologies in preventive care 7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions 8. Assess the health, healthcare, and emergency preparedness needs of a defined

population 9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty and other emergency situations 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability and premature death 11. Participate in clinical prevention and population-focused interventions with attention to effectiveness, efficiency, cost-effectiveness and equity 12. Advocate for social justice, including a commitment to the health of vulnerable populations and the elimination of health disparities 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease VIII.

Professionalism and Professional Values 1. Demonstrate the professional standards of moral, ethical, and legal conduct 2. Assume accountability for personal and professional behaviors 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession 4. Demonstrate professionalism, including attention to appearance, demeanor, respect for self and others, and attention to professional boundaries with patients and families as well as among caregivers 5. Demonstrate an appreciation of the history of and contemporary issues in nursing and their impact on current nursing practice 6. Reflect on one’s own beliefs and values as the relate to professional practice 7. Identify personal, professional and environmental risks that impact personal and professional choices and behaviors 8. Communicate to the healthcare team one’s personal bias on difficult healthcare decisions that impact one’s ability to provide care 9. Recognize the impact of attitudes, values and expectations on the care of the very young, frail older adults and other vulnerable populations 10. Protect patient privacy and confidentiality of patient records and other privileged communications 11. Access interpforessional and intraprofessional resources to resolve ethical and other practice dilemmas 12. Act to prevent unsafe, illegal or unethical care practices 13. Articulate the value of pursuing practice excellence, lifelong learning and professional engagement to foster professional growth and development 14. Recognize the relationship between personal health, self renewal, and the ability to deliver sustained quality care

IX.

Baccalaureate Generalist Nursing Practice 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches 2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings 4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions 10. Facilitate patient-centered transitions of care, including discharge planning and ensuring the caregiver’s knowledge of care requirements to promote safe care 11. Provide nursing care based on evidence that contributes to safe and high quality patient outcomes within healthcare Microsystems 12. Create a safe environment that results in high quality patient outcomes 13. Revise the plan of care based on an ongoing evaluation of patient outcomes 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team 15. Manage care to maximize health, independence and quality of life for a group of individuals that approximates a beginning practitioner’s workload 16. Demonstrate the application of psychomotor skills for efficient, safe and compassionate delivery of patient care 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care 18. Develop an awareness of patients as well as healthcare professionals’ spiritual beliefs and values and how those beliefs and values impact health care 19. Manage the interaction of multiple functional problems affecting patients across the lifespan, including common geriatric syndromes 20. Understand one’s role and participation in emergency preparedness and disaster response with an awareness of environmental factors and the risks they pose to self and patients 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient

relationship 22. Demonstrate tolerance for the ambiguity and unpredictability of the world and its effect on the healthcare system as related to nursing practice

AACN Cultural Competency in Baccalaureate Nursing Education Cultural Competencies 1. Apply knowledge of social and cultural factors that affect nursing and health care across multiple contexts a. Demonstrate an understanding of culture and cultural competence in practice b. Compare similarities and differences in values, beliefs and practices among and within diverse populations c. Explain the relationship among cultural, physiological, ecological, pharmacologic and genetic factors d. Integrate social and cultural assessment data (including language and health literacy) in planning, implementing and evaluating care 2. Use relevant data sources and best evidence in providing culturally competent care: a. Critique existing research and knowledge sources to determine its relevance and applicability to diverse groups (Appropriate for a management text) b. Integrate best evidence and patient perspectives in planning care c. Facilitate access to data resources and services to provide culturally competent care d. Participate in the collection, documentation and use of cultural and social data in the planning, delivery and evaluation of care e. Advocate for the protection of vulnerable populations in human subjects research 3. Promote achievement of safe and quality outcomes of care for diverse populations a. Advocate for effective resources to facilitate cross-cultural communication for patients with limited English proficiency (LEP) and health literacy b. Participate in providing leadership to interprofessional teams to minimize and prevent health disparities and to achieve culturally competent programs and services c. Recognize quality and patient safety as complex system issues that involve patients and members of the healthcare team d. Collaborate with patients and families to identify mutually agreed upon goals and outcomes of care 4. Advocate for social justice, including commitment to the health of vulnerable populations and the elimination of health disparities a. Recognize the historic and contemporary implications of public policies and discrimination affecting health, healthcare systems and use of healthcare services by racial, ethnic, and other vulnerable groups b. Recognize and report individual and institutional discrimination practices, unequal treatment practices, breaches of patients’ human and civil rights, or violations of respect for patient autonomy to appropriate authorities c. Demonstrate leadership in addressing behavior that is insensitive, lacks cultural understanding, or reflects prejudice in order to improve adherence to professional standards of respect and civility d. Demonstrate cultural competence in ethical decisions about care delivery 5. Participates in continuous cultural competence development a. Engage in ongoing self-reflection of own behaviors toward diverse patients and other members of the interpfrofessional team b. Articulate the value of pursuing lifelong learning about different cultures to foster professional growth and development and provide culturally competent care c. Engage in a variety of activities to develop understanding of cultural differences and similarities about health and healthcare to improve ability to work with diverse and vulnerable populations

AACN, July 2010

Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults: A Supplement to The Essentials of Baccalaureate Education for Professional Nursing Practice September 2010 1. Incorporate professional attitudes, values, and expectations about physical and mental aging in the provision of patient-centered care for older adults and their families.

2. Assess barriers for older adults in receiving, understanding, and giving of information.

3. Use valid and reliable assessment tools to guide nursing practice for older adults.

4. Assess the living environment as it relates to functional, physical, cognitive, psychological, and social needs of older adults.

5. Intervene to assist older adults and their support network to achieve personal goals, based on the analysis of the living environment and availability of community resources.

6. Identify actual or potential mistreatment (physical, mental or financial abuse, and/or selfneglect) in older adults and refer appropriately.

7. Implement strategies and use online guidelines to prevent and/or identify and manage geriatric syndromes.

8. Recognize and respect the variations of care, the increased complexity, and the increased use of healthcare resources inherent in caring for older adults.

9. Recognize the complex interaction of acute and chronic co-morbid physical and mental conditions and associated treatments common to older adults.

10. Compare models of care that promote safe, quality physical and mental health care for older adults such as PACE, NICHE, Guided Care, Culture Change, and Transitional Care Models.

11. Facilitate ethical, non-coercive decision making by older adults and/or families/caregivers for maintaining everyday living, receiving treatment, initiating advance directives, and implementing end-of-life care.

12. Promote adherence to the evidence-based practice of providing restraint-free care (both physical and chemical restraints).

13. Integrate leadership and communication techniques that foster discussion and reflection on the extent to which diversity (among nurses, nurse assistive personnel, therapists, physicians, and patients) has the potential to impact the care of older adults.

14. Facilitate safe and effective transitions across levels of care, including acute, community-based, and long-term care (e.g., home, assisted living, hospice, nursing homes) for older adults and their families.

15. Plan patient-centered care with consideration for mental and physical health and well being of informal and formal caregivers of older adults.

16. Advocate for timely and appropriate palliative and hospice care for older adults with physical and cognitive impairments.

17. Implement and monitor strategies to prevent risk and promote quality and safety (e.g., falls, medication mismanagement, pressure ulcers) in the nursing care of older adults with physical and cognitive needs.

18. Utilize resources/programs to promote functional, physical, and mental wellness in older adults.

19. Integrate relevant theories and concepts included in a liberal education into the delivery of patient-centered care for older adults.

Standards of Professional Nursing Practice 1. Assessment The registered nurse collects comprehensive data pertinent to the patient’s health and/or the situation Competencies: The registered nurse 1. Collects comprehensive data including but not limited to physical, functional psychosocial, emotional, mental, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments in a systematic and ongoing process while honoring the uniqueness of the person 2. Elicits patient values, preferences, expressed needs and their knowledge of the healthcare situation 3. Involves the patient, family/support system other healthcare providers, and environment as appropriate, in holistic data collection 4. Identifies barriers (such as psychosocial, financial, cultural, etc) to effective communication and makes appropriate adaptations 5. Recognizes impact of personal attitudes, values and beliefs when assessing patients with diverse backgrounds or situations 6. Assess family dynamics and impact on patient health and wellness 7. Prioritizes data collection activities based on the patient’s immediate condition, or anticipated needs of the patient or situation 8. Uses appropriate evidence-based assessment techniques and instruments and tools 9. Synthesizes available data, information and knowledge relevant to the situation to identify patterns and variances 10. Documents relevant data in a retrievable format 11. Applies ethical, legal, and privacy guidelines and policies to the collection, maintenance, use and dissemination of data and information 12. Recognizes the person as the authority on his/her own health and honors their preferences in regards to their care 2. Diagnosis The registered nurse analyzes the assessment data to determine the diagnoses or issues Competencies: The registered nurse 1. Derives the diagnoses or issues based on assessment data 2. Validates the diagnoses or issues with the patient, family and other healthcare providers when possible and appropriate 3. Documents diagnoses or issues in a manner that facilitates the determination of the expected outcomes and plan 4. Identifies actual or potential risks to the patient’s health and safety or barriers to health, which may include but are not limited to interpersonal, systematic, or environmental circumstances 5. Uses standardized classification systems, when available, in naming diagnoses 3. Outcomes Identification: The registered nurse identifies expected outcomes for a plan individualized to the patient or the situation Competencies: The registered nurse 1. Involves patient, family, significant others, and other healthcare providers in formulating expected outcomes when possible and appropriate 2. Derives culturally appropriate expected outcomes from the diagnoses 3. Considers associated risks, benefits, costs, current scientific evidence, expected

trajectory of the condition, and clinical expertise when formulating expected outcomes 4. Defines expected outcomes in terms of the patient, patient values, ethical considerations, environment or situation with such consideration as associated risks, benefits and costs and current scientific evidence 5. Includes a time estimate for the attainment of expected outcomes 6. Develops expected outcomes that provide direction for continuity of care 7. Modifies expected outcomes that provide direction in the status of the patient or evaluation of the situation 8. Documents expected outcomes and measureable goals 4. Planning The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes Competencies: The registered nurse 1. Develops in partnership with the person, family and others an individualized plan considering the person’s characteristics or situation, including but not limited to, values, beliefs, spiritual and health practices, preferences, choices, developmental level, coping style, culture and environment and available technology 2. Develops the plan in conjunction with the patient, family and others, synthesizing patients’ values and beliefs, developmental level, and coping styles 3. Includes strategies in the plan of care that address each of the identified diagnoses or issues. These strategies may include, but are not limited to, strategies for promotion and restoration of health and prevention of illness, injury, and disease, the alleviation of suffering and provision of supportive care for those who are dying 4. Provides for continuity with the plan of care 5. Incorporates an implementation pathway or timeline within the plan 6. Establishes the plan priorities with the patient, family and others as appropriate 7. Utilizes the plan to provide direction to other members of the healthcare team 8. Defines the plan to reflect current statues, rules and regulations and standards 9. Integrates current scientific evidence, trends and research affecting care in planning 10. Considers the economic impact of the plan on the patient, family, caregivers or other affected parties 11. Documents the plan of care in a manner that uses standardized language or recognized terminology, and is understood by all participants 12. Includes strategies for health, wholeness, and growth from in fancy through old age 13. Explores practice settings and safe space and time for both the nurse and person/family/significant others to explore suggestion, potential and alternative options 14. Modifies the plan based on the ongoing assessment of the patient’s response and other outcome indicators 5. Implementation The registered nurse implements the identified plan Competencies: The registered nurse 1. Partners with the person/family/significant others/ caregiver to implement the plan in a safe, realistic and timely manner 2. Demonstrates caring behaviors towards patients, significant others and groups of people receiving care 3. Documents implementation and any modifications, including changes or omissions,

of the identified plan 4. Utilizes technology to measure, record and retrieve patient data, implement the nursing process and enhance nursing practice 5. Utilizes evidence-based interventions and treatments specific to the diagnosis or problem 6. Provides holistic care that addresses the needs of diverse populations across the lifespan 7. Advocates for health care that is sensitive to the needs of patients, with particular emphasis on the needs of diverse populations 8. Applies appropriate knowledge of major health problems and cultural diversity in implementing the plan of care 9. Applies health care technologies to maximize optimal outcomes for patients 10. Utilizes community resources and systems to implement the plan of care 11. Collaborates with health care providers from diverse backgrounds to implement the plan 12. Integrates care with other members of the interprofessional health care team 13. Evaluates and assesses the usefulness in integrating traditional and complementary health care practices 14. Implements the plan of care in a safe and timely manner in accordance with the National Patient Safety goals 15. Promotes the person’s capacity for the optimal level of participation and problem solving, honoring the person’s choices 16. Coordinates the health care of individuals across the lifespan using principles of interpforessional models of care delivery and case management 5A. Coordination of Care: The registered nurse coordinates care delivery Competencies: The registered nurse 1. Coordinates implementation of the plan 2. Documents the coordination of the care 3. Coordinates and manages care to meet the special needs of vulnerable populations in order to maximize independence and quality of life 4. Assists the person to recognize alternatives by identifying options for care choices 5B. Health Teaching and Health Promotion The registered nurse employs strategies to promote health and a safe environment Competencies: The registered nurse 1. Provides health teaching that addresses such topics as healthy lifestyles, risk-reducing behaviors, developmental needs, activities of daily living and preventive self-care 2. Uses health promotion and health teaching methods appropriate to the situation and the patient’s values, beliefs, health practices 3. Seeks opportunities for feedback and evaluation of the effectiveness of the strategies used 5C. Consultation and 5D.Prescriptivie Authority Reserved for APRN 6. Evaluation The registered nurse evaluates progress toward attainment of outcomes Competencies: The registered nurse

1. Conducts a systematic, ongoing and criterion-based evaluation of the outcomes in relation to the structures and processes prescribed by the plan of care and the indicated timeline 2. Collaborates with the person and others involved in the care or situation in the evaluation process 3. Evaluates, in partnership with the person, the effectiveness of the planned strategies in relation to the person’s responses and the attainment of the expected outcomes 4. Documents the results of the evaluation 5. Uses ongoing assessment data to revise the diagnoses, outcomes, the plan, and the implementation as needed 6. Disseminates the results to the patient, family and others involved in accordance with federal and state regulations 7. Actively participates in assessing and assuring the responsible and appropriate use of interventions in order to minimize unwarranted or unwanted treatment and patient suffering Standards of Professional Performance 7. Ethics The registered nurse integrates ethical provisions in all areas of practice.

Competencies: The registered nurse 1. Uses Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) to guide practice 2. Delivers care in a manner that preserves and protects patient autonomy, dignity, rights, values and beliefs 3. Respects the centrality of the patient/family as core members of any health care team 4. Upholds and advocates for patient confidentiality within legal and regulatory parameters 5. Serves as a patient advocate assisting patients in developing skills for self advocacy and informed decision-making 6. Maintains a therapeutic and professional patient-nurse relationship with appropriate professional role boundaries 7. Demonstrates a commitment to practicing self-care, managing stress, and connecting with self and others 8. Contributes to resolving ethical issues involving patients, colleagues, community groups, systems and other stakeholders 9. Takes appropriate action regarding instances of illegal, unethical or inappropriate behavior that can endanger or jeopardize the best interest of the patient or situation 10. Cooperates in an interpforessional team to make ethical decisions regarding the application of technologies and the acquisition and sharing of data 11. Demonstrates professional comportment (openness, honesty, integrity and authenticity) 12. Speakes up when appropriate to question health care practice when necessary for safety and quality improvement 8. Education The registered nurse attains knowledge and competency that reflects current nursing practice Competencies: The registered nurse 1. Incorporates new ideas and interventions to improve patient care

2. Participates in ongoing educational activities related to appropriate knowledge bases and professional issues 3. Demonstrates a commitment to lifelong learning through self-reflection and inquiry to address learning and personal growth needs 4. 4. Seeks experiences that reflect current practice to maintain knowledge, skills, abilities and judgment in clinical practice or role performance 5. Acquires knowledge and skills appropriate to the specialty area, practice setting, role or situation 6. Maintains professional records that provide evidence of competency and life long learning 7. Uses technology to support evidence-based nursing practice that facilitates improved patient outcomes 8. Seeks experiences and formal and independent learning activities to maintain and develop clinical and professional skills and knowledge 9. Identifies learning needs based on nursing knowledge, the various roles the nurse may assume, and the changing needs of the population 10. Completes personal self-assessment of one’s own role and competence 11. Stays informed of local and national issues that would impact public and social policy and professional nursing practice 12. Participates in ongoing consultation to address issue of caring for others 9. Evidence-Based Practice and Research The registered nurse integrates evidence and research findings into practice Competencies: The registered nurse 1. Utilizes current evidence-based nursing knowledge, including research findings, to guide practice decisions 2. Critically analyzes evidence-based practice and research findings for application to practice 3. Participates in the development of evidence-based practice through research activities.

Participation levels occur appropriate to the nurse’s education and position 4. Shares research activities and/or findings with peers and others 10. Quality of Practice The registered nurse systematically enhances the quality and effectiveness of nursing practice Competencies: The registered nurse 1. Demonstrates quality by documenting the application of the nursing process in a responsible, accountable, and ethical manner 2. Uses the results of quality improvement activities to initiate changes in nursing practice and in the healthcare delivery system 3. Uses creativity and innovation in nursing practice to improve care delivery 4. Incorporates new knowledge to initiate changes in nursing practice 5. Participates in quality improvement activities 6. Obtains and maintains professional certification if available in the area of expertise 11. Communication The registered nurse uses a a wide variety of communication skills and formats in all areas of practice Competencies: The registered nurse 1. Communicates effectively in a variety of written, spoken and technological formats 2. Assesses own level of communication skill in encounters with patients and families

3. Seeks continuous improvement of own communication and conflict resolution skills 4. Acknowledges different styles of communication used by patients, families and health care providers 5. Models effective communication and promotes cooperative behaviors 6. Initiates requests for assistance when situation warrants it 7. Uses information technologies to communicate health promotion/disease prevention information to the patient in a variety of settings 8. Understands the principles of group process and negotiation 9. Participates in building consensus or resolving conflict in the context of patient care 10. Demonstrates effective communication and information sharing across disciplines and throughout transitions in care 11. Identifies problems that occur in day to day work routines and participates in deriving solutions to inefficiencies 12. Asserts own position/perspective in discussions about patient care 13. Questions the rationale supporting routine approaches to care processes and decisions when they do not appear to be in the best interest of the patient 14. Communicates observations or concerns related to hazards and errors to patients, families and/or health care team 15. Follows communication practices to minimize risks associated with transfers between providers and across transition in care delivery 12. Leadership The registered nurse demonstrates leadership in the professional practice setting and the profession Competencies: The registered nurse 1. Promotes healthy work environments in local, regional, national or international communities 2. Directs the coordination of care across setting and among caregivers 3. Oversees the nursing care given by others while retaining accountability for the quality of care given to the patient 4. Displays the ability to define a clear vision, the associated goals, and a plan to implement and measure progress 5. Demonstrates a commitment to continuous, lifelong learning and education for self and others 6. Mentors others for the advancement of nursing practice, the profession and quality health care 7. Contributes to a culture where creativity, flexibility and innovation are expected in the work environment 8. Demonstrates positive energy, excitement and a passion for quality work 9. Values people as the most precious asset in an organization 10. Treats others with respect, trust and dignity 11. Participates in key roles on committees, councils and administrative teams 12. Participates in professional organizations 13. Communicates effectively with team members and others 14. Manages conflict effectively 15. Seeks ways to advance nursing’s professional autonomy, accountability and selfregulation 16. Demonstrates awareness of own strengths and constraints as a team member 17. Participates in designing systems that support effective teamwork and positive

outcomes 18. Participates in efforts to influence health care policy on behalf of patients and the profession 13. Collegiality The registered nurse interacts with and contributes to the professional development of peers and colleagues Competencies: The registered nurse 1. Adheres to standards and applicable codes of conduct that govern behavior among peers and colleagues to create an environment promoting cooperation, respect and trust 2. Shares knowledge and skills with peers and colleagues as evidenced by such activities as patient care conferences or presentations at formal or informal meetings 3. Provides peers with feedback regarding their practice and/or role performance 4. Interacts with peers and colleagues to enhance one’s own professional nursing practice and/or role performance 5. Maintains compassionate and caring relationships based on mutual respect between peers and colleagues 6. Contributes to an environment that is conducive to the education of healthcare professionals 7. Contributes to a supportive and healthy work environment 14. Collaboration The registered nurse collaborates with patient, family and others in the conduct of nursing practice Competencies: The registered nurse 1. Partners with others to effect change and generate positive outcomes through the sharing of knowledge of the patient and/or situation 2. Communicates with patient, family and healthcare providers regarding patient care and the nurse’s role in the provision of that care 3. Promotes conflict management and engagement 4. Cooperates in creating a documented plan focused on outcomes and decisions related to care and delivery of services that indicates communication with patients, families and others 5. Documents referrals, including provisions for continuity of care 15. Professional Practice Evaluation The registered nurse evaluates one’s own nursing practice in relation to professional practice standards and guidelines, relevant statues, rules and regulations Competencies: The registered nurse 1. Provides age appropriate care in a culturally and ethnically sensitive manner 2. Engages in self-evaluation of practice on a regular basis, identifying areas of strength as well as areas in which professional development would be beneficial 3. Obtains informal feedback regarding one’s own practice from patients, peers, professional colleagues and others 4. Participates in systematic peer review as appropriate 5. Takes action to achieve goals identified during evaluation process 6. Provides rationales for practice beliefs, decisions and actions as part of the informal and formal evaluation processes 16. Resource Utilization The registered nurse utilizes appropriate resources to plan and provide nursing services that

are safe, effective and financially responsible Competencies: The registered nurse 1. Assess individual patient care needs and resources available to achieve desired outcomes 2. Allocates resources based on identified patient care needs, potential for harm, complexity of the task and desired outcome 3. Delegates tasks based on patient need and caregiver competency 4. Identifies cost and benefits in evaluating resources available with the patient, family and healthcare team 5. Advocates for the design and implementation of technology that enhances nursing practice and healthcare delivery 6. Modifies practice when necessary to promote a positive interface between patients, care providers and healthcare delivery 7. Assists the patient and family in identifying and securing appropriate and available services to address needs across the healthcare continuum 8. Assists the patient and family in understanding costs, risks and benefits of treatment and care 17. Environmental Health The registered nurse integrates the principles of environmental health for nursing in all areas of practice Competencies: The registered nurse 1. Works to reduce or eliminate environmental health risks in the healthcare setting 2. Participates in creating environments that promote health and healing, including attention to sound, noise and light 3. Advocates for the mitigation of the negative impact of products used in the healthcare system on the environment 4. Communicates environmental health risks and exposure reduction strategies to patients, families, colleagues and communities 5. Utilizes scientific evidence to determine if a product or treatment is a potential environmental threat 6. Advocates for environmental justice, including a commitment to the health of vulnerable populations and the elimination of health disparities

Institute of Medicine Core Competencies IOM Competencies 1. Provide patient-centered care: a. Identify, respect, and care about patients’ differences, values, preferences, and expressed needs b. Relieve pain and suffering c. Coordinate continuous care d. Listen to, clearly inform, communicate with and educate patients e. Share decision making and management f. Continually advocate disease prevention, wellness and promotion of healthy lifestyles, including a focus on population health 2. Work in interdisciplinary teams: a. Cooperate, collaborate, communicate and integrate care in teams to ensure that care is continuous and reliable 3. Employ evidence-based practice: a. Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible 4. Apply quality improvement: a. Identify errors and hazards in care b. Understand and implement basic safety design principles, such as standardization and simplification c. Continually understand and measure quality of care in terms of structure, process, and outcomes in relation to patient and community needs d. Design and test interventions to change processes and systems of care, with the objective of improving quality 5. Utilize informatics: a. Communicate, manage knowledge, mitigate error and support decision making using information technology.

Institute of Medicine Core Competencies , July 2010

I. Safe and Effective Care Environment The nurse promotes achievement of client outcomes by providing and directing nursing care that enhances the care delivery setting in order to protect clients and health care personnel.

A. Management of Care – providing and directing nursing care that enhances the care delivery setting to protect clients and health care personnel.

Related content includes, but is not limited to: Advance Directives Advocacy Assignment, Delegation and Supervision Case Management Client Rights Collaboration with Interdisciplinary Team Concepts of Management Confidentiality/Information Security Continuity of Care Establishing Priorities Ethical Practice Informed Consent Information Technology Legal Rights and Responsibilities Performance Improvement (Quality Improvement) Referrals B. Safety and Infection Control – protecting clients and health care personnel from health and environmental hazards.

Related content includes, but is not limited to: Accident/Error/Injury Prevention Emergency Response Plan Ergonomic Principles Handling Hazardous and Infectious Materials Home Safety Reporting of Incident/Event/Irregular Occurrence/Variance Safe Use of Equipment Security Plan Standard Precautions/Transmission- Based Precautions/Surgical Asepsis Use of Restraints/Safety Devices

II. Health Promotion and Maintenance The nurse provides and directs nursing care of the client that incorporates the knowledge of expected growth and development principles, prevention and/or early detection of health problems, and strategies to achieve optimal health.

Related content includes, but is not limited to: Aging Process Ante/Intra/Postpartum and Newborn Care Developmental Stages and Transitions Health Promotion/Disease Prevention Health Screening High Risk Behaviors Lifestyle Choices Self-Care Techniques of Physical Assessment

III. Psychosocial Integrity The nurse provides and directs nursing care that promotes and supports the emotional, mental and social wellbeing of the client experiencing stressful events, as well as clients with acute or chronic mental illness Related content includes, but is not limited to: Abuse/Neglect Behavioral Interventions Chemical and Other Dependencies/Substance Use Disorder Coping Mechanisms Crisis Intervention Cultural Awareness/Cultural Influences on Health End of Life Care Family Dynamics Grief and Loss Mental Health Concepts Religious and Spiritual Influences on Health Sensory/Perceptual Alterations Stress Management Support Systems Therapeutic Communication Therapeutic Environment

IV. Physiological Integrity The nurse promotes physical health and wellness by providing care and comfort, reducing client risk potential and managing health alterations.

A. Basic Care and Comfort - providing comfort and assistance in the performance of activities of daily living Related content includes but is not limited to: Assistive Devices Elimination Mobility/Immobility Non-Pharmacological Comfort Interventions Nutrition and Oral Hydration Personal Hygiene Rest and Sleep

B. Pharmacological and Parenteral Therapies - providing care related to the administration of medications and parenteral therapies.

Related content includes but is not limited to: Adverse Effects/Contraindications/Side Effects/Interactions Blood and Blood Products Central Venous Access Devices Dosage Calculation Expected Actions/Outcomes Medication Administration Parenteral/Intravenous Therapies Pharmacological Pain Management Total Parenteral Nutrition

C. Reduction of Risk Potential - reducing the likelihood that clients will develop complications or health problems related to existing conditions, treatments or procedures.

Related content includes but is not limited to: Changes/Abnormalities in Vital Signs Diagnostic Tests Laboratory Values Potential for Complications from Surgical Procedures and Health Alterations Potential for Alterations in Body Systems Potential for Complications of Diagnostic Tests/Treatments/Procedures System Specific Assessments Therapeutic Procedures

D. Physiological Adaptation - managing and providing care for clients with acute, chronic or life threatening physical health conditions.

Related content includes but is not limited to: Alterations in Body Systems Fluid and Electrolyte Imbalances Hemodynamics Illness Management Medical Emergencies Pathophysiology Unexpected Response to Therapies

National Patient Safety Goals 2013 NPSG Standards 1. Identify patients correctly: a. Use at least two ways to ID patients b. Make sure correct patient gets correct blood type when they get a blood transfusion 2. Improve staff communication a. Quickly get important test results to the right person 3. Use medications safely a. Label all medicines that are not already labeled (in syringes, cups and basins). b. Take extra care with patients who take medicines to thin their blood c. Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.

4. Prevent infection a. Use the hand cleaning guidelines from the CDC and Prevention or the WHO b. Use proven guidelines to prevent infections that are difficult to treat c. Use proven guidelines to prevent infection of the blood from central lines d. Use safe practices to treat the part of the body where surgery was done e. Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.

5. Check patient medicines a. Find out what medicines each patient is taking b. Give a list of the patient’s medicines to their next caregiver or to their regular doctor before the patient goes home c. Give a list of the patient’s medicines to the patient and their family before they go home. Explain the list. d. Some patients may get medicine in small amounts for a short time. Make sure that it is OK for those patients to take those medicines with their current medicines 6. Identify patient safety risks a. Find out which patients are most likely to kill themselves www.jointcommission.org Retrieved 2/15/13.

QSEN Competencies

I.

Patient-centered Care

Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.

A. Knowledge 1.

Integrate understanding of multiple dimensions of patient centered care: o o o o o o

2.

patient/family/community preferences, values coordination and integration of care information, communication, and education physical comfort and emotional support involvement of family and friends transition and continuity

B. Skills 1.

2.

3.

Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care Communicate patient values, preferences and expressed needs to other members of health care team Provide patient-centered care with sensitivity and respect for the diversity of human experience

Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort.

1.

2.

3.

4.

5.

6.

4.

5.

6.

7.

4. Examine how the safety, quality and cost effectiveness of health care can be improved through the active involvement of patients and families

C. Attitudes

8.

9.

Value seeing health care situations "through patients' eyes" Respect and encourage individual expression of patient values, preferences and expressed needs Value the patient's expertise with own health and symptoms Seek learning opportunities with patients who represent all aspects of human diversity Recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds Willingly support patient-centered care for individuals and groups whose values differ from own

Assess presence and extent of pain and suffering Assess levels of physical and emotional comfort Elicit expectations of patient & family for relief of pain, discomfort, or suffering Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs

7.

Remove barriers to presence of families and other designated surrogates based on patient preferences Assess level of patient's decisional conflict

10. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care 11. Respect patient preferences for degree of active

1

8.

9.

Recognize personally held values and beliefs about the management of pain or suffering Appreciate the role of the nurse in relief of all types and sources of pain or suffering Recognize that patient expectations influence outcomes in management of pain or suffering

5.

Examine common barriers to active involvement of patients in their own health care processes Describe strategies to empower patients or families in all aspects of the health care process

and provide access to resources 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management

engagement in care process 12. Respect patient's right to access to personal health records

Explore ethical and legal implications of patientcentered care Describe the limits and boundaries of therapeutic patient-centered care

11. Recognize the boundaries of therapeutic relationships 12. Facilitate informed patient consent for care

13. Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care 14. Appreciate shared decision-making with empowered patients and families, even when conflicts occur

9. Discuss principles of effective communication 10. Describe basic principles of consensus building and conflict resolution 11. Examine nursing roles in assuring coordination, integration, and continuity of care

13. Assess own level of communication skill in encounters with patients and families 14. Participate in building consensus or resolving conflict in the context of patient care 15. Communicate care provided and needed at each transition in care

15. Value continuous improvement of own communication and conflict resolution skills

6.

7.

8.

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II. TEAMWORK AND COLLABORATION

Definition: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decisionmaking to achieve quality patient care.

A. Knowledge 1. Describe own strengths, limitations, and values in functioning as a member of a team

B. Skills 1.

Demonstrate awareness of own strengths and limitations as a team member Initiate plan for self-development as a team member Act with integrity, consistency and respect for differing views

1. Acknowledge own potential to contribute to effective team functioning 2. Appreciate importance of intra- and interprofessional collaboration

Function competently within own scope of practice as a member of the health care team Assume role of team member or leader based on the situation Initiate requests for help when appropriate to situation Clarify roles and accountabilities under conditions of potential overlap in team member functioning Integrate the contributions of others who play a role in helping patient/family achieve health goals

3. Value the perspectives and expertise of all health team members 4. Respect the centrality of the patient/family as core members of any health care team 5. Respect the unique attributes that members bring to a team, including variations in professional orientations and accountabilities

Communicate with team members, adapting own style of communicating to needs of the team and situation 10. Demonstrate commitment to team goals 11. Solicit input from other team members to improve individual, as well as team, performance

6. Value teamwork and the relationships upon which it is based 7. Value different styles of communication used by patients, families and health care providers 8. Contribute to resolution of conflict and disagreement

2.

3.

2. Describe scopes of practice and roles of health care team members 3. Describe strategies for identifying and managing overlaps in team member roles and accountabilities 4. Recognize contributions of other individuals and groups in helping patient/family achieve health goals

4.

5.

6.

7.

8.

5. Analyze differences in communication style preferences among patients and families, nurses and other members of the health team 6. Describe impact of own communication style on others 7. Discuss effective strategies for communicating

C. Attitudes

9.

3

and resolving conflict

12. Initiate actions to resolve conflict

4

8. Describe examples of the impact of team functioning on safety and quality of care 9. Explain how authority gradients influence teamwork and patient safety

13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care 14. Assert own position/perspective in discussions about patient care 15. Choose communication styles that diminish the risks associated with authority gradients among team members

9. Appreciate the risks associated with handoffs among providers and across transitions in care

10. Identify system barriers and facilitators of effective team functioning 11. Examine strategies for improving systems to support team functioning

16. Participate in designing systems that support effective teamwork

10.Value the influence of system solutions in achieving effective team functioning

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III. EVIDENCE-BASED PRACTICE (EBP)

Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.

A. Knowledge

B. Skills

C. Attitudes

1. Demonstrate knowledge of basic scientific methods and processes 2. Describe EBP to include the components of research evidence, clinical expertise and patient/family values.

1. Participate effectively in appropriate data collection and other research activities 2. Adhere to Institutional Review Board (IRB) guidelines 3. Base individualized care plan on patient values, clinical expertise and evidence

1. Appreciate strengths and weaknesses of scientific bases for practice 2. Value the need for ethical conduct of research and quality improvement 3. Value the concept of EBP as integral to determining best clinical practice

3. Differentiate clinical opinion from research and evidence summaries 4. Describe reliable sources for locating evidence reports and clinical practice guidelines

4. Read original research and evidence reports related to area of practice 5. Locate evidence reports related to clinical practice topics and guidelines

4. Appreciate the importance of regularly reading relevant professional journals

5. Explain the role of evidence in determining best clinical practice 6. Describe how the strength and relevance of available evidence influences the choice of interventions in provision of patientcentered care

6. Participate in structuring the work environment to facilitate integration of new evidence into standards of practice 7. Question rationale for routine approaches to care that result in less-than-desired outcomes or adverse events

5. Value the need for continuous improvement in clinical practice based on new knowledge

7. Discriminate between valid and invalid reasons for modifying evidence-based clinical practice based on clinical expertise or patient/family preferences

8. Consult with clinical experts before deciding to deviate from evidence-based protocols

6. Acknowledge own limitations in knowledge and clinical expertise before determining when to deviate from evidence-based best practices

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IV. QUALITY IMPROVEMENT (QI)

Definition: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.

A. Knowledge

B. Skills

1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice

1.

2. Recognize that nursing and other health professions students are parts of systems of care and care processes that affect outcomes for patients and families 3. Give examples of the tension between professional autonomy and system functioning

3.

4. Explain the importance of variation and measurement in assessing quality of care

5.

2.

4.

6.

7.

5. Describe approaches for changing processes of care

C. Attitudes

Seek information about outcomes of care for populations served in care setting Seek information about quality improvement projects in the care setting

1. Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals

Use tools (such as flow charts, causeeffect diagrams) to make processes of care explicit Participate in a root cause analysis of a sentinel event

2. Value own and others' contributions to outcomes of care in local care settings

Use quality measures to understand performance Use tools (such as control charts and run charts) that are helpful for understanding variation Identify gaps between local and best practice

3. Appreciate how unwanted variation affects care 4. Value measurement and its role in good patient care

8.

Design a small test of change in daily work (using an experiential learning method such as Plan-Do-Study-Act) 9. Practice aligning the aims, measures and changes involved in improving care 10. Use measures to evaluate the effect of

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5. Value local change (in individual practice or team practice on a unit) and its role in creating joy in work 6. Appreciate the value of what individuals and teams can to do to improve care

change

V. SAFETY

Definition: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.

A. Knowledge 1.

2.

3.

4.

5.

B. Skills

C. Attitudes

Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as, work-arounds and dangerous abbreviations) Describe the benefits and limitations of selected safety-enhancing technologies (such as, barcodes, Computer Provider Order Entry, medication pumps, and automatic alerts/alarms) Discuss effective strategies to reduce reliance on memory

1. Demonstrate effective use of technology and standardized practices that support safety and quality 2. Demonstrate effective use of strategies to reduce risk of harm to self or others 3. Use appropriate strategies to reduce reliance on memory (such as. forcing functions, checklists)

1. Value the contributions of standardization/reliability to safety 2. Appreciate the cognitive and physical limits of human performance

Delineate general categories of errors and hazards in care Describe factors that create a culture of safety (such as, open communication strategies and organizational error reporting systems)

4. Communicate observations or concerns related to hazards and errors to patients, families and the health care team 5. Use organizational error reporting systems for near miss and error reporting

3. Value own role in preventing errors

6. Participate appropriately in analyzing errors and designing system improvements 7. Engage in root cause analysis rather than blaming when errors or near misses occur

4. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team

6. Describe processes used in understanding causes of error and allocation of responsibility and accountability (such as, root cause analysis and failure mode effects

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analysis)

7. Discuss potential and actual impact of national patient safety resources, initiatives and regulations

8. Use national patient safety resources for own professional development and to focus attention on safety in care settings

5. Value relationship between national safety campaigns and implementation in local practices and practice settings

VI. INFORMATICS

Definition: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.

A. Knowledge

B. Skills

C. Attitudes

1. Explain why information and technology skills are essential for safe patient care

1. Seek education about how information is managed in care settings before providing care 2. Apply technology and information management tools to support safe processes of care

1. Appreciate the necessity for all health professionals to seek lifelong, continuous learning of information technology skills

2. Identify essential information that must be available in a common database to support patient care 3. Contrast benefits and limitations of different communication technologies and their impact on safety and quality

3. Navigate the electronic health record 4. Document and plan patient care in an electronic health record 5. Employ communication technologies to coordinate care for patients

2. Value technologies that support clinical decision-making, error prevention, and care coordination 3. Protect confidentiality of protected health information in electronic health records

4. Describe examples of how technology and information management are related to the quality and safety of patient care 5. Recognize the time, effort, and skill required for computers, databases and other technologies to become reliable and

6. Respond appropriately to clinical decisionmaking supports and alerts 7. Use information management tools to monitor outcomes of care processes 8. Use high quality electronic sources of healthcare information

4. Value nurses' involvement in design, selection, implementation, and evaluation of information technologies to support patient care

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effective tools for patient care

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