BACHELOR OF SCIENCE IN NURSING:

HEALTH ASSESSMENT
COURSE MODULE COURSE UNIT WEEK
1 4 4

Holistic Nursing Assessment

✓ Read course and unit objectives

✓ Read study guide prior to class attendance
✓ Read and comprehend required learning resources
✓ Engage in classroom discussions
✓ Participate in weekly discussion board (Canvas)
✓ Answer and submit course unit tasks

At the end of this unit, the students are expected to:

Cognitive:
1. Describe the factors that affect the vital signs and accurate measurement of them.
2. Correctly perform an accurate general survey.
3. Differentiate between normal and abnormal findings in the general survey and vital signs.
4. Describe appropriate nursing care for alterations in vital signs.
5. Differentiate between the etiology of acute and chronic pain.
6. Discuss the various physiologic responses to pain.
7. Discuss how both mental health and mental disorders affect the mental status.
8. Analyze client’s mental status and substance abuse risk assessment data to formulate valid
nursing diagnosis, collaborative problems, and or referrals.
 9. Describe the following theories: Freud (psychosexual), Erickson (psychosocial), Piaget
(cognitive), and Kohlberg (moral).
10. Differentiate between normal and abnormal findings of psychosocial, cognitive and moral
development.
11. Describe how to prepare a physically and emotionally safe environment in which to interview
and assess a client who has experienced domestic violence.
12. Discuss the importance of accurate documentation of physical assessment findings in clients
who have experienced abuse.
13. Describe culture and its basic characteristics.
14. Explain how the interaction of culture, genetics, and environmental factors affect health
status.
15. Describe the difference between religion and spirituality.
16. Discuss how understanding the client’s spirituality assists the nurse to understand the client’s
decision-making processes and support systems.
17. Perform a nutritional assessment – including height, body build, and other anthropometric
measurements – using the correct techniques.
18. Differentiate between normal and abnormal nutrition and hydration.

Affective:
1. Inculcate that the assessment phase is the most important phase of the nursing process. An
effective nursing care plan contains an accurate assessment.
2. Listen attentively during class discussions
3. Demonstrate tact and respect when challenging other people’s opinions and ideas
4. Accept comments and reactions of classmates on one’s opinions openly and graciously.

Psychomotor:
1. Participate actively during class discussions
2. Confidently express personal opinion and thoughts in front of the class

Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing 6th Edition, Philadelphia:
Wolters Kluwer

A. GENERAL HEALTH STATUS

General Survey
• The first part of the physical examination that begins the moment the nurse meets the client.
 • Observations lead to clues about the health status of the client.
• The general survey includes observation of the client’s:
o Physical development and body build
o Gender and sexual development
o Apparent age as compared to reported age
o Skin condition and color
o Dress and hygiene
o Posture and gait
o Level of consciousness
o Behaviors, body movements, and affect
o Facial expression
o Speech
o Vital signs

B. VITAL SIGNS

• Are the body’s indicators of health

• Also known as “Cardinal Signs”
• Common, noninvasive physical assessment procedure that most clients are accustomed to
o First step in physical assessment
• Provide data that reflect the status of several body systems, including but not limited to the
cardiovascular, neurologic, peripheral vascular, and respiratory systems

When to Assess Vital Signs

• Upon admission
• A change in health status
• Pre and Post Op/ Procedure
• Pre and Post medication administration
• Before and after any nursing intervention that could affect the vital signs
o Activity, talking, gum – chewing, and anxiety affect pulse, respirations and blood pressure
▪ ALLOW 5 minutes of REST before beginning to take VS

Temperature
• A core body temperature between 36.5OC and 37.9OC must be maintained for the body to function
at a cellular level
• Approximate reading of core body temperature can be taken at various anatomic sites but none
of them is completely accurate – they are simply an approximation of the core body temperature
o Oral temperature
▪ Between 35.9OC – 37.5OC
o Axillary temperature
▪ Between 35.4OC – 37.0OC
o Temporal artery temperature
▪ Between 36.3OC – 37.9OC
o Rectal temperature
 ▪ Between 36.3OC – 37.9OC
o Tympanic membrane temperature
▪ Between 36.7OC – 38.3OC
• Measured in degrees
• Body temperature is
o Lowest early in the morning (4:00 AM to 6:00 AM)
o Highest late in the evening (8:00 PM to 12:00 MN)
o Regulated by the hypothalamus

Purpose
• To establish Baseline data for subsequent evaluation
• To identify whether the core temperature is within normal range
• To determine changes in core temperature in response to specific therapies
• To monitor clients at risk for imbalanced body temperature

Factors That Affect Heat Production

• BMR (Basal Metabolic Rate)
o Rate of energy utilization in the body required to maintain essential activities
o Cool someone down and their metabolic rate slow down, heat them up and their
metabolism increases up
o A thermoneutral environment is one in which nothing except basal metabolic rate is
required to maintain core body temperature at 37 degrees
o The cooler the environment, the more your body will attempt to keep you warm by cranking
up your metabolism
• Muscle activity
o Increases metabolic rate
o Using large muscles to make heat rather than movement
o Strenuous exercises cause normal variations in the body temperature
o SHIVERING (using large muscles to make heat rather than movement) IS THE MOST
OBVIOUS OUTWARD SIGN
• Thyroxine (T4) output
o A Thyroid hormone for regulation of metabolism (BMR)
o Increased Thyroxine output increases metabolism (Chemical Thermogenesis)
o Thyroid hormones affect blood vessels to determine body temperature
o Affect protein synthesis
o An overactive thyroid (HYPERTHYROIDISM) can cause a person to feel too hot
o An underactive thyroid (HYPOTHYROIDISM) can cause a person to feel too cold
o Sample thyroid hormones
▪ Thyroxine (T4)
▪ Triiodothyronine (T3)
▪ T0, T1, T2 – hormone precursors – byproduct of thyroid hormones but do not act
on thyroid hormone receptor and appear to be totally inert
• Epinephrine, Norepinephrine and Sympathetic Stimulation
o Sympathetic Nervous System
 o Plays important role on the maintenance of core body temperature through
thermoregulatory processes
o Thermoregulation is a process that allows your body to maintain its core temperature
• Fever
o Increase in the body temperature’s set point
o Increases cellular metabolic rate
o Increase in set point triggers increased muscle contractions
o Can be caused by medical conditions (viral, bacterial, parasitic infections)
o Pyrexia
▪ A body temperature above the usual range is called Pyrexia, Hyperthermia or
Fever

Types of Heat Transfer

• Conduction
o Transfer of heat from one molecule to a molecule of lower temperature
• Radiation
o Transfer of energy in the form of waves and particles
• Convection
o Is the dispersion of heat by air currents
• Vaporization / Evaporation
o Is a continuous evaporation of moisture from the respiratory tract and from the mucosa of
the mouth and from the skin

Factors Affecting Body Temperature

• Age
o infants and older clients are greatly influenced by environment
• Diurnal variations
o temperature normally change throughout the day (fluctuating temperature, there is a rate
or magnitude of change)
• Exercise
o strenuous activity = high temp
• Hormones
o women = progesterone increases temp (.3-.6 C)
• Stress
o stimulates sympathetic nervous system = increase metabolic activity
• Environment
o room temp may affect assessment

Types of Fevers
• Intermittent
o alternates at regular intervals between periods of fever and periods of normal/subnormal
temperatures.
• Remittent
o wide range of temperature fluctuations all of which are above normal
 • Relapsing
o short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal
temperature
• Constant
o fluctuates minimally but always remain above normal

Clinical Onset of Fever

• ONSET / CHILL
o set point increases from normal to higher than normal
o Core temperature needs time to adjust thus the body will compensate by heat production
response
o Manifestations may include
▪ ↑ heart rate
▪ ↑RR
▪ Shivering
▪ Cold, pallid skin
▪ Cyanotic nail beds
▪ “Gooseflesh”
▪ Cessation of sweating
• COURSE / PLATEAU
o after the core temp has reach a new set point, the person neither feels warn nor cold
o manifestations may include
▪ Absence of Chills
▪ Skin that feels warm
▪ Photosensitivity
▪ Glassy eyed appearance
▪ ↑ PR and RR
▪ ↑ thirst
▪ Dehydration
▪ Drowsiness, restlessness, delirium
▪ Loss of appetite
▪ Malaise
• DEFERVESCENCE
o occurs when the cause of fever is suddenly removed
o The hypothalamus attempts to normalize the temperature resulting in a sudden
vasodilation
o This event is known as CRISIS, the FLUSH DEFERVESCENT STAGE OF PYREXIA
o Manifestations may include
▪ Flushed skin
▪ Sweating
▪ Decreased shivering
▪ Possible dehydration
Nursing Interventions During Fever
• Monitor vital signs and skin color
• Monitor lab values
• Provide adequate nutrition and fluids
• Oral hygiene
• Tepid sponge bath
• Dry clothing and linens
• Antipyretics

Pulse
• A shock wave produced by the contraction of the heart and forceful pumping of blood out of the
ventricles into the aorta
• Commonly called the arterial or peripheral pulse
• Is an indirect measurement of cardiac output obtained by counting the number of apical or
peripheral pulse waves over a pulse point
• A normal pulse rate for adults is between 60 and 100 beats per minute

Arterial or Peripheral Pulse Sites

• Temporal
o Superior and lateral to the eye
o Used when radial pulse is not accessible
• Carotid
o Internal
▪ Branches into the anterior and middle cerebral arteries and supplies the brain
o External
▪ Branches into the superior thyroid, inguinal, facial, occipital posterior auricular,
superficial temporal, and maxillary arteries and supplies the thyroid, head and
mouth
o Used during cardiac arrest/shock in adults
• Apical
 o Located at the apex of the heart
o Routinely used for infants and children up to 3 years of age
o Used to determine discrepancies with radial pulse
o Used in conjunction with some medications
• Brachial
o Supplies the humerus and the muscles and skin of the upper arm
o Inner aspect of the biceps muscle of the arm or medially in the antecubital space
o Used to measure blood pressure
o Used during cardiac arrest for infants
• Radial
o Runs along the radial bone, on the thumb side of the inner aspect of the wrist
o Supplies the forearm and hand on the radial side
o Gives a good overall picture of the client’s health status
• Femoral
o Passes alongside the inguinal ligament
o Supplies the thighs
o Used in cases of cardiac arrest/shock
o Used to determine circulation to a leg
• Popliteal
o Passes behind the knees
o Supplies the knees, the posterior femoral, gastrocnemius, and soleus muscles and the
skin on the back of the leg
o Used to determine circulation to the lower leg
• Posterior tibialis
o Medial surface of the ankle, passes behind the medial malleolus
o Supplies the back of the leg and the ankle
o Used to determine circulation to the foot
• Dorsalis pedis
o Passes over the bones of the foot, on an imaginary line drawn from the middle of the ankle
to the space between the big and second toes
o Supplies the feet
o Used to determine circulation to the foot

Assessing the Pulse Rate

1. The nurse should begin the assessment by speaking with the client about the normal pulse rate.
2. Palpate a peripheral pulse by placing the first two fingers on the pulse point with moderate
pressure.
3. Count the rate for a full minute, noting the regularity (rhythm).
o When an irregular peripheral pulse is present, the nurse needs to assess for a pulse deficit
▪ Pulse deficit
• condition in which the apical pulse rate is greater than the radial pulse rate
• A pulse deficit results from the ejection of a volume of blood that is too small
to initiate a peripheral pulse wave
 • a deficit or a discrepancy may present heart condition such as in atrial
fibrillation
o When a discrepancy exists between the apical and radial pulses, the deficit is assessed
by simultaneously measuring the apical and radial pulses for a minute

Pulse Characteristics
• A normal pulse has defined characteristics: quality, rate, rhythm, and volume (strength or
amplitude), and elasticity
• Pulse quality refers to the “feel” of the pulse, its rhythm and forcefulness
• Normally, pulsation is equally strong in both wrists
• Amplitude can be quantified as follows:
o 0 – absent
o 1 + Weak, diminished, easy to obliterate
o 2 + Normal, obliterate with moderate pressure
o 3 + Bounding, unable obliterate or requires firm pressure
• Pulse rhythm
o is the regularity of the heartbeat
o there are regular intervals between beats
• Dysrhythmia
o arrhythmia
o irregular heart beat
• Pulse Volume
o is a measurement of the strength or amplitude of force exerted by the ejected blood
against the arterial wall with each contraction
• Arterial elasticity
o Artery feels straight, resilient, and springy
• Bradycardia
o is a heart rate less than 60 beats per minute in an adult
o may be normal in well – conditioned clients
• Tachycardia
o is a heart rate in excess of 100 beats per minute in an adult
o may be normal in clients who have just finished strenuous exercise

Respirations
• The act of breathing
• Rate and character are additional clues to the client’s overall health status

Process of Respiration
• External respiration
o Interchange of o2 and co2 between the alveoli and the pulmonary blood
• Internal respiration
o Interchange of o2 and co2 between the circulating blood (pulmonary blood) and body
tissues
 • Inhalation
o Intake of air into the lungs
• Exhalation
o Movement of air from lungs to the atmosphere
• Ventilation
o Movement of air in and out of the lungs

Types of Breathing
• Costal / Thoracic
o External intercostal muscles
o Accessory muscles
o Chest upward then outward
o Chest expansion is centered at midpoint
o More work to be done in lifting the rib cage
o Useful for vigorous activities
o Usually occurs when the individual is aroused by challenges or danger (tension and
anxiety)
• Abdominal / Diaphragmatic
o Contraction and relaxation of the diaphragm
o Movement of the abdomen
o Diaphragm is the principal muscle of use (strong dome – shaped sheet of muscle that
separates chest cavity from the abdomen
o Breath-in, diaphragm CONTRACTS – lungs expand, creating a partial vacuum, allows air
to be drawn in (INHALATION)
o Breath-out, diaphragm RELAXES – abdominal muscles contract and expel air that
contains carbon dioxide
o Diaphragmatic breathing is the most efficient because greater expansion and ventilation
occurs in the lower part of the lung where blood perfusion is the greatest

Normal breathing is accomplished by:

1. The downward and upward movement of the diaphragm to lengthen or shorten the chest cavity
2. The elevation and depression of the ribs to increase and decrease the anteroposterior diameter
of the chest cavity

Major Physical Pulmonary Functions

• Ventilation
o The inflow and outflow of air between the atmosphere and the lung alveoli
• Circulation
o The quantity of blood flowing through the lungs is approximately 4 to 6 l/min
• Diffusion
o The exchange of oxygen and carbon dioxide between the alveoli and the blood
• Transport
o The carrying of oxygen and carbon dioxide in the blood and body fluids to and from the
cells
Assessing Respiration
• Normal breathing is slightly observable, effortless, quiet, automatic, and regular
• It can be assessed by observing chest wall expansion and bilateral symmetrical movement of the
thorax
• Sites
o chest wall
o thorax
o nose and mouth

How to do it?
• Place your hand over client’s wrist and observe one complete respiratory cycle.
• Start to count with first inspiration while looking at second hand sweep of watch.
• Nursing consideration
o Observe respirations without alerting the client by watching the chest movement while
continuing to palpate the radial pulse

Altered Breathing Pattern / Sounds

• Rate
o Tachypnea
▪ Quick, shallow breathing
o Bradypnea
▪ Abnormally slow
o Apnea
▪ Cessation of breathing
o Eupnea
▪ Normal breathing
• Volume
o Hyperventilation
▪ Overexpansion of the lungs, rapid deep breaths
o Hypoventilation
▪ Underexpansion of the lungs, shallow breaths
• Effort
o Dyspnea - difficulty of breathing (DOB)
o Orthopnea - DOB when lying supine
▪ Atelectasis – partial or complete collapse of alveoli of lungs (insufficient O2)
• Sounds
o Stridor
▪ Shrill harsh sound during inspiration – laryngeal obstruction
o Stertor
▪ Snoring or sonorous respiration – partial obstruction of upper airway
o Wheeze
▪ High pitched musical squeak on expiration – narrowed/partially obstructed airway
(asthma)
o Bubbling
 ▪ Gurgling sounds – moist secretions (productive cough)
• Chest movement
o Intercostal retractions
▪ Upper airway (trachea)or small airways (bronchioles) are blocked
▪ As a result, intercostal muscles are sucked inward between the ribs
▪ Reduced air pressure inside chest
▪ A sign of a blocked airway
o Substernal retractions
▪ Beneath the breastbone
▪ Indrawing of the abdomen just below the sternum (breastbone)
▪ Belly breathing
o Suprasternal retractions
▪ Above the clavicles
• Secretions
o Hemoptysis
o Productive cough
o Non-productive cough

Blood Pressure
• Blood pressure is the measure of pressure exerted as blood flows through the artery.
• Measurement of the pressure of the blood in the arteries when the ventricles are contracted
(systolic blood pressure -SBP) and when the ventricles are relaxed (diastolic blood pressure -
DBP)
• It is measured in terms of millimeters of mercury (mm Hg) and written in fraction form.
• NORMAL VALUE is below 120 (systolic) and below 80 (diastolic)

C. MENTAL STATUS

Refers to a client’s level of cognitive functioning (thinking, knowledge, problem solving) and
emotional functioning (feelings, mood, behaviors, stability).

Mental health
• An essential part of one’s total health and is more than just the absence of mental disabilities
or disorders
• A state of well – being in which an individual realizes his or her own capabilities, can cope
with the normal stresses of life, can work productively and is able to make a contribution to
his or her own community – WHO

Major areas of mental status assessment include language, orientation, memory, and attention span
and calculation.
Assessment Techniques

• Positioning
o Sitting on the examination table, wearing examination gown
• Observe the patient
o Note hygiene, grooming, posture, body language, facial expressions, speech, and
ability to follow directions
▪ Abnormal findings
• Inadequate self-care, flatness of affect, and inability to follow directions
may be associated with mental illnesses such as depression or
schizophrenia
• Anormal facial expression or body language may be reflective of
neurological or psychiatric disorders
• Note the patient’ speech and language abilities
o Note rate of speech, ability to pronounce words, tone of voice, loudness or softness
of voice and ability to speak softly and clearly
o Note patient’s choice of words, ability to respond to questions, and ease of response
made
▪ Abnormal findings
• Changes in speech could reflect anxiety, Parkinson’s disease,
depression or dysphasia
• Assess patient’s sensorium
o Determine the patient’s orientation to date, time, place, as well as the need for the
physical assessment
o Grade the level of alertness on a scale from full alertness to coma
o Abnormal findings
▪ Neurologic disease can produce a sliding or changing degree of alertness
▪ Change in the level of consciousness (LOC) may be related to cortical or brain
stem disease
▪ Stroke, seizure, or hypoglycemia could also contribute to a change in the LOC
• Assess the patient’s memory
o Ask the patient’s DOB, names and ages of any children or grandchildren, education
history with dates and events, work history with dates and job descriptions
o Abnormal findings
▪ Loss of long-term memory may indicate cerebral cortex damage, which occurs
in Alzheimer’s disease
• Assess the patient’s ability to calculate problems
o Start with a simple problem such as 4+3, 8÷2, and 15-4
o Abnormal findings
▪ Inability to calculate simple problems may indicate the presence of organic
brain disease, or it may simply indicate lack of exposure to mathematical
 concepts, nervousness, or an incomplete understanding of the examiner’s
language
• Also consider that a poor response to calculations should not be
considered an abnormal finding
▪ Use problems that are appropriate for the patient’s developmental, educational,
and intellectual levels
• Assess the patient’s ability to think abstractly
o Ask the patient to identify similarities and differences between 2 objects or topics, such
as wood and coal, king and president, orange and apple
o Quote a proverb and ask the patient to explain it
▪ Be aware that culture and age influence the ability to explain quotes or proverbs
o Abnormal findings
▪ Responses made by the client may reflect lack of education, mental retardation
or dementia
• Assess the patient’s mood and emotional state
o Observe the patient’s body language, facial expressions and communication
technique
o Abnormal findings
▪ Lack of congruence of facial expression and tone of voice may occur with
neurologic problems, emotional disturbance or a psychogenic disorder
o The patients mood and emotions should reflect the current situation or response to
events that trigger mood change or call for an emotional response
o Abnormal findings
▪ Lack of emotional response, lack of change in emotional expression, and flat
tone of voice can indicate problems with mood or emotional responses
▪ Other states related to mood and emotions include anxiety, depression, fear,
anger, overconfidence, ambivalence, euphoria, impatience and irritability
▪ Mood disorders include bipolar disorder, anxiety disorders, and major
depression
• Assess perceptions and thought processes
o Listen to patients’ statements. It should be logical and relevant. It should be with
complete thought
o Abnormal findings
▪ Disturbed thought processes can indicate neurologic dysfunction or mental
disorder
o Assessment of perception includes determining the patient’s awareness of reality
▪ Disturbances in sense of reality can include hallucination and illusion
▪ These are associated with mental disturbances as seen in schizophrenia
• Assess the patient’s ability to make judgments
o Determine if the patient is able to evaluate situations and to decide on a realistic
course of action
o Abnormal findings
 ▪ Impaired judgment can occur in emotional disturbances, schizophrenia and
neurologic dysfunction

D. PSYCHOSOCIAL, COGNITIVE AND MORAL DEVELOPMENT

• Freud Theory of Psychosexual Development

o Personality development was based on understanding the individual life history of a
person
o Stages
▪ Oral
• 0 – 1.5 years
▪ Anal
• 1.5 – 3 years
▪ Phallic
• 3 – 6 years
▪ Latency
• 6 – 11 years
▪ Genital
• Adolescence
• Erikson Theory of Psychosocial Development
o Societal, cultural, and historical factors as well as biophysical processes and cognitive
function influence personality development
o Stages
▪ Infant
• Basic trust vs. Basic mistrust
▪ Toddler
• Autonomy vs. Shame and doubt
▪ Preschooler
• Initiative vs. Guilt
▪ School – age child
• Industry vs. Inferiority
▪ Adolescent
• Identity vs. Role confusion
▪ Young adult
• Intimacy vs. Isolation
▪ Middle – age adult
• Generativity vs. Stagnation
▪ Older adult
• Ego integrity vs. Despair
• Piaget Theory of Cognitive Development
 o Physical maturity, social interaction, environmental stimulation and experience in
general are interrelated and were necessary for cognition to occur
o Stages
▪ Sensorimotor
• 0 – 2 years
▪ Preoperational
• 2 – 7 years
▪ Concrete operational
• 7 – 11 years
▪ Formal operational
• 11 – 15+ years
• Kohlberg Theory of Moral Development
o Individual morality has been viewed as a dynamic process that extends over one’s
lifetime, primary involving the affective and cognitive domains in determining what is
“right” and “wrong”
o Stages
▪ Preconventional
• Preschool through early school age
▪ Conventional
• School age through adulthood
▪ Postconventional
• Middlescence through older adulthood

E. PAIN: THE 5TH VITAL SIGN

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage

Nature of Pain
• Pain is subjective and highly individualized
• Its stimulus is physical and/or mental in nature
• It interferes with personal relationships and influences the meaning of life
• Only the patient knows whether pain is present and how the experience feels
• May not be directly proportional to amount of tissue injury

Signs and Symptoms of Pain

• Increased RR
• Increased HR
• Peripheral vasoconstriction
• Pallor
• Elevated BP
 • Diaphoresis
• Moaning
• Guarding behavior
• Restlessness
• Irritability

Types of Pain
• Acute Pain
o Lasts only through the expected recovery period
o Of short duration, has limited tissue damage and emotional response
o Eventually resolves with or without treatment, after and injured area heals
o Complete pain relief is not always achievable, but reducing pain to a tolerable level is
realistic
o Unrelieved acute pain can progress to chronic pain
• Chronic Pain
o Pain that lasts longer than 6 months and is constant or recurring with a mild-to-severe
intensity
o Leads to great personal suffering
o Associate symptoms of chronic pain include fatigue, insomnia, anorexia, weight loss,
hopelessness and anger

Pain Concepts
• Radiating Pain
o perceived at the source of the pain and extends to the nearby tissues
• Referred Pain
o felt in a part of the body that is considerably removed or far from the tissues causing
the pain
 • Persistent Pain
o a pain that contributes insomnia, weight gain, constipation, etc.
• Severe Pain
o an emergency situation deserving attention and professional treatment
• Hyperalgesia
o excessive sensitivity to pain
• Pain Threshold / Sensation
o the amount of pain stimulation a person requires before feeling pain
o least level of pain that the patient is able to detect
• Pain Tolerance
o maximum amount and duration of pain that an individual is willing to endure
• Pain Perception
o the point which the person becomes aware of the pain
• Allodynia
o pain due to a stimulus that does not normally provoke pain
• Dysesthesia
o unpleasant abnormal sensation, imitates the pathology of central neuropathic pain
disorder
• Nociceptive Pain
o pain directly related to tissue damage and may be somatic
• Sensitization
o an increased sensitivity of a receptor after repeated activation by noxious stimuli or
nociceptor
• Breakthrough Pain
o a transitory increase in pain that occurs on a background of otherwise controlled
persistent pain
• Bradykinin
o universal stimulus for pain
• Comfort
o implies renewal amplification of power

F. VIOLENCE

Violence is the use of physical force to harm someone, to damage property, etc. – Merriam-Webster
Online 2015

Aggression is defined as a forceful action or procedure (unprovoked attack) especially when

intended to dominate or master – Merriam-Webster Online 2015
• Positive connotation of aggression
o Associated with the drive for success, as in aggressive men
• Negative connotation of aggression
 o Often associated with the notion of aggressive women, which violates what is
considered appropriate for gender norms in many cultures
o Also associated with aggression against family member when one person tries to
dominate or master another

Domestic violence is a pattern of abusive behavior in any relationship that is used by one partner
to gain or maintain control over another intimate partner – US DOJ Office on Violence against
Women

5 Theories Related to Violence for Why Men Batter Women – McCue (2008)
1. Psychopathology theory
• batterers suffer personality disorders
2. Social learning theory
• violence is a learned behavior from childhood
3. Biologic theory
• physiologic changes from childhood trauma, head injuries, or through heredity cause
violent behavior)
4. Family systems theory
• violence grows through family system function, but some criticize this theory as
blaming the victim
5. Feminist theory
• male/female inequity in patriarchal societies lead to violence

Walker’s Cycle of Violence / Tension Building or Explosion Model

• Phase 1 – Criticism
o The tension-building phase
o The abuser makes unrealistic demands and when expectations are not satisfied,
criticism and/or ridicule leads to shoving or slapping
• Phase 2 – The acute battering stage
o Triggered by something minor but results in violence lasting up to 24 hours
o Victim rarely able to stop the abuse
• Phase 3 – The honeymoon phase
o Period of reconciliation

Types of Family Violence

• Physical abuse
o includes pushing, shoving, slapping, kicking, choking, punching, and burning
o may also involve holding, tying, or other methods of restraint
o victim may be left in a dangerous place without resources
o abuser may refuse to help the victim when sick, injured, or in need
• Psychological abuse
o Aka emotional abuse
 ▪ humiliation, intimidation, infantilization, or any other treatment which may
diminish the sense of identity, dignity, and self-worth – Vancouver Coastal
Health (2013)
o involves the use of constant insults or criticism, blaming the victim for things that are
not the victim’s fault, threats to hurt children or pets, isolation from supporters (family,
friends or coworkers), deprivation, humiliation, stalking and intimidation, and
manipulation of various kinds, such as threats of suicide
• Economic abuse
o Aka financial abuse
▪ improper exploitation of another person’s personal assets, properties, or funds
o may be evidenced by preventing the victim from getting or keeping a job, controlling
money and limiting access to funds, spending the victim’s money, and controlling
knowledge of family finances
• Sexual abuse
o involves forcing the victim to perform sexual acts against her or his will, pursuing
sexual activity after the victim has said no, using violence during sex, and using
weapons vaginally, orally, or anally

Categories of Family Violence

• Intimate Partner Violence (IPV)
o a pattern of assaultive behavior and coercive behavior that may include physical injury,
psychologic abuse, sexual assault, progressive isolation, stalking, deprivation,
intimidation, and reproductive coercion – Family Violence Prevention Fund (2010)
• Child Abuse
o physical or mental injury, sexual abuse, negligent treatment or maltreatment of a child
under the age of 18 by a person who is responsible for the child’s welfare under
circumstances that indicate that the child’s health or welfare is harmed – The Child
Welfare Information Gateway (2008b)
o may be either by commission or by omission and is rarely an isolated incident
o 4 broad categories of child abuse:
▪ Neglect
▪ Emotional abuse
▪ Sexual abuse
▪ Physical abuse
o Long-term consequences of child abuse and neglect (The Child Welfare
Information Gateway (2008b))
▪ Physical
• Chronic health conditions
• Impaired brain development
• Brain injury with head trauma
• Emotional conditions
▪ Psychological
 • Lifelong psychological consequences eg. Low self-esteem, depression
• Cognitive and social difficulties
▪ Behavioral
• Adolescent issues eg. Substance abuse, delinquency
• Greater likelihood of being raped
• Juvenile delinquency and adult criminality
• Alcohol and drug abuse
• Greater likelihood to become abusive parents
▪ Societal
• Increased used of health care system
• Juvenile and adult criminal activity
• Mental illness
• Substance abuse
• Domestic violence
• Employment problems
• Financial problems
• Absenteeism from work
• Elder Mistreatment
o Aka elder abuse
o Includes neglect, physical abuse, sexual abuse, financial abuse, psychological abuse
(including humiliation, intimidation, and threats), exploitation, abandonment, or
prejudicial attitudes that decrease quality of life and are demeaning to those over the
age of 65 years
o Abuse may be from commission, but is frequently from omission
o Consequences of elder mistreatment – (CDC, 2015a)
▪ Physical
• Injuries eg. Bruises, lacerations, head injuries, broken bones, pressure
sores
• Persistent physical pain and soreness
• Nutrition and hydration issues
• Sleep disturbances
• Increased susceptibility to new illnesses
• Exacerbation of pre-existing health conditions
• Increased risk of premature death
▪ Psychological
• Increased risk for developing fear and anxiety reactions
• Learned helplessness
• Posttraumatic stress disorder
Assessment Procedure

Perform General Survey

• Observe general appearance and body build
o Normal findings
▪ Client appears stated age, is well developed, and appears healthy
o Abnormal findings
▪ Abused children may appear younger than stated age due to developmental
delays or malnourishment
▪ Older clients who have been abused may appear thin and frail due to
malnourishment
• Note dress and hygiene
o Normal findings
▪ Client is well groomed and dressed appropriately for season and occasion
o Abnormal findings
▪ Poor hygiene and soiled clothing may indicate neglect
▪ Long sleeves and pants in warm weather may be an attempt to cover bruising
or other injuries
▪ Victims of sexual abuse may dress provocatively
• Assess mental status
o Normal findings
▪ Client is coherent and relaxed
▪ A child shows proper developmental level for age
o Abnormal findings
▪ Client is anxious, depressed, suicidal, withdrawn, or has difficulty concentrating
▪ Client has poor eye contact or soft passive speech
▪ Client is unable to recall recent or past events
▪ Child does not meet developmental expectations
• Evaluate vital signs
o Normal findings
▪ Vital signs are within normal limits
o Abnormal findings
▪ As with any condition of prolonged stress, hypertension may be seen in victims
of abuse
▪ Acute stress may result in elevated heart rate and respiration rate
• Inspect skin
o Normal findings
▪ Skin is clean, dry, and free of lesions, bruises, or burns
o Abnormal findings
▪ Client has scars, bruises, burns, welts or swelling on face, breasts, arms, chest,
abdomen, or genitalia, including evidence of cigarette or cigar burns; hand or
 finger patterns on arms, legs, or neck; or heating element patterns as though
pushed against a heater or radiator
• Inspect the head and neck
o Normal findings
▪ Head and neck are free of injuries
o Abnormal findings
▪ Client has hair missing in clumps, subdural hematomas, or rope marks or
finger/hand strangulation marks on neck, or obvious past or present nose
injuries
• Inspect the eyes
o Normal findings
▪ Eyes are free of injury
o Abnormal findings
▪ Client has bruising or swelling around eyes, unilateral ptosis of upper eyelids
(due to repeated blows causing nerve damage to eyelids), or a subconjunctival
hemorrhage
• Assess the ears
o Normal findings
▪ Ears are clean and free of injuries
o Abnormal findings
▪ Client has external or internal ear injuries
• Assess the abdomen
o Normal findings
▪ Abdomen is free of bruises and other injuries, and is nontender
o Abnormal findings
▪ Client has bruising in various stages of healing
▪ Assessment reveals intra-abdominal injuries
▪ A pregnant client has received blows to abdomen
• Assess genitalia and rectal area
o Normal findings
▪ Client’s genitalia and rectal areas are free of injury
o Abnormal findings
▪ Client has irritation, tenderness, bruising, bleeding, or swelling of genitals or
rectal area
▪ Discharge, redness or lacerations may indicate abuse in young children
▪ Hemorrhoids are unusual in children and may be caused by sexual abuse
▪ Extreme apprehension during this portion of the examination may indicate
physical or sexual abuse
• Assess the musculoskeletal system
o Normal findings
▪ Client shows full range of motion and has no evidence of injuries
o Abnormal findings
 ▪ Dislocation of shoulder; old or new fractures of face, arms, or ribs; and poor
range of motion of joints are indicators of abuse
• Assess the neurologic system
o Normal findings
▪ Client demonstrates normal neurologic function
o Abnormal findings
▪ Abnormal findings include tremors, hyperactive reflexes, and decreased
sensations to areas of old injuries secondary to neurologic damage

G. CULTURE AND ETHNICITY

Culture may be defined as a shared system of values, beliefs, and learned patterns of behavior.
The totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and
all other products of human work and thought characteristic of a population or people that guide their
worldview and decision making – Purnell and Paulanka (2008)

Culture is learned, shared, associated with adaptation to the environment, and is universal.

Purposes and Scope of Assessment

• To learn about the client’s beliefs and usual behaviors associated with health and illness
• To compare and contrast the client’s beliefs and practices to standard Western health care
• To compare the client’s beliefs and practices with those of other persons from a similar
cultural background
• To assess the client’s health relative to diseases prevalent in the specific cultural group

Cultural beliefs and values to assess include:

• Value orientation
• Beliefs about human nature
• Beliefs about relationship with nature
• Beliefs about purpose of life
• Beliefs about health, illness, and healing
• Beliefs about what causes disease
• Beliefs about health
• Beliefs about who serves in the role of healer or what practices bring about healing

Factors Affecting Approach to Providers

• Ethnicity
• Generational status
• Educational level
• Religion
• Previous health care experiences
 • Occupation and income level
• Beliefs about time and space
• Communication needs/preferences

Communication
All communication is culturally based
• Verbal communication can have many variations based on both language differences and
usual tone of voice
o Eg. a harsh tone of voice may be normal in some cultures and thought to be rude in
others.
• Nonverbal communication has the most often misinterpreted variations
o Time
▪ Different cultural groups tend to place different values on the past versus
present versus future
▪ Those focused on the past value practices that are unchanged from ancestors
and are often resistant to new ways
▪ Those focused on the present perceive what is happening in the present to be
more important than what will occur in the future
o Space
▪ everyone who’s ever felt cramped in a crowd knows that the skin is not the
body’s only boundary. We each wear a zone of privacy like a hoop skirt, inviting
others in or keeping them out with body language—by how closely we
approach, the angle at which we face them, and speed with which we break a
gaze – Davis’s 1990 classic article on cultural differences in personal space
o Eye Contact and Face Positioning
o Body Language and Hand Gestures
o Silence
▪ 2 types of silence
• One is simply remaining silent for long periods
• The other is used to space talking between two people carrying on a
conversation
o Touch
▪ Touch is very culturally based
• How much touch is comfortable and allowable, and by whom, are all
based on culture

Factors Affecting Disease, Illness, Health State

• Biomedical variations
• Nutrition/dietary habits
• Family roles and organization, patterns
• Workforce issues
• High-risk behaviors
 • Pregnancy and childbirth practices
• Death rituals
• Religious and spiritual beliefs and practices
• Health care practices
• Health care practitioners
• Environment

H. SPIRITUALITY AND RELIGIOUS PRACTICES

Religion
• Rituals, practices, and experiences involving asearch for the sacred (i.e., God, Allah, etc.)a
that are shared within a group.
• Characteristics
o Formal
o Organized
o Group oriented
o Ritualistic
o Objective, as in easily measurable (e.g., church attendance)

Spirituality
• A search for meaning and purpose in life, which seeks to understand life’s ultimate questions
in relation to the sacred.
• Characteristics
o Informal
o Nonorganized
o Self-reflection
o Experience
o Subjective, as in difficult to consistently measure (e.g., daily spiritual experiences,
spiritual well-being, etc.)

Spiritual Assessment
• Active and ongoing conversation that assesses the spiritual needs of the client.
• Characteristics
o Formal or informal
o Respectful
o Non-biased

Spiritual Care
• Addressing the spiritual needs of the client as they unfold through spiritual assessment.
• Characteristics
o Individualistic
o Client oriented
 o Collaborative

Major World Religions and Common Health Beliefs

• Christianity
o Beliefs focus around the Old and New Testaments of the Bible and view Jesus Christ
as the Savior
o Prayers may be directed to one or all of the Holy Trinity (God, Holy Spirit, and Jesus
Christ)
o Illness
▪ Most view illness as a natural process for the body and even as a testing of
faith
o End of Life
▪ There is belief in miracles, especially through prayer
• Buddhism
o Suffering is a part of human existence, but the inward death of the self and senses
leads to a state beyond suffering and existence
o Illness
▪ Prayer and meditation are used for cleansing and healing
o End of life
▪ Life is the opportunity to cultivate understanding, compassion, and joy for self
and others
▪ Death is associated with rebirth
• Hinduism
o Nirvana (oneness with God) is the primary purpose of the religion
o Illness
▪ Illness is the result of past and current life actions (Karma)
o End of life
▪ Death marks a passage because the soul has no beginning or end
• Islam
o Mohammed is believed to be the greatest of all prophets
o Worship occurs in a mosque
o Illness
▪ Illness is often believed to be a trial sent by God, and the outcome depends on
the person’s attitude of pious endurance
o End of life
▪ All outcomes, whether death or healing, are seen as predetermined by Allah
• Judaism
o Judaism includes religious beliefs and a philosophy for a code of ethics with four major
groupings of Jewish beliefs
▪ Reform
▪ Reconstructionist
▪ Conservative
 ▪ Orthodox
o Illness
▪ Restrictions related to work on holy days are removed to save a life
o End of Life
▪ Psalms and the last prayer of confession (vidui) are held at bedside

Assessment Procedure

• Explore the client’s religious and spiritual background

o Normal findings
▪ Client makes reference to involvement in religious groups and/or spiritual
practices that have provided comfort and social support
o Abnormal findings
▪ Reports lost connections to religious group, while continuing to focus on the
negative aspect of spirituality (e.g., suppressive religious rules)
▪ Comments and body language reveal a lack of hope with symptoms of
depression
• Observe nonverbal and verbal communication patterns in presence of others
o Normal findings
▪ Eye contact is maintained (appropriate to cultural group) with nonverbal cues
correlating with conversation
o Abnormal findings
▪ Client displays poor eye contact
▪ The presence of others strongly influences information client shares
• Begin to focus questions
• What do you hold onto during difficult times?
• What sustains you and keeps you going?
o Normal findings
▪ Reports spirituality giving a sense of peace that transcends illness or disease
▪ Reports that meditation and exercise facilitate a sense of peace
▪ Family frequently mentioned as source of strength and motivation
▪ Client places a strong emphasis on spirituality as a guiding force in life
o Abnormal findings
▪ Describes no connection to others such as God, nature, family, or peers.
▪ Shares pessimistic and fatalistic attitude toward recovery
▪ Identifies limited coping resources with little desire to adopt new ones
• Ask questions about family and community support:
• Do you have family support for your spiritual beliefs and practices?
• Does your community support your spiritual beliefs and practices?
o Normal findings
▪ Client relates full support for beliefs and practices (both for health care and
generally) from family and religious leaders
 ▪ Relates no differences with community
o Abnormal findings
▪ Client describes disagreement among family, religious, or community members
regarding choice of spiritually based health care decisions
• Ask transition question from organizational to personal beliefs.
• Ask client to specify differences or similarities in own beliefs and the beliefs of the faith or
denomination with which affiliated.
o Normal findings
▪ Describes personal beliefs that coincide with denominational beliefs
o Abnormal findings
▪ Abnormal findings may include reporting very limited similarities between
denomination and personal beliefs, past utilization of prayer and listening to
religious music, but currently has no avenue for the fostering of spirituality
• Ask the questions:
• Has being sick (or your current situation) affected your ability to do the things that usually
help you spirituality? (Or affected your relationship with God?)
• As a nurse, is there anything I can do to help you access the resources that usually help you?
o Normal findings
▪ Client views present diagnosis of cancer as “part of God’s will for her life” or/and
desires to continue nature walks and other spiritual practices to develop a
closer relationship with God
o Abnormal findings
▪ Client appears traumatized with cancer diagnosis and views the illness as a
fault of her past lifestyle or a punishment
▪ Refuses visits from local clergy and hospital chaplains
▪ Declines conversation and just wants to be sent home to die

I. NUTRITIONAL STATUS

Nutrition refers to the “process by which substances in food are transformed into body tissues and
provide energy for the full range of physical and mental activities that make up human life” –
Carpenter, 2016

For adequate nutrition, essential nutrients—including carbohydrates, proteins, fats, vitamins,

minerals, and water— must be ingested in appropriate amounts.

Primary Factors that are Emphasized on a Newer Evidence for Nutrition (The Dietary Guidelines for
Americans)
• Follow a healthy eating pattern across the lifespan
• Focus on variety, nutrient density, and amount
• Limit calories from added sugars and saturated fats and reduce sodium
• Shift to healthier food and beverage choices
 • Support healthy eating patterns for all

Optimal Nutrition
• The most beneficial nutritional status requires a balance of nutrient intake to meet daily
metabolic demands
• Balance of calories and exercise

Malnutrition
• Risk factors
o Lower socioeconomic status (SES), making nutritious foods unaffordable
o Lifestyle of long work hours and obtaining one or more meals from a fast-food chain
or vending machine
o Poor food choices by children, teens, and adults
o Chronic dieting, particularly with fad diets, to meet perceived societal norms for weight
and appearance
o Chronic diseases (e.g., Crohn’s disease, cirrhosis, or cancer) that may interfere with
absorption or use of nutrients
o Dental and other factors such as difficulty chewing, loss of taste sensation, depression
o Limited access to sufficient food regardless of SES such as being physically unable
to shop, cook, or feed self
o Disorders whereby food is self-limited or refused (e.g., anorexia nervosa, bulimia,
depression, dementia, or other psychiatric disorders)
o Illness or trauma that increases client’s nutritional needs dramatically but that
interferes with the ability to ingest adequate nourishment (e.g., extensive burns)

Overnutrition
• Increased caloric consumption, especially of food high in fat and sugar, with decreased
energy expenditure has led to near epidemic obesity
o Obesity is defined as excessive body fat in relation to lean body mass
o The amount of body fat, or adipose tissue, includes concern for both the fat distribution
throughout the body as well as the size of the fat deposits
o The health risks of obesity are numerous and include diabetes, heart disease, stroke,
hypertension, some forms of cancers, osteoarthritis, and sleep apnea

Hydration
• Another important indicator of the client’s general health status, but may be overlooked or
confused with the signs and symptoms of nutritional changes
• Signs and symptoms that may indicate changes in hydration status
o Exposure to excessively high environmental temperatures
o Inability to access adequate fluids, especially water (e.g., clients who are unconscious,
confused, or physically or mentally disabled)
 o Excessive intake of alcohol or other diuretic fluids (coffee, sugar-rich and/or caffeine-
rich carbonated soft drinks)
o People with impaired thirst mechanisms
o People taking diuretic medications
o Diabetic clients with severe hyperglycemia
o People with high fevers

Dehydration
• Can have a seriously damaging effect on body cells and the execution of body functions
• A chronically and seriously ill client who is not receiving adequate fluids either orally or
parenterally is at high risk for dehydration unless monitored carefully

Overhydration
• In a healthy person is usually not a problem because the body is effective in maintaining a
correct fluid balance
• Clients at risk for overhydration or fluid retention are those with kidney, liver, and cardiac
diseases in which the fluid dynamic mechanisms are impaired

Evaluating Nutritional Disorders

Assessment Procedure

• Observe body build as well as muscle mass and fat distribution

o Normal findings
▪ In general,the normal body is proportional
▪ Bilateral muscles are firm and well developed
▪ There is equal distribution of fat with some subcutaneous fat
▪ Body parts are intact and appear equal without obvious deformities
o Abnormal findings
▪ A lack of subcutaneous fat with prominent bones is seen in the undernourished
▪ Abdominal ascites is seen in starvation and liver disease
▪ Abundant fatty tissue is noted in obesity
• Measure height
o Measure the client’s height by using the L-shaped
measuring attachment on the balance scale.
o Instruct the client to stand shoeless on the balance scale
platform with heels together and back straight, and to look
straight ahead.
o Raise the attachment above the client’s head.
o Then lower it to the top of the client’s head
o Record the client’s height.
o Normal findings
▪ Height is within range for age, and ethnic and
genetic heritage
▪ Children are usually within the range of parents’
height
o Abnormal findings
▪ Extreme shortness is seen in achondroplastic dwarfism and Turner’s syndrome
▪ Extreme tallness is seen in gigantism (excessive secretion of growth hormone)
and in Marfan’s syndrome
• Measure weight
o Level the balance beam scale at zero
before weighing the client.
o Do this by moving the weights on the scale
to zero and adjusting the knob by turning it
o until the balance beam is level.
o Ask the client to remove shoes and heavy
outer clothing and to stand on the scale.
o Adjust the weights to the right and left until
the balance beam is level again.
o Record weight
▪ (2.2 lb = 1 kg)
 o Normal findings
▪ Desirable weights for men and women in BMI chart

o Abnormal findings
▪ Weight does not fall within range of desirable weights for women and men
• Determine ideal body weight (IBW) and percentage of IBW
o Use this formula to calculate the client’s IBW:
▪ Female: 100 lb for 5 ft + 5 lb for each inch over 5 ft ± 10% for small or large
frame
▪ Male: 106 lb for 5 ft + 6 lb for each inch over 5 ft ± 10% for small or large frame
o Calculate the client’s percentage of IBW by the following formula:
▪ Actual weight x 100 = %IBW
IBW
o Normal findings
▪ Body weight is within 10% of ideal range
o Abnormal findings
▪ A current weight that is 80% to 90% of IBW indicates a lean client and possibly
mild malnutrition
▪ Weight that is 70% to 80% indicates moderate malnutrition; less than 70% may
indicate severe malnutrition possibly from systemic disease, eating disorders,
cancer therapies, and other problems.
▪ Weight exceeding 10% of the IBW range is considered overweight; weight
exceeding 20% of IBW is considered obesity.
 • Measure body mass index (BMI)
o Most commonly used screening method is the body mass index (Weight-control
Information Network, 2011)
o BMI is calculated based on height and weight regardless of gender.
o It is a practical measure for estimating total body fat and is calculated as weight in
kilograms and divided by the square height in meters.
▪ Weight in kgs = BMI
Height in mtrs2
▪ Weight in kgs x 703 = BMI
Height in inches2
o Normal findings
▪ BMI is between 18.5 and 24.9
o Abnormal findings
▪ BMI <18.5 is considered underweight.
▪ BMI between 25.0 and 29.9 is considered overweight and increases risk for
health problems.
▪ A BMI of 30 or greater is considered obese and places the client at a much
higher risk for type 2 diabetes, cardiovascular disease, osteoarthritis, and sleep
apnea.

D’Amico, D., and Barbarito, C., (2019) Health & Physical Assessment in Nursing 3rd Edition,
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Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing

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