NGCM 101 Outline

Module 1: Introduction to Health Assessment: Collecting and 8. Roles and relationships

Analyzing Data 9. Coping and stress tolerance
Overview/Introduction: 10. Sexuality and reproduction
I. Review of Nursing Process 11. Values and Beliefs
A. Nursing
B. Process 2. Head-to-Toe Framework
C. Nursing Process  Definition: collecting data starts from the
D. Purpose of Nursing Process head and proceeds systematically to the toes
E. Components of Nursing Process  General: General health state, vital signs and
1. Assessment weight, nutritional status
 Description  Regional: Head (hair, scalp, eyes.\, ears, oral
 Purpose cavity, cranial nerves), Neck, Chest,
 Activities Abdomen, Extremities, Genitals, Rectum
2. Diagnosis 3. Body Systems Framework - may be used during
 Description focused assessment especially among acutely or
 Purpose critically ill clients
 Activities E. Four Basic Types of Assessment
3. Planning 1. Initial Comprehensive Assessment
 Description  collection of subjective data
 Purpose  collection of objective data
 Activities  total assessment needed (when client
4. Implementation first enters a health care system)
 Description 2. Ongoing/Partial Assessment
 Purpose
 occurs after the comprehensive
 Activities
database is established
5. Evaluation
 on-going process along with nursing
 Description
care
 Purpose
3. Focused/Problem Oriented Assessment
 Activities
 thorough assessment of a particular
II. Health Assessment
client problem and does not cover
A. Role of Nurse in Health Assessment
areas not related to the problem
1. Collects Data
4. Emergency Assessment
2. Analyze Data
B. Definition and Dimensions of Health Assessment  very rapid assessment (needs
immediate diagnosis)
 Definition - A comprehensive health assessment
F. USPF Assessment Tools
encompasses the physical, psychological,
1. Nursing Assessment
social, and spiritual dimensions of human
2. Obstetrics Assessment
living
3. Pediatrics Assessment
 Dimensions
4. Psychiatric Assessment
1. Physical
G. Steps of Health Assessment
2. Psychological
1. Collection of Subjective Data
3. Social
 can be elicited and
4. Spiritual
verified only by the client
C. Purpose of Health Assessment
major areas:
 To establish a database
• Biographical information
 To provide essential foundation for client care
• Physical symptoms r/t each body part or
D. Frameworks
system
1. Functional Health Framework
• Past health history
 Evaluates the effects of the mind, body and • Family history
environment in relation to a person’s ability • Health and lifestyle practices
to perform the tasks of daily living 2. Collection of Objective Data
 Organized using:  Directly observed by the examiner:
o Gordon’s 11 Functional Health • Physical characteristics
Patterns (to provide a comprehensive • Body functions
nursing assessment; systematic & • Appearance
standardized approach) • Behavior
1. Health perception and health • Measurements
management • Results of laboratory testing
2. Activity and Exercise 3. Validating Assessment Data
3. Nutrition and metabolism  Process of confirming or verifying
4. Elimination collected data
5. Sleep and Rest  Steps:
6. Cognition and Perception
7. Self-perception and self-concept
 1. Deciding whether the data requires
validation
2.Determining ways to validate data
 Recheck
 Ask additional questions
 consult another healthcare
professional
 compare objective –
subjective data
3.Identifying missing data
4. Documentation of Data
- a way to communicate data with others the
database as foundation of care
H. Analysis of Assessment Data
1. Nursing Diagnosis – 2nd step of nursing process
2. Process of Data Analysis

Module 2: Collecting Subjective Data: The Interview and Health • Problems at birth
History • Childhood illnesses
Overview/Introduction: • Immunization to date
A. Assessment Methods • Adult illnesses (physical,
1. Observing – using 5 senses and noticing stimuli emotional, mental)
2. Interviewing - planned communication • Surgeries
or a conversation with a purpose • Accidents
o Two Approaches • Prolonged pain or pain
o Kins of Interview Questions patterns
o Patients interview • Allergies
o 3 basic phases 5. Family History (Genogram)
o Communication during interview • Age of parents (living?
o Special considerations Deceased date?)
• Parent illnesses
3. Examining – Physical Examination (IPPA)
• Grandparent’s illnesses
B. Complete Health History
• Aunt’s and uncle’s age and
1. Biographical Data
illnesses?
1. Name
• Children’s age and illnesses
2. Address
or handicaps
3. Phone
• May be illustrated with a
4. Gender
genogram
5. Provider of history
6. Review of body systems for current health
6. Birth date
problems
7. Place of birth
7. Lifestyle/Health Practices Profile
2. Reason for seeking health care (Chief complaints)
8. Developmental Level (Erik Erickson’s Dev’t
3. History of Present Illness (Medical/Surgical)
Stage
(COLDSPA)
Others: Obstetrics History & Environmental
4. History of Past Illness
History

Module 3: Collecting Objective Data: The Physical Examination • Therapeutic communication

Overview/Introduction: • Seek help
A. Preparation for the Examination 4. Approaching and Preparing the
1. Preparation of Needed Equipment Client for Physical Assessment
a) Equipment needed for all examination General Principles to Keep in Mind while Performing a
> Gloves Physical Assessment
b) Equipment needed for vital signs > Wash hands
> Sphygmomanometer > Wear Gloves
> Stethoscope > Discard used pin and use new one
> Thermometer > Wear mask and protective eye goggles
> Watch w/ second hand Standard Precaution (by Center for Disease Control)
2. Preparation of Physical Setting > Hand Hygiene
 Comfortable, warm room temperature - Handwashing is indicated when hands are visibly
soiled
 Private and Quiet Area
- Antiseptic handrub when hands are not visibly
 Adequate Lighting
soiled
 Firm examination table or bed at a > Gloves
height that prevents stooping > Mask, Eye Protection, Face Shield
 Bedside table or tray (for needed > Gown
equipment > Patient Care Equipment
3. Preparation of Oneself > Environmental Control
• Assess your own feelings and anxieties > Linen
before examining the client > Occupational Health and Bloodborne
• Develop self-confidence Pathogens
• Preventing transmission of infectious agents > Patient Placement
• Theoretical knowledge
• Examination techniques and equipment
 Description: Provide needs of patients, begin with less  Slides or specimen container,
intrusive procedures, talk and explain to client calmly, and prepare bifid spatula, and cotton-tipped
client for position changes applicator
 Positioning the Client  For Anus, Rectum, and Prostate
 Sitting Position Examination
 Supine Position  Lubricating Jelly
 Dorsal Recumbent Position  Specimen Container
 Sim’s Position  For Peripheral Vascular Examination
 Standing Position  Stethoscope and
 Prone Position sphygmomanometer
 Knee-chest position  Flexible tape measure
 Lithotomy Position  Cotton ball and paper clip
 General Considerations for Examining Older  Tuning fork
Adults  Doppler ultrasound probe blood
 perform the examination in a
manner that minimizes position  For Musculoskeletal Examination
changes  Tape measure
 allow rest periods  Goniometer
 explain the procedure and  For Neurologic Examination
 integrate teaching in a clear and  Tuning fork
slow manner  Cotton, wisp, paper clip
 For Anthropometric Measurements  Soap, coffee
 Skinfold calipers  Salt, sugar, lemon, pickle juice
 Platform scale with height  tongue depressor
attachment  coin or key\
 Flexible tape measure  Reflex hammer
 For Skin, Hair, and Nail Examination 5. Performance of the Four
 Ruler with centimeter markings Assessment Techniques (IPPA)
 Magnifying glass a) Inspection
 Wood’s light  Guidelines in Practicing
 For Head and Neck Examination Inspection
 Small cup of water
 For Eye Examination o Room at comfortable
 Penlight temperature
 Ophthalmoscope o good lighting
 Newspaper or Rosenbaum pocket o look and observe before
screener touching
 Snellen charts o note color, patterns, size,
 Cover card location, consistency,
 For Ear Examination symmetry, movement,
 Stethoscope behavior, odors, or sounds.
 Marking pencil and centimeter o completely expose body
ruler
part to inspect
 Stethoscope
 Types of Inspection
 For Mouth, Nose, Throat, and Sinus
o Direct Inspection
Examination
o Indirect Inspection
 Penlight
 Piece of Small Gauze b) Palpation
 Otoscope with wide-tip  Using parts of hand to touch and feel for the
attachment following characteristics:
 Tongue depressor 1. Texture
 For Thoracic and Lung Examination 2. Temperature
 Stethoscope 3. Moisture
 Marking pencil and centimeter 4. Mobility
ruler 5. Consistency
 For Heart and Neck Vessel Examination 6. Strength of Pulses
 Stethoscope 7. Size
 Two cm rulers 8. Shape
 For Abdominal Examination 9. Degree of Tenderness
 Stethoscope  Uses 3 parts of the hand
 Marking pencil and tape measure 1. Finger pads/Tips
with cm markings 2. Ulnar or Palmar Surface
 2 small pillows
 For Female Genitalia Examination 3. Dorsal or Back Surface
 Vaginal speculum and lubricant
  In general, keep fingernails short and comfortable • Requires the use of a stethoscope to
temperature, follow standard precautions, and listen for heart sounds, movement of
proceed from light, moderate, and to deep blood through the cardiovascular
palpation system, movement of the bowel, and
movement of air through the
 Types of Palpation respiratory tract.
1. Light Palpation • Sounds detected are classified
2. Moderate Palpation according to the intensity (loud or
3. Deep Palpation soft), pitch (high/low), duration
4. Bimanual Palpation (length), and quality (musical,
crackling, raspy) of the sound.
c) Percussion
 Different Assessment Uses Guidelines to Practice techniques of
1. Eliciting Pain Auscultation
2. Determining
Location, Size, and 1. Eliminate distracting or competing
Shape noises
3. Determining Density 2. Expose the body part
4. Detecting Abnormal 3. Do not auscultate through client’s
Masses clothing or gown
5. Eliciting Reflexes 4. Diaphragm for high pitched sounds
 Types of Percussion and bell for low pitched sounds (do not
1. Direct Percussion apply too much pressure
(Immediate) 5. Warm diaphragm or bell
2. Indirect or Mediate Explain what you are listening
Percussion 6. Earpiece pointing forward
3. Fist or Blunt 7. Work on patient’s right side
Percussion 7. wet her
i. Direct Fist 8. Close eyes
Percussion 9. Selective listener
ii. Indirect Fist 10. Practice
Percussion
d) Auscultation

Module 4: Validating, Analyzing, and Documenting Data

I. Validating Gathered Data
 Purpose
Confirm or verify that the subjective and
objective data you have collected is reliable and
accurate.
◦ Failure to validate data may result in premature
closure of the assessment and or collection
of inaccurate data.
◦ can cause judgments to be made on unreliable
data which result in diagnostic errors during
the second part of the nursing process –
analysis of data (determining nursing diagnosis)
 Steps of Validation
1. Deciding whether the data
requires validation
2. Determining ways to
validate data
3. Identifying missing data
 Conditions that Require Data to be Validated
Discrepancies or gaps between the subjective and
objective data
Discrepancies or gaps between what the client
says at one time then at another time
Very abnormal / inconsistent findings
 Methods of Validation
1. Recheck data through a
repeat assessment
2. Asking additional questions
3. Verifying data with another healthcare
professional
4. Compare objective with subjective
findings
II. Documenting Gathered Data
 Purpose
1. Provide the HC team with a database that
becomes the foundation for care
2. Helps to identify health problems, formulate
nursing diagnosis and plan immediate and
ongoing interventions
3. Establishes a way to communicate with the
multidisciplinary team
 Information Requiring Documentation
1. Nursing History (subjective data)
2. Physical Assessment (objective data)
 Guidelines for Documentation
1. Document legibly or print neatly in non-
erasable ink
2. Use correct grammar and spelling
3. Avoid wordiness that creates redundancy
4. Use phrases instead of sentences to record
data
5. Record data findings, not how they were
obtained
6. Errors in documentation are usually corrected by
drawing one line
through the entry, writing “ERROR” and initialing the
entry
 7. Use only abbreviations that are acceptable and obtained during the physical examination
approved by the  Assessment Forms Used
institution. 1. Initial assessment form
8. Write bowel sounds present in all quadrants at 2. Frequent or ongoing assessment
36/minute. form
9. The clients lung sounds were clear both in the right 3. Focused or specialty area
and left lungs. assessment form
Instead, write “Bilateral lung sounds clear.” III. Analyzing data using Critical Thinking
10. Write entries objectively without making A. Steps
premature judgments or diagnoses 1. Identifying abnormal data and strengths
11. Record client’s understanding or perception of 2. Clustering data
the problem 3. Drawing inferences
12. Avoid recording the word “normal” for normal 4. Proposing possible nursing diagnoses
findings 5. Checking for defining characteristics
13. Record complete information and details 6. Confirming or ruling out diagnoses
14. Support objective data with specific observations 7. Documenting conclusions

Module 5: Assessing General Status and Vital Signs 1. Cancer/Malignant Pain

I. Assessing General Survey (Overall Impression) 2. Chronic/Non-Cancer Pain
A. General Appearance  Underlying Pathology
1. Body build, height, and weight in relation to client’s  Nociceptive Pain
2. Posture and Gait  Neuropathic Pain
3. Overall Hygiene and Grooming D. Seven Dimensions of Pain
4. Body and breath odor 1. Physical
5. Signs of distress in posture or facial expression 2. Sensory
6. Obvious signs of illness 3. Behavioral
B. Mental Status 4. Sociocultural
1. Attitude 5. Cognitive
2. Affect/mood; appropriateness of responses 6. Affective
3. Quantity and quality of speech 7. Spiritual
4. Relevance and organization of thoughts E. Pain Assessment
C. Vital Signs  Collecting Subjective Data: Health History
- common non-invasive physical assessment (“hands-  Health History
on”)  Current/Past Health Status (PQRST)
1. Temperature  Pain Description
2. Pulse  High Risk
3. Respirations  High Risk Pain Populations
4. Blood pressure  Pain in Special Populations
D. Health Assessment
 Reassessment and Ongoing Assessment of
E. Documenting the General Survey
Pain
II. Pain Assessment
1. OLDCART
A. Definition of Terms
2. COLDSPA
 Pain  Collection of Objective Data
 Pain Screen  Physical Examination
B. Pain Screen o Pain Scales for Adults
C. Classification of Pain
o Pain Scales for Children
 Acute or Chronic
o FLACC for Adults and Children
 Acute Pain
 Chronic Pain

NGCM 103 Lecture Outline

I. History of Nursing - St. Elizabeth of Hungary:
Overview: patroness of nursing
A. Intuitive Nursing - St. Catherine of Siena: first lady
 Prehistoric times - Christian era with a lamp
 based on instinct to care out of wish to help C. Dark Period of Nursing
 no proper/formal education  17th to 19th century
B. Apprentice Nursing  reformation from the civil war
 based on apprenticeship from experienced nurses  nursing was for least desirable women (image is
(informal education) tarnished)
 on the job training  nurses were overworked
 important personalities: D. Educated Nursing
- St. Clare: cared for the ill &  June 15, 1860: Florence Nightingale School of
afflicted Nursing opened St. Thomas Hospital in London
  Influenced by trends from wars 3. 1920
 arousal of societal consciousness due to increase 4. 1921
in educational opportunities for women 5. 1953
E. Contemporary Nursing VI. Nursing Education and Programs
 World war II – present Overview:
 advancement and development of technologies, A. Types of Educational Programs
tools, & equipment 1. Licensed Practical (Vocational) Nursing Programs
 presence of a few male nurses 2. Registered Nursing Programs
II. Historical Perspectives i. Diploma Programs
Overview: ii. Associate Degree Programs
A. Women’s Roles iii. Baccalaureate Degree Programs
B. Religion 3. Graduate Nursing Programs
C. War i. Master’s Degree Programs
1. Crimean War (1854 – 1856) ii. Doctoral Programs
2. American Civil War (1861 – 1865) 4. Continuing Education
3. World War I VII. Contemporary Nursing Practice
4. World War II A. Definition of Nursing
5. Vietnam War B. Recipients of Nursing
D. Societal Attitudes C. Scope of Nursing
 Before mid-1800s D. Settings for Nursing
 In 1896 E. Nurse Practice Acts
 Later part in the 19th century F. Standards of Nursing Practice
 Early part of 19th century VIII. Roles and Functions of Nurse
 World War II Overview:
 Late 1900s A. Caregiver
 Early 1990s B. Communicator
 2002 C. Teacher
E. Nursing Leaders D. Client Advocate
F. Men in Nursing E. Counselor
III. Early Hospitals in the Philippines during the Spanish Regime F. Change Agent
A. Hospital Real de Manila (1577) G. Leader
B. San Lazaro Hospital (1578) H. Manager
C. Hospital de Indios (1586) I. Case Manager
D. Hospital de Aguas Santas (1590) J. Research Consumer
E. Philippine General Hospital (1596) K. Expanded Career Roles
IV. Prominent Personages Involved during the Philippine 1. Nurse Practitioner
Revolution 2. Clinical Nurse Specialist
A. Josephine Bracken 3. Nurse Anesthetist
B. Rose Sevilla de Alvaro 4. Nurse Midwife
C. Hilaria de Aguinaldo 5. Nurse Researcher
D. Melchora Aquino (Tandang Sora) 6. Nurse Administrator
E. Captain Salomen 7. Nurse Educator
F. Agueda Kahabagan 8. Nurse Entrepreneur
G. Trinidad Tecson (Ina ng Biyak na Bato) 9. Forensic Nurse
V. School and College of Nursing IX. Criteria of a Profession
A. School of Nursing A. Specialized Education
1. St. Paul’s Hospital School of Nursing, Intramuros B. Body of Knowledge
Manila (1900) C. Service Orientation
2. Iloilo Mission Hospital Training School (1906) D. Ongoing Research
3. St. Luke’s Hospital Training School of Nursing E. Code of Ethics
(1907) F. Autonomy
4. Mary Johnston Hospital School of Nursing (1907) G. Professional Organization
5. Philippine General Hospital School of Nursing X. Socialization to Nursing
(1910) XI. Factors Influencing Contemporary Nursing Practice
B. College of Nursing XI. Nursing Organizations
1. UST College of Nursing (1877) 1. American Nurses Association (ANA)
2. MCU College of Nursing (1947) 2. National League for Nursing (NLN)
3. UP College of Nursing (1948) 3. International Council of Nurses (ICN)
4. FEU Institute of Nursing (1955) 4. National Student Nurses Association (NSNA)
5. UE College of Nursing (1958) 5. Sigma Theta Tau International (STTI) Honor Society of
C. Important Timeline Nursing
1. 1909 6. Philippine Nurses Association (PNA)
2. 1919 XII. Different Fields of Nursing
NGCM 103 Lab Outline
1. Explain the purpose and goals and obtain consent
2. Position for support stability and access segment to exercise; drape as necessary
3. Grasp part to be exercised (complete & unrestricted ROM)
4. Perform ROM based on patient needs and goals (predetermined)
5. Do aftercare of patient

1. Ensure client understands reason for ROM exercise

2. Remove rings 9prevent hand swelling)
3. Clothe client in loose gown and cover body with blanket
4. Use correct body mechanics (apply to client-nurse)
5. Bed at an appropriate height
6. Expose only part being exercised
7. Support limbs above and below joint
8. Firm grip (for handling limb)
9. Avoid forcing body part beyond limitation
10. stop temporarily (if muscle spasms occur), and continue slowly to allow relaxation
11. Contracture: Apply slow firm pressure
12. Rigidity: Apply pressure against rigidity
13. Teach client’s caregiver about ROM exercise if appropriate
14. Avoid hypertension of joints in older adults (if arthritic)
15. Use exercise to assess skin condition

HEALTH ASSESSMENT INTRODUCTION TO HEALTH ANALYZING DATA

ASSESSMENT: COLLECTING AND
MODULE 1
INTRODUCTION
•The role of the nurse in assessment and
diagnosis is more prevalent today than
ever before in the history of nursing.
•Assessment is the first and most critical
phase of the nursing process.
•If data collection is inadequate or
inaccurate, incorrect nursing judgments
may be made that adversely affect the
remaining phases of the process.
•The nursing process should be thought
of as circular, not linear.
LEARNING OUTCOMES:
At the end of the module, students
should be able to:
1. Explain how assessment skills are
needed for every situation the nurse
encounters.
2. Describe hoe assessment fits into the
total nursing process.
3. Describe the steps of the nursing
process.
4. Describe the steps of the analysis
phase of the nursing process.
5. Compare and contrast the types of
nursing assessment.
Overview of Nursing Assessment
A Review of the Nursing Process
NURSING PROCESS
NURSING
• The diagnosis and treatment of
HUMAN RESPONSES to actual or
potential health problems (American
Nurses Association, 1980)
PROCESS
• Series of planned actions or operations
directed toward a particular result or
goal
• is a systematic, organized method of
planning, and providing quality and
individualized nursing care.
• it is synonymous with the PROBLEM
SOLVING APPROACH that directs the
nurse and the client to determine the
need for nursing care, to plan and
implement the care and evaluate the
result.
• It is a G O S H approach (goal
oriented, organized, systematic and
humanistic care) for efficient and
effective provision of nursing care.
Other Characteristics:
• Client-centered
• Open and flexible nature
• Involves skill in Decision-making
• Uses Critical Thinking skills
• Cyclic and Dynamic in
• Permits creativity
• Interpersonal and collaborative
• Emphasis feedback
• Universally applicable
PURPOSE OF NURSING PROCESS:
1. To identify a client’s health status; his
actual/present and potential/possible
health problems or needs.
2. To establish a plan of care to meet
identified needs.
3. To provide nursing interventions to
meet those needs.
4. To provide an individualized, holistic,
effective and efficient nursing care.
COMPONENTS OF THE NURSING
PROCESS
1. ASSESSMENT
2. DIAGNOSIS
3. PLANNING
4. IMPLEMENTATION
5. EVALUATION
ASSESSMENT
Description:
• collecting, organizing, validating, and
communicating/recording client data
Purpose:
• to establish a database about the
client’s response to health concerns or
illness and the ability to manage health
care needs.
Activities:
• Establish a database
 Obtain health history
 Conduct physical assessment
 Review client records
 Review literature
 Consult support persons
 Consult health professionals
Activities:
• Update data as needed
• Organize data
• Validate data
• Communicate/document data
DIAGNOSIS
Description:
• Analyzing and synthesizing data
Purpose:
• To identify client’s strengths and
health problems that can be prevented or
resolved by collaborative and
independent nursing interventions
• To develop a list of nursing diagnoses
and collaborative problems
CATEGORIES OF
NURSING DIAGNOSIS
3 Categories of Nursing Diagnosis:
1. Wellness diagnosis (opportunity to
enhance health status)
Ex. Readiness for enhanced
breastfeeding
2. Risk diagnosis (focus is on reducing
the risk) – potential diagnosis (possible)
Ex. Risk for ineffective breastfeeding
3. Actual diagnosis – presence of
current/ existing client problem.
Ex. Ineffective breast feeding related to
poor mother-infant attachment.
Activities:
• Interpret and analyze data
 Compare data against standards
 Cluster or group data
 Identify gaps and inconsistencies
• Determine client’s strengths, risks, and
problems
• Formulate nursing diagnoses and
collaborative problem statements
PLANNING
Description:
• Determining how to prevent, reduce or
resolve the identified client problems;
how to support client strengths; and how
to implement nursing interventions in an
organized, individualized, and outcome/
goal-directed manner
Purpose:
• To develop an individualized care plan
that specifies client goals/expected
outcomes and related nursing
interventions
Activities:
• Set priorities and goals/outcomes in
collaboration with client
• Write goals/outcome criteria
• Select nursing strategies/interventions
• Consult other health professionals
• Write nursing orders and nursing care
plan
• Communicate care plan to relevant
health care providers
IMPLEMENTATION
Description:
• Carrying out the planned nursing
interventions
Purpose:
• To assist the client to meet desired
goals/outcomes; promote health and
wellness; prevent illness and disease;
and facilitate coping with health
problems
Activities:
• Reassess the client to update database
• Determine need for nursing assistance
• Perform or delegate planned nursing
interventions
• Communicate nursing actions
implemented
 Document care and client responses to
care
 Give verbal reports as necessary
EVALUATION
Description:
• Measuring the degree to which
goals/outcomes have been achieved and
identifying factors that positively or
negatively influence goal achievement
Purpose:
• To determine the extent to which client
goals/outcomes have been achieved and
to determine whether to continue,
modify, or terminate the plan of care
Activities:
• Collaborate with client and collect data
related to expected outcomes
• Judge whether goals/outcomes have
been achieved
• Relate nursing actions to client
outcomes
• Make decisions about problem status
• Review and modify the care plan as
indicated or terminate nursing care
ROLE OF THE NURSE IN HEALTH
ASSESSMENT
1. Collects data
2. Analyze data
DEFINITION OF HEALTH
ASSESSMENT
Definition:
• A comprehensive health assessment
encompasses the physical,
psychological, social, and spiritual
dimensions of human living.
DIMENSIONS:
• Physical – breathing, eating, and
walking
• Psychological – intellect, self-concept,
emotions, and behavior
• Social – relationships and interactions
among family, friends and colleagues
• Spiritual – belief in a higher being,
personal interpretations of the meaning
of life, and attitudes towards moral
decisions and personal conduct
PURPOSE OF HEALTH
ASSESSMENT
Purpose:
 To establish a database for the
client’s normal abilities, risk factors that
can contribute to dysfunction or health
problems
 An accurate assessment provides an
essential foundation for the care of the
client
FRAMEWORKS FOR HEALTH
ASSESSMENT IN NURSING
1. Functional health framework
2. Head-to-toe framework
3. Body systems framework
Each framework helps nurses to
organize information they collect and to
ensure that they do not miss important
assessment data.
1. FUNCTIONAL HEALTH
FRAMEWORK
• Evaluates the effects of the mind, body
and environment in relation to a person’s
ability to perform the tasks of daily
living; this health assessment framework
organizes data collection in terms of the
Gordon’s 11 Functional Health Patterns:
• developed by Marjory Gordon.
• a method used by nurses in the nursing
process to provide a comprehensive
nursing assessment of the patient.
• Gordon's functional health pattern
includes 11 categories which is a
systematic and standardized approach to
data collection.
GORDON’S 11 FUNCTIONAL
HEALTH PATTERNS:
1. Health perception and health
management
2. Activity and exercise
3. Nutrition and metabolism
4. Elimination
5. Sleep and rest
6. Cognition and perception
7. Self-perception and self-concept
8. Roles and relationships
9. Coping and stress tolerance
10. Sexuality and reproduction
11. Values and beliefs
2. HEAD-TO-TOE FRAMEWORK
• This system of collecting data starts
from the head and proceeds
systematically to the toes
• General: general health state, vital
signs and weight, nutritional status
• Head: hair, scalp, eyes, ears, oral
cavity, cranial nerves
• Neck
• Chest
• Abdomen
• Extremities
• Genitals
• Rectum
3. BODY SYSTEMS FRAMEWORK
• This may be used during focused
assessment especially among acutely or
critically ill clients
• Respiratory
• Cardiovascular
• Musculoskeletal
• Gastrointestinal
• Integumentary
• Endocrine
• Genitourinary
• Reproductive
• Neurologic
• Sensory
• Psychosocial
TYPES OF ASSESSMENT
Four basic types are:
1.Initial comprehensive assessment
2.Ongoing or partial assessment
3.Focused or problem-oriented
assessment
4.Emergency assessment
1. INITIAL COMPREHENSIVE
ASSESSMENT
• Involves collection of subjective data
about the client’s perception of his/her
health of all body parts or systems, past
health history, family history, and
lifestyle and health practices (which
includes information related to the
client’s over-all function) as well as
objective data gathered during a step-by-
step physical examination
• Total assessment needed when the
client first enters a health care system
2. ONGOING OR PARTIAL
ASSESSMENT
• Consists of data collection that occurs
after the comprehensive database is
established
• Involves mini-overview of the client’s
body systems and holistic health patterns
as a follow-up on his health status
• On-going process integrated with
nursing care
3. FOCUSED OR PROBLEM-
ORIENTED ASSESSMENT
• Consists of a thorough assessment of a
particular client problem and does not
cover areas not related to the problem
4. EMERGENCY ASSESSMENT
• Is a very rapid assessment performed in
life-threatening situations (choking,
cardiac arrest, drowning)
• An immediate diagnosis is needed to
provide prompt treatment
STEPS OF HEALTH ASSESSMENT
1. Collection of subjective data
2. Collection of objective data
3. Validation of data
4. Documentation of data
1. COLLECTION OF SUBJECTIVE
DATA
• Sensations or symptoms, feelings,
perceptions, desires, preferences, beliefs,
ideas, values and personal information
that can be elicited and verified only by
the client
Major areas:
• Biographical information
• Physical symptoms r/t each body part
or system
• Past health history
• Family history
• Health and lifestyle practices
2. COLLECTION OF OBJECTIVE
DATA
Directly observed by the examiner:
• Physical characteristics
• Body functions
• Appearance
• Behavior
• Measurements
• Results of laboratory testing
3. VALIDATING ASSESSMENT
DATA
HEALTH ASSESSMENT
COLLECTING SUBJECTIVE DATA:
THE INTERVIEW AND HEALTH
HISTORY
MODULE 2
OVERVIEW/INTRODUCTION:
• Nurses need to review information
about the health history interview
techniques related to obtaining
subjective data during the nursing
assessment. Subjective data may be
sensed or reported by the client or
significant other people, such as family
or friends or health care personnel.
Subjective data often are not observable
or measurable.
• The collection of a health history
from a patient - that is, subjective data
which focuses on the patient's symptoms
- is the first step in health observation
and assessment, and is a fundamental
skill for nurses working in all clinical
areas.
• This module introduces the knowledge
and skills required by nurses to collect a
comprehensive health history from a
patient. It begins with an explanation of
the place of health history in the health
observation and assessment process, a
description of the different types of
health histories and their uses, and a
detailed overview of the components of
a comprehensive health history.
• This module goes on to explain the
importance of therapeutic
communication and rapport in the health
history interview, and the use of
• Process of confirming or verifying that
the subjective and objective data you
have collected are reliable and accurate
• Steps:
1.Deciding whether the data requires
validation
2.Determining ways to validate data
3.Identifying missing data
Methods of Validation:
• Recheck your own data through a
repeat assessment
• Clarifying data with the client by
asking additional questions
• Verifying data with another healthcare
professional
• Compare objective with subjective
findings
questioning, interpersonal skills and
other communication techniques to
facilitate data collection. Finally, this
module considers a variety of barriers
and challenges to effective
communication in the health history
interview, and how nurses can respond
effectively to these.
LEARNING OUTCOMES:
At the end of the module, students
should be able to:
1. Explain the place of the health history
in the health observation and assessment
process.
2. Discuss the different types of health
histories, and their uses in different
clinical contexts.
3. Identify the components of a
comprehensive health history.
4. Demonstrate the use of therapeutic
communication and rapport in the health
history interview.
5. Describe the importance of effective
questioning, and the use of a variety of
interpersonal skills and communication
techniques, in the health history
interview.
ASSESSMENT METHODS
1. Observing
2. Interviewing
3. Examining
OBSERVING
• Gathering data using the five senses:
1. Vision
2. Smell
3. Hearing
4. DOCUMENTATION OF DATA
• Establishes a way to communicate with
the multidisciplinary team members the
database that becomes the foundation of
care
PREPARING FOR THE
ASSESSMENT
• will be discussed on the following
modules.
ANALYSIS OF
ASSESSMENT DATA
1. Nursing Diagnosis – the step 2 of the
nursing process
2. Process of Data Analysis (will be
discussed on the following modules)
4. Touch
5. Taste
• Noticing the stimuli and selecting,
organizing, and interpreting data
INTERVIEWING
• A planned communication or a
conversation with a purpose (to give
information, to identify problems of
mutual concern, evaluate change,
teach, provide support, or provide
counseling or therapy)
EXAMINING
• The physical examination is a
systematic data-collection method that
uses observational skills to detect health
problems
• Techniques used:
 Inspection
 Auscultation
 Palpation
 Percussion
INTERVIEWING
Two Approaches to Interviewing:
1. DIRECTIVE
• highly structured and elicits
specific information
2. NON-DIRECTIVE
• rapport-building; the nurse allows
the client to control the purpose, subject
matter and pacing
Kinds of Interview Questions:
1. CLOSED-ENDED QUESTIONS
• directive, strictive and requires
short answers giving specific
information
2. OPEN-ENDED QUESTIONS
• nondirective, lead/invite clients to
discover and explore their thoughts and
feelings
PATIENT INTERVIEW:
1. Select a quiet and private setting
(consider time, seating arrangement,
distance)
2. Choose terms carefully and avoid
using medical jargon
3. Use appropriate body language
4. Confirm patient statements to avoid
misunderstanding.
• Age of parents (living? Deceased
COMPLETE HEALTH HISTORY date?)
1. Biographical Data • Parent illnesses
2. Reason for seeking health care (Chief • Grandparent’s illnesses
Complaints) • Aunt’s and uncle’s age and illnesses?
3. History of Present Illness • Children’s age and illnesses or
4. History of Past Illness (Medical/ handicaps
Surgical) • May be illustrated with a genogram
5. Family History (Genogram)
6. Review of body systems for current
health problems
7. Lifestyle/Health Practices Profile
8. Developmental Level (Erik
Erickson’s Dev’t Stage)
Others:
• Obstetrical History
• Environmental History

3 Basic Phases: BIOGRAPHICAL DATA

1. The Introductory Phase 1. Name
– Establish rapport/ Courtesy 2. Address
– Greeting/Introducing 3. Phone
– Orientation 4. Gender
2. The Working Phase 5. Provider of history
– Ongoing 6. Birth date
3. The Closing Phase 7. Place of birth
Others:
Communication During an Interview: • Race or ethnic background
• Listen attentively, using all your • Educational level
senses, and speak slowly and clearly • Occupation
• Use language the client understands, • Significant Others or Support Persons
and clarify points that are not
understood, for instance, by asking the REASONS FOR SEEKING HEALTH
person to describe what a word means to CARE
the person • Reason(s) for seeking health care (chief
• Plan questions to follow a logical complaints)
sequence • Feelings about seeking health care
• Ask only one question at a time.
Double questions limit the client to one HISTORY OF PRESENT ILLNESS
choice and may confuse both the nurse (COLDSPA)
and the client • Character (How does it feel, look,
• Allow the client the opportunity to smell, sound, etc.?
look at things the way they appear to • Onset (When did it begin; is it better,
him or her and not the way they appear worse, or the same since it began?)
to nurse or someone else • Location (Where is it? Does it radiate?)
• Do not impose your own values on the • Duration (How long it lasts? Does it
client recur?)
• Avoid using personal examples, such • Severity (How bad is it on a scale of 1-
as saying, “If I were you…” 10)
• Nonverbally convey respect, concern, • Pattern (What makes it better? What
interest, and acceptance makes it worse?)
• Use and accept silence to help the • Associated Factors (aggravating,
client search for more thoughts or to relieving factors)
organize them
• Use eye contact and be calm, HISTORY OF PAST ILLNESS
unhurried, and sympathetic • Problems at birth
• Childhood illnesses
Special Considerations during Interview • Immunization to date
• Gerontologic variations in • Adult illnesses (physical, emotional,
communications mental)
• Cultural variations in communication • Surgeries
• Emotional variations in • Accidents
communications • Prolonged pain or pain patterns
• Allergies
COLLECTING SUBJECTIVE DATA FAMILY HEALTH HISTORY

HEALTH ASSESSMENT
VALIDATING, ANALYZING AND
DOCUMENTING DATA
MODULE 4
OVERVIEW/INTRODUCTION:
After the nurse collect assessment data:
 What do you do with them?
 How do you know that they are
reliable information?
Validation of data is the process of
confirming or verifying that the
subjective and objective data you have
collected is reliable and accurate.
 How does this data become part of the
client’s record?
Health care agencies have individual
policies and procedures for
documentation of client data.
Electronic Health Records may be
used by a variety of health care providers
to focus on the total health of the client
to share data with other health care
providers to promote collaboration of all
those involved in the client’s care.
The primary reason for documentation
of assessment data is to promote
effective communication among
multidisciplinary health team members
to facilitate safe and efficient client care.
Sorting through subjective and
objective assessment data may seem to
be an overwhelming task.
This analysis of data is the second step
of the nursing process – diagnostic
phase/ diagnosis phase. This phase
requires the nurse:
 to use critical thinking skills
 to differentiate normal findings from
abnormal findings
 to draw inferences
 to make nursing diagnoses, and
 to confirm or rule out conclusions.
The end result of the phase is the
identification of a nursing diagnosis
(actual, risk, or health promotion),
collaborative problem, or the need for
referral to another health care
professional.
LEARNING OUTCOMES:
At the end of the module, students
should be able to:
1. Explain the definition of data
validation and the steps of the validation
process.
2. Describe conditions or situations that
require data to be rechecked and
validated, and several ways to validate.
3. Recognize the purposes of
documenting assessment data and its
general guidelines and rules.
4. Demonstrate the seven distinct steps
to perform data analysis.
5. Apply the assessment data of
different situations and analyze the data
to formulate nursing diagnosis.
VALIDATING AND DOCUMENTING
DATA
VALIDATING GATHERED DATA
PURPOSE:
1. Confirm or verify that the subjective
and objective data you have collected is
reliable and accurate.
◦ Failure to validate data may result in
premature closure of the assessment and
or collection of inaccurate data.
◦ can cause judgments to be made on
unreliable data which result in diagnostic
errors during the second part of the
nursing process – analysis of data
(determining nursing diagnosis)
STEPS OF VALIDATION:
1. Deciding whether the data requires
validation
2. Determining ways to validate data
3. Identifying missing data
CONDITIONS THAT REQUIRE
DATA TO BE VALIDATED:
Discrepancies or gaps between the
subjective and objective data. (ex. A
male client tells you that he is very
happy despite learning that he has
terminal cancer.)
Discrepancies or gaps between what
the client says at one time then at
another time
Very abnormal / inconsistent findings
METHODS OF VALIDATION
1. Recheck your own data through a
repeat assessment
2. Clarifying data with the client by
asking additional questions
3. Verifying data with another healthcare
professional
4. Compare objective with subjective
findings
DOCUMENTING GATHERED DATA
PURPOSE
1. Provide the HC team with a database
that becomes the foundation for care
2. Helps to identify health problems,
formulate nursing diagnosis and plan
immediate and ongoing interventions
3. Establishes a way to communicate
with the multidisciplinary team
INFORMATION REQUIRING
DOCUMENTATION
1. Nursing History (subjective data)
2. Physical Assessment (objective data)
GUIDELINES FOR
DOCUMENTATION
1. Document legibly or print neatly in
non-erasable ink
2. Use correct grammar and spelling
3. Avoid wordiness that creates
redundancy
4. Use phrases instead of sentences to
record data
5. Record data findings, not how they
were obtained
6. Errors in documentation are usually
corrected by drawing one line through
the entry, writing “ERROR” and
initialing the entry. Never obliterate the
error with white paint, or tape, eraser or
a marking pen.
7. Use only abbreviations that are
acceptable and approved by the
institution.
8. Write bowel sounds present in all
quadrants at 36/minute.
9. The clients lung sounds were clear
both in the right and left lungs. Instead,
write “Bilateral lung sounds clear.”
10. Record data findings, not how they
were obtained (Ex. Client was
interviewed for past history of high
blood pressure and blood pressure was
taken. Instead, write “Has history of
hypertension treated with medication.
BP=140/86 Right arm, BP=136/86 left
arm.
11. Write entries objectively without
making premature judgments or
diagnoses
12. Record client’s understanding or
perception of the problem
13. Avoid recording the word “normal”
for normal findings
14. Record complete information and
details
15. Support objective data with specific
observations obtained during the
physical examination
ASSESSMENT FORMS USED
1. Initial assessment form
2. Frequent or ongoing assessment form
3. Focused or specialty area assessment
form
ANALYZING DATA USING
CRITICAL THINKING

STEPS:
1. Identifying abnormal data and
strengths
2. Clustering data
3. Drawing inferences
4. Proposing possible nursing diagnoses
5. Checking for defining characteristics
6. Confirming or ruling out diagnoses
7. Documenting conclusions
CLIENT CASE
Mary Guzman, a 29-year-old separated
woman, works as an office manager for
a large, prestigious law firm. She reports
she recently went to see a doctor because
“my hair was falling out in chunks, and I
have a red rash on my face and chest. It
looks like a bad case of acne.” After
doing some blood work, her physician
diagnosed her condition as discoid lupus
erythematosus (DLE). She says she has
come to see you, the occupational health
nurse because she feels “so ugly,” and
she is concerned that she may lose her
job because of how she looks. During
the interview, she tells you that she is a
surfer and is out in the sun all day nearly
every weekend. She shares that she uses
sunscreen but forgets to put it on at
regular intervals during the day. Your
physical examination reveals an
attractive, tanned, thin, anxious-
appearing young woman. You note
confluent and non-confluent
maculopapular lesions on her neck, chest
above the nipple line, and over the
shoulders and upper back to about the
level of the T5 vertebra. Many of the
lesions appear as red, scaling plaques
with depressed, pale centers. A few of
the lesions of the lesions on her forehead
and cheeks appear blistered. Patchy
alopecia is also present. Her vital
signs are within normal limits, and no
other abnormalities are apparent at this
time.
Step1: Identify abnormal data and
strengths
Subjective:
“Hair falling out in chunks”
Red rash on face and chest, “looks like a
bad case of acne”
“So ugly”
Concerned that she may lose her job
because of how she looks
Surfer – out in the sun all day on
weekends – minimal use of sunscreen
Sought out occupational health nurse
Objective:
Anxious appearance diagnosed with
discoid lupus erythematosus
Red, raised plaques on face, neck and
shoulders, back and chest
Patchy alopecia etiology/causeRisk for infection r/t
presence of dirty wound/ burn
Step 2: Clustering data wounds/presence of chest tube
One identified cluster would be:
Maculopapular Rash on face, neck, Step 7: Document conclusions
chest
and back Actual Diagnosis:
Patchy alopecia NANDA label (for problem) + r/t +
Flaky, scaly, dry skin etiology + AMB + defining
characteristics
Step 3: Draw inference Fatigue r/t an increase in job demands
“Changes in physical appearance are and personal stress AMB client’s
affecting self-perception.” statements of feeling exhausted all of the
“Skin condition maybe related to work time and inability to perform usual work
or lifestyle” and home responsibilities
Step 4: Propose Possible Nursing
Diagnosis
Body image disturbance related to
changes in physical appearance as
manifested by or evidenced by …………
Impaired skin integrity related to
interruption of tissues
Example:
Ineffective airway clearance related to
excessive secretions/ retained secretions/
foreign body obstruction
F-Focus Problem/Nursing Diagnosis -
Altered airway clearance related to
excessive secretions
D - apple noted at _________
- coin noted at ………..
Step 5: Check for defining
characteristics
Refer to NANDA Nursing Diagnoses/
Nursing
Pocket Guide: definitions and
classifications
“verbalize negative response to actual
change in structure”
Negative feelings
Step 6: Confirm or rule out diagnoses
You may accept the diagnosis because it
meets defining characteristics and is
validated by the client
Step 7: Document conclusions
Use appropriate format
Wellness Diagnosis:
Readiness for enhanced + diagnostic
label + related to + etiology/cause/reason
+ as manifested by (AMB) + symptoms
(defining characteristics)
Readiness for enhanced parenting r/t
effective bonding with children and
effective basic parenting skills AMB
parent’s verbalized concern to continue
effective parenting skills during child’s
illness
Risk/ Potential Diagnosis:
Risk for + diagnostic label + r/t +

ASSESSING MENTAL STATUS
AND PSYCHOSOCIAL
DEVELOPMENTAL LEVEL
MODULE 6
OVERVIEW:
 Nurses assess a client’s
psychosocial and mental status in a
variety of contexts. Clients may be
screened at intake to a service and at
annual staffing, often to determine
eligibility for professional services or
supportive interventions. In this type of
referral, the important question is
whether or not there is a clinically
significant problem that requires
attention.
 This can also take place during
ongoing evaluation of response to
various interventions such as
psychotropic medications, behavioral
interventions, and other forms of
therapy. In this context the key question
is whether or not there has been a change
in functioning in response to
interventions.
 Assessment of psychosocial and
mental status may also take place in
response to a referral following a decline
in functioning. On these occasions
relevant questions often relate to
determination of the causes in the
change in functioning, requests for
modifications and refinements to
existing treatment plans, and
development of new interventions or
movement to new service settings, such
as a residence.
 Effective patient care requires
consideration of the psychological as
well as physiologic aspects of health. A
patient who seeks medical help for chest
pain, for example, may also need to be
assessed for anxiety and depression.
 Knowing the brain’s basic function
and structures will help you perform a
comprehensive mental health assessment
and recognize abnormalities.
LEARNING OUTCOMES:
At the end of the module, students
should be able to:
1. Explain the concept of mental health
and status, and psychosocial
development.
2. Recognize the methods for
establishing a therapeutic relationship
with a patient.
3. Demonstrate the different
techniques for assessing mental status
and psychosocial development.
4. Describe the major theories of
development.
5. Differentiate between normal and
abnormal findings of mental and
psychosocial development.
MENTAL STATUS ASSESSMENT
OBTAINING A HEALTH HISTORY
 Establish a therapeutic relationship
with the patient that is built on trust.
 Thoughts and behaviors are
important.
 Effective communication involves:
1. Speech/ verbal
2. Non-verbal – eye contact, posture,
facial expressions, gestures, clothing,
affect, silence
GENERAL PRINCIPLES
 Choose a quiet, private setting.
 Interruptions and distractions
threaten confidentiality and interfere
with effective listening.
 Introduce and explain the purpose.
 Position in a comfortable distance
and give undivided attention.
 If with cognitive/ memory losses,
reorient before beginning the interview.
 Be professional but friendly, eye
contact.
 Calm, non-threatening tone of
voice, avoid judgements.
 Don’t rush the interview, trusting
therapeutic relationship takes time.
THERAPEUTIC
COMMUNICATION TECHNIQUES
Therapeutic Communication
 Is the foundation of any good
nurse-patient relationship. Some
effective techniques for developing
relationship:
1. Offering self
2. Listening
3. Rephrasing
4. Broad openings and general
statements
5. Exploring
6. Clarifying
7. Accepting
8. Focusing
9. Silence
10. Suggesting collaboration
11. Summarizing
12. Validating perceptions
1. Offering Self
 Offer emotional support. Ex. “I’ll
sit with you until your family arrives.”
2. Listening
 Enables the nurse to hear and
analyze everything the patient is saying,
alerting the nurse to the patient’s
communication patterns.
3. Rephrasing
 Helps ensure that the nurse
understands and emphasizes important
points in patient’s message.
Ex. “You’re feeling angry and you say
it’s because of the way you friend treated
you yesterday.”
4. Broad Openings and General
Statements
 Initiate conversation and
encourages to talk about any subject.
These openings allow the patient to
focus the conversation and demonstrate
the nurse’s willingness to interact.
Ex. “Is there something you would like
to talk about?”
5. Exploring
 Helps the patient feel free to talk
and examine issues in depth.
Ex. “Tell me what happened.”
6. Accepting
 Let the patient know the nurse
understands his thought and feelings.
Ex. “I can imagine how you feel.”
7. Clarifying
 Asking the patient to clarify a
confusing and vague message
 Nurse’s desire to understand. Also
elicit precise information.
Ex. “What you said is…..”
8. Focusing
 Nurse helps the patient redirect
attention toward something specific. It
fosters patient’s self-control and avoid
vague generalizations so patient can
accept responsibility for facing problems
Ex. “Let’s go back to what we were just
talking about.”
9. Silence
 It gives patient time to talk, think,
and gain insight into problems. Allows
the nurse to gather information. Nurse
must be careful to avoid the impression
of judgement or disinterest.
10. Suggesting Collaboration
 Gives the patient the opportunity to
explore the pros and cons of a suggested
approach. Needs to be careful to avoid
directing the patient.
Ex. “Perhaps we can meet with your
parents to discuss the matter”.
11. Summarizing
 Nurse systematically synthesizes
important ideas discussed. Ex. “So far,
we have discussed……”
12. Validating Perceptions
 Gives the patient a chance to
correct the nurse’s understanding of
what’s being communicated.
Ex. “Tell me if my perception of what
you’re telling me agrees with yours.”
 Communication styles vary among
different cultures.
 Qualities viewed as desirable in our
culture (such as eye contact, having a
certain degree of openness, offering
insight, portraying emotional expression)
may not be considered appropriate in
another culture.
TRANSCULTURAL
COMMUNICATION
Examples:
 Direct eye contact – inappropriate
and disrespectful > some Asian, Black,
Native American, Appalachian in North
America
 Focus solely in the present, view
future as something to be accepted as it
occurs rather than planned > some
Middle Eastern
 Strongly value harmonious
interpersonal relationships. They may
nod, smile, and provide answers they
feel are expected to maintain harmony
rather than their true feelings and
concerns > some Asians
 Direct questions as impolite >
some of Pacific Islands, Native
American, African groups
Assess cultural variations and
differences – RESPECT…
PATIENT INTERVIEW
 Establish a baseline and provides
clues to the underlying or precipitating
cause of the patient’s current problem.
 Not reliable source of information >
mental illness or other mental
impairment.
 Verify his responses with family
members, friends, or caregiver.
 Check hospital records for previous
admissions. Compare past and present
behavior, symptoms and circumstances.
GENERAL CONSIDERATIONS
Chief Complaints
 May not directly voice his chief
complaints
 Note if having difficulty coping
 Exhibiting unusual behaviors
 Determine whether the patient is
aware of the problem.
 When documenting the patient’s
response, write it word for word and
enclose it in quotation marks.
 Inquire about severity and
persistence of symptoms, occurred
suddenly or developed overtime.
GENERAL CONSIDERATIONS
History of Psychiatric Illnesses
 Past psychiatric disturbances:
 Delusions
 Violence
 Attempted suicides
 Drug or alcohol abuse
 Depression
 Previous psychiatric treatments
 Family history of psychiatric
illnesses or substance abuse.
GENERAL CONSIDERATIONS
Demographic Data
 Age, ethnic origin, primary
language, birthplace, religion,
occupation, marital status > use to
establish a baseline and confirm that the
patient’s record is correct.
Socioeconomic Data
 Suffering hardships > more likely
to show symptoms of distress
 Educational level, family, housing
conditions, income, employment status >
provide clues to current problem
GENERAL CONSIDERATIONS
Cultural and Religious Beliefs
 Affects how he responds to illness
and adapts to care. Certain questions and
behaviors considered acceptable in one
culture may be inappropriate in another.
Medication History
 Certain medications can cause
symptoms of mental illness. Review all
medications taken.
 If taking psychiatric drugs, ask if
symptoms have improved, taking it as
prescribed and if had any adverse
reactions.
 If taking illegal drugs – ask what
and how often.
GENERAL CONSIDERATIONS
Physical Illness
 History of medical disorders that
may cause distorted thought process,
disorientation, depression, or other
symptoms of mental illness.
 Renal failure
 Hepatic failure
 Infection
 Thyroid disease
 Neurodegenerative disease
GUIDELINES FOR AN EFFECTIVE
MENTAL HEALTH INTERVIEW
 Begin with broad, empathetic
statement: “You look distressed, tell me
what’s bothering you.”
 Explore normal behaviors before
abnormal ones. “What do you think has
enabled you to cope with the pressures
of your job?”
 Phrase inquiries sensitively to
lessen the patient’s anxiety. “Things
were going well at home and you
became depressed. Tell me about that.”
 Ask the patient to clarify vague
statements. “Explain to me what you
mean when you say, they’re all after
me.”
 Help the patient who rambles to
focus on his most pressing problem.
“You’ve talked about several problems.
Which one bothers you the most?”
 Interrupt nonstop talkers as tactfully
as possible. “Thank you for your
comments. Now let’s move on.”
 Express empathy toward tearful,
silent, or confused patients who have
trouble describing their problem. “I
realize that it’s difficult for you to talk
about this.”
 Assess the following:
 Appearance
 Behavior
 Mood
 Thought processes
 Cognitive function
 Coping mechanisms
ASSESSING MENTAL STATUS
 Mental status assessment can be
done during an interview.
 Potential for self-destructive
behavior
APPEARANCE
 Indicates emotional and mental
status
 Note dress and grooming
 Appearance is clean and
appropriate for age, gender and situation
 Posture is erect or slouched
 Head lowered
 Gait – brisk, slow, shuffling,
unsteady, normal
 Facial expression
 Look alert, stare blankly, appear
sad or angry
 Maintain eye contact or stare at long
periods
 Arms crossed. Face turns away while
talking
BEHAVIOR
 Patient’s demeanor and overall
attitude
 Extraordinary behavior – speaking
to someone who is not present
 Mannerisms
 Bite nails, fidget or pace
 Tics or tremors
 Cooperative, friendly, hostile, or
indifferent
MOOD
 Appear anxious or depressed
 Crying, sweating, breathing
heavily, or trembling
 Ask to describe the current feelings
in concrete terms and to suggest possible
reasons for the feelings.
 Note inconsistencies between body
language and mood – smiling while
talking about anger-provoking situation
or sad story.
THOUGHT PROCESSSES AND
COGNITIVE FUNCTION
 Orientation to time, place and
person
 Note any confusion or
disorientation
 Delusions, hallucinations,
obsessions, compulsions, fantasies or
daydreams
 Attention span and ability to recall
in both distant and recent past.
Ex. Immediate recall – ask to repeat a
series of 5 to 6 objects.
 Intellectual functioning – add series of
numbers
 Sensory perception and
coordination – copy some drawing
 Inappropriate responses to
hypothetical situation – What would you
do if you won the lottery? – can indicate
impaired judgement.
 Consider cultural background to
influence answers
 Speech characteristics –
monosyllabic responses, irrelevant or
illogical replies, convoluted or
excessively detailed speech, slurred
speech, flight of ideas, sudden silence
without reason.
 Assess insight – ask if he
understands the significance of illness,
treatment plan, effect of illness to his
life.
COPING MECHANISMS
 Patient who faced with stressful
situations may adopt coping or defense
mechanisms – behaviors that operate on
an unconscious level to protect the ego.
 Coping and defense mechanisms
helps to relieve anxiety.
 Denial, displacement, fantasy,
identification, projection, repression
 Listen for an excessive reliance on
these coping mechanisms.
 Denial – refusal to admit truth and
reality.
 Displacement – transferring an
emotion from its original object to a
substitute.
Ex. Angry to child because of bad day at
work.
 Fantasy – creation of unrealistic or
improbable images to escape from daily
pressures and responsibilities.
 Identification – unconscious
adoption of another person’s personality
characteristics, attitudes, values and
behaviors.
 Projection – displacement of
negative feelings onto another person.
Ex. Strong dislike to someone, believe
that they do not like you.
 Rationalization – substitution of
acceptable reasons for the real or actual
reasons that are motivating behavior.
Ex. Low exam because of my instructor
rather than own lack of study
 Reaction formation – behaving in a
manner opposite from the way the
persons feel.
Ex. Treating the person
you dislike in an extremely friendly
manner.
 Regression – return of behavior of
an earlier, more comfortable time.
Ex. Act like a child
 Repression – exclusion of
unacceptable thoughts and feelings from
the conscious mind, leaving them to
operate in the subconscious.
Ex. Memories of abuse suffered as a
child.
POTENTIAL FOR SELF-
DESTRUCTIVE BEHAVIOR
 Death-defying risks > dangerous
sports – normal to a mentally healthy
person
 Death-seeking > abnormal – self-
destructive behavior
 Self-destructive behavior – suicidal
in intent
 Makes the person feels alive.
 Lost touch with reality may cut or
mutilate body parts to focus on physical
pain
 Assess for suicidal tendencies or
ideations
 Assess for depression
RECOGNIZING AND RESPONDING
TO SUICIDAL PATIENT
Warning Signs of Impending Suicide:
 Withdrawing from life
 Avoiding any social situation
 Signs of depression – constipation,
crying, fatigue, helplessness,
hopelessness, poor concentration,
reduced interest in sex and other
activities, sadness and weight loss
 Bidding farewell to friends and
family
 Putting affairs in order
 Giving away prized possessions
 Expressing covert suicide messages
and death wishes
 Voicing obvious suicide messages.
“I’ll be better dead.”
ABNORMAL FINDINGS
Abnormal Thought Processes
 Derailment – speech vacillates from
one subject to another. Subjects are
unrelated with two opinions, ideas slip
out of track
 Flight of ideas – patient jumps
abruptly from topic to topic in a
continuous flow of speech
 Neologisms – words are distorted
or invented
 Blocking – patient suddenly stops
speaking
 Circumstantiality – unnecessary
detail and irrelevant remarks delay the
patient from getting to his point.
 Perseveration – patient persistently
repeats words or ideas
 Confabulation – the patient fabricates
facts and events to fill in the gaps where
memory loss has occurred.
 Clanging – patient chooses a word
based on the sound rather than the
meaning
 Echolalia – patient repeats words or
phrases that others say.
 Incoherence – patient’s speech is
incomprehensible.
ABNORMAL FINDINGS
Abnormal Thought Content
Ex. “You told me a few minutes ago that
your mother was responsible of your
illness, would you please elaborate?” –
Find thought content abnormalities
 Obsessions – recurrent,
uncontrollable thoughts, images, or
impulses that the patient considers
unacceptable
 Compulsions – repetitive behaviors
that result from attempts to alleviate the
obsession.
 Phobia – an irrational and
disproportionate fear of objects or
situations.
 Depersonalization – the feeling that
one has become detached from one’s
mind or body or has lost one’s identity.
 Delusions – false, fixed beliefs that
aren’t shared by others
 Poverty of content – thoughts that
give little information because of
vagueness, empty repetition, or obscure
phases.
ABNORMAL FINDINGS
Perception Abnormalities
Ex. “What did the voice say to you when
you heard it speaking? How did you
feel?” – If patient doesn’t open about
abnormal perceptions, ask if he ever
hears peculiar voices or frightening
sounds.
 Illusions – misinterpretations of
external stimuli.
Ex. Blanket as if it is a ghost.
 Hallucinations – auditory, visual,
tactile, somatic, or gustatory sensory
perceptions when so external stimuli is
present.
HEALTH ASSESSMENT
ASSESSING VICTIMS
OF VIOLENCE
MODULE 7
Chapter 7: Domestic Violence
Assessment
OVERVIEW/INTRODUCTION:
• Family and domestic violence
(including child abuse, intimate partner
abuse, and elder abuse) is a common
issue worldwide. It is a national public
health problem, and virtually all
healthcare professionals will at some
point evaluate or treat a patient who is a
victim of some form of domestic or
family violence.
• Unfortunately, each form of family
violence begets interrelated forms of
violence, and the "cycle of abuse" is
often continued from exposed children
into their adult relationships, and finally
to the care of the elderly.
• Domestic and family violence
includes a range of abuse including
economic, physical, sexual, emotional,
and psychological toward children,
adults, and elders.
• Intimate partner violence includes
stalking, sexual and physical violence,
and psychological aggression by a
current or former partner.
• Domestic violence is thought to be
underreported.
• Domestic violence affects the victim,
families, co-workers, and community. It
causes diminished psychological and
physical health, decreases the quality of
life, and results in decreased
productivity.
• Domestic and family violence is
difficult to identify, and many cases go
unreported to health professionals or
legal authorities. Due to the prevalence
in our society, all healthcare
professionals, including psychologists,
nurses, pharmacists, and physicians will
at some point evaluate and possibly treat
a victim or perpetrator of domestic or
family violence.
LEARNING OUTCOMES:
At the end of the module, students
should be able to:
1. Describe how to prepare a physically
and emotionally safe environment for a
client who has experienced domestic
violence.
2. Explain the concept of violence and
its different classifications.
3. Describe how to teach clients at risk
for violence and how to develop a safety
plan.
4. Discuss the significance of accurate
and objective documentation of physical
findings in clients who have experienced
abuse.
5. Analyze data from the client interview
and physical assessment of a client at
risk of violence and suspected to have
suffered abuse.
DEFINITION
INTIMATE PARTNER VIOLENCE
DEFINED
• Intimate partner violence defined by
the Centers for Disease Control and
Prevention (CDC)
• Physical and/or sexual violence, use
of physical force, or threat of such
violence
• Psychological or emotional abuse
and/or coercive tactics after prior
physical violence between persons who
are spouses or non-marital partners, or
former spouses or non-marital partners
CHILD ABUSE AND NEGLECT
DEFINED
• Most state statutes incorporate the
following definitions
• Neglect: failure to provide for a
child’s basic physical, educational,
medical, and emotional needs
• Physical abuse: physical injury due to
punching, beating, kicking, biting,
burning, shaking, or otherwise harming a
child; even if parent or caretaker did not
intend harm, such acts are considered
abuse when done purposefully
• Most state statutes incorporate the
following definitions:
• Sexual abuse: includes fondling
child’s genitals, incest, penetration, rape,
sodomy, indecent exposure, and
exploitation through prostitution or
production of pornographic materials
• Emotional abuse: any pattern of
behavior that harms child’s emotional
development or sense of self-worth;
includes frequent belittling, rejection,
threats, and withholding of love and
support
ELDER ABUSE AND NEGLECT
DEFINED
• Almost every state has some form of
mandatory reporting of abused elderly
and other vulnerable patients
• As mandatory reporters of abuse, you
need only have suspicion that elder
abuse and/or neglect may have occurred
in order to call authorities
• Many nurses, physicians, and social
workers are erroneously under the
assumption that they must have proof of
abuse before calling authorities
• Physical abuse: violent acts that result
or could result in injury, pain,
impairment, and/or disease
• Physical neglect: failure of family or
caregiver to provide basic goods and
services such as food, shelter, health
care, and medications
• Psychological abuse: behaviors that
result in mental anguish
• Psychological neglect: failure to
provide basic social stimulation
• Financial abuse: intentional misuse of
elderly person’s financial and material
resources
• Financial neglect: failure to use
elderly person’s assets to provide needed
services
HEALTH EFFECTS OF VIOLENCE
• Violent experiences have significant
effects on women’s health
• Injury serious enough to require
medical attention
• Abused women have significantly
more chronic health problems:
Neurologic, gastrointestinal,
gynecologic, and chronic pain
• Forced sex that accompanies physical
abuse contributes to a host of
reproductive health problems including
chronic pelvic pain, unintended
pregnancy, sexually transmitted
infections (STIs) including HIV, and
urinary tract infections
HEALTH EFFECTS OF VIOLENCE
• Health care system can be an
extremely important early point of
contact
• Abused women have significantly
more depression, suicidality,
posttraumatic stress disorder (PTSD)
symptoms, and problems with substance
abuse
• Abuse during pregnancy has serious
results for both the pregnant mother and
the infant, including low birth weight
and increased risk of child abuse
• By uncovering abuse in early stages, it
is hoped the pattern of violence can be
stopped and long-term health problems
can be avoided or minimized
HEALTH EFFECTS OF VIOLENCE
• Health effects of elder abuse include:
• Complications from injuries or
bleeding from trauma can cause changes
in circulatory
homeostasis and fluctuations in blood
pressure
and pulse, shock, and death
• Infections can progress to generalized
sepsis, then death in
immunocompromised aging patients
• Assault, or stress leading up to or
following assault, can contribute to
cardiac complications
• STIs and related complications for
younger women are present in older
sexually assaulted women
• Abuse of the elderly often is coupled
with neglect
• Family or others working with aging
persons may consciously, and with
malice, withhold food, water,
medication, and necessities, while
concurrently stealing assets of the
elderly, dependent person
• This type of neglect is often, by
definition, criminal in nature
• Family members or others caring for
elderly persons may struggle with their
own severe physical and cognitive health
challenges
• Elderly patients may thus experience
profound unintentional neglect
• Unintentional neglect is reportable to
adult protective service agencies
• Self-neglect raises often
unanswerable questions about one’s
right to live autonomously
• Suspected self-neglect is also a
mandatory reportable activity to adult
protective services
HEALTH EFFECTS OF VIOLENCE
• There are many long-term physical
and psychological effects of child
maltreatment
• Immediate consequences include a
spectrum of injuries such as bruises,
fractures, and lacerations and can
involve more severe injury such as
shaken baby syndrome
• More severe forms of maltreatment
can lead to death or long-term disability
such as mental retardation, blindness,
and physical disability
• Child maltreatment can have long-
term effects on a child’s development
and adult life
• Interrupts bond between child and
caregiver
• Ongoing maltreatment can lead to
changes in brain structure and chemistry
and may lead to long-term physical,
psychological, emotional, social, and
cognitive dysfunction in adulthood
• Approximately one third of abused
children will abuse their own children
• Two out of three people in drug
treatment programs report abuse as
children
• Risk factors that may contribute to
child maltreatment
• Disabilities or mental retardation in
children that may increase caregiver
burden
• Social isolation of families
• Parents’ lack of understanding of
children’s needs and child development
• Parents’ history of domestic abuse
• Poverty and other socioeconomic
disadvantages, such as unemployment
• Family disorganization, dissolution,
and violence
• Substance abuse in family
• Young, single, non-biological parents
• Parental thoughts and emotions
supporting maltreatment behaviors
• Parental stress and distress, including
depression or other mental health
conditions
• Community violence
VIOLENCE ASSESSMENT
ASSESSING FOR INTIMATE
PARTNER VIOLENCE
• Routine, universal screening for IPV
means asking every woman at every
health care encounter if she has been
abused by a husband, boyfriend, or other
intimate partner or ex-partner
• Routine, universal screening for IPV
has been
called for by most nursing professional
organizations
ASSESSING FOR INTIMATE
PARTNER VIOLENCE
• How to assess
• Many precede questions with
introduction such as “Because domestic
violence is so common in our society,
we are asking all women the following
questions.”
• Or, “Because domestic violence has
such serious health care consequences,
we are asking all of our female patients
the questions that follow.”
• Alerts women that questions about
domestic violence are coming, and
makes sure they know they are not being
singled out for these questions
ASSESSING FOR INTIMATE
PARTNER VIOLENCE
• Assessment
• If a woman answers yes to any of the
Abuse Assessment Screen (AAS)
questions, then ask questions to assess
how recent and how serious the abuse
was
• Even if the woman only says yes to
the first question and calls abuse “only
emotional” or “not that bad,” more abuse
may be uncovered by gently continuing
the assessment
• This is not “denial,” but normal
minimization that often accompanies
trauma from violence
• It is appropriate to show concern and
distress about degree of violence
• One message that needs to be
conveyed is that abuse is not the
woman’s fault; this can be said several
times
• Also, express concern and that
reassure patient that help is possible
• Furthermore, inform patient that
several health problems can occur
because of domestic violence and that is
why it is
necessary to conduct a thorough
assessment
SCREENING FREQUENCY
PROTOCOL:
ALL WOMEN OVER 14 YEARS OF
AGE
• Primary care: every visit for new
complaint
• Emergency/urgent care: all women,
all visits
• OB/GYN: each prenatal/postpartum
visit; each new intimate relationship; all
routine gynecological visits; all visits in
STI and abortion clinics
• Mental health: every initial
assessment, each new intimate
relationship, and annually
• Inpatient: all admissions and
discharges
ASSESSING FOR ELDER AND
VULNERABLE PERSON ABUSE
AND NEGLECT
• Assessment of abuse or neglect in
cognitively
challenged persons is complicated
• Physical findings inconsistent with
history
provided by patient, family, or caregiver
are red
flags of possible abuse and neglect
ELDER ABUSE SCREEN
• Has anyone:
• Ever touched you inappropriately?
• Made you do things you didn’t want
to do?
• Taken things that were yours without
asking?
• Physically hurt, scolded, or
threatened you?
• Failed to help you take care of
yourself?
• Have you signed documents you
didn’t understand?
• Are you afraid of anyone at home?
• Are you alone a lot?
HISTORY
• History of traumatic injuries may
have an impact on current health
condition
• Assess and document prior abuse:
IPV, childhood abuse, and prior rapes
• Mental status examination important
in cases of IPV or elder abuse, for
potential head trauma or neurological
symptoms
• All survivors of violence should be
given a mental status examination, with
attention to mental health problems
associated with violence: depression,
suicidality, PTSD,
substance abuse, and anxiety
SCREENING FOR CHILD ABUSE
AND NEGLECT
• Medical history important part of
evaluation
• Previous hospitalizations, injuries, or
does he/she suffer from any chronic
medical conditions?
• Take medications that may cause
easy bruising?
• History of repeated visits to
hospital?
• Delays seeking care for other than
minor injury?
• If child is verbal, history should be
obtained away from caretakers through
open-ended questions or spontaneous
statements
SCREENING FOR CHILD
ABUSEAND NEGLECT
• Documentation
• When documenting history and
physical findings of child abuse and
neglect, use words child has used to
describe how their injury
occurred
• Remember the possibility that abuser
may be accompanying the child
• If child is nonverbal, use reports of
caregivers
• Know your institutional protocol for
obtaining history in cases of suspected
child maltreatment
• Some protocols may delay a full
interview until it can be done by a
forensically-trained interviewer
PHYSICAL EXAMINATION
• Important components of physical
examination of known survivor of IPV
and/or elder abuse include:
• Complete head-to-toe visual
examination, especially if patient is
receiving health services for reported
abuse
• Health evaluations for known or
suspected elder abuse and neglect should
include baseline laboratory tests,
including a complete blood count with
platelet level, basic blood chemistries,
serum liver function tests, a coagulation
panel, and urinalysis
PHYSICAL EXAMINATION
• Physical examination of children
• Visual inspection of child from head
to toe is important in any physical
examination
• Significant injuries can be hidden
under clothing, diapers, socks, and long
hair
• Bruising in “atypical” places such as
buttocks, hands, feet, and abdomen is
exceedingly rare and should arouse
concern
• Any bruise in shape of an object
should be considered highly specific for
abuse
• Bruising found in non-mobile
children should raise concern for further
injury, including fractures and
intracranial injury
SIGNS OF PHYSICAL ABUSE
• bruises, black eyes, welts,
lacerations, and rope marks
• broken bones
• open wounds, cuts, punctures,
untreated injuries in various stages of
healing
• broken eyeglasses/frames, or any
physical signs of being punished or
restrained
• laboratory findings of either an
overdose or under dose medications
• individual's report being hit, slapped,
kicked, or mistreated
• vulnerable adult's sudden change in
behavior
• the caregiver's refusal to allow
visitors to see a vulnerable adult alone
SIGNS OF SEXUAL ABUSE
• bruises around the breasts or genital
area
• unexplained venereal disease or
genital infections
• unexplained vaginal or anal bleeding
• torn, stained, or bloody underclothing
• an individual's report of being
sexually assaulted or raped
SIGNS OF MENTAL/ EMOTIONAL
ABUSE
• being emotionally upset or agitated
• being extremely withdrawn and non-
communicative or non responsive
• unusual behavior usually attributed to
dementia (e.g., sucking, biting, rocking)
• nervousness around certain people
• an individual's report of being
verbally or mentally mistreated
SIGNS OF NEGLECT
• dehydration, malnutrition, untreated
bed sores and poor personal hygiene
• unattended or untreated health
problems
• hazardous or unsafe living condition
(e.g., improper wiring, no heat or
running water)
• unsanitary and unclean living
conditions (e.g., dirt, fleas, lice on
person, soiled bedding, fecal/urine smell,
inadequate clothing)
• an individual's report of being
mistreated
SIGNS OF EXPLOITATION/
FINANCIAL ABUSE
• sudden changes in bank account or
banking practice, including an
unexplained withdrawal of large sums of
money
• adding additional names on bank
signature cards
• unauthorized withdrawal of funds
using an ATM card
• abrupt changes in a will or other
financial documents
• unexplained disappearance of funds
or valuable possessions
• bills unpaid despite the money being
available to pay them
• forging a signature on financial
transactions or for the titles of
possessions
• sudden appearance of previously
uninvolved relatives claiming rights to a
vulnerable adult’s possessions
• unexplained sudden transfer of assets
to a family member or someone outside
the family
• providing services that are not
necessary
• individual's report of exploitation
DOCUMENTATION
• Documentation of IPV, child abuse,
and elder abuse must include:
• Detailed, nonbiased progress notes
• Use of injury maps
• Photographic documentation in
health record
• Other aspects of abuse history,
including reports of past abusive
incidents, can be paraphrased with use of
partial direct
quotations
PHOTOGRAPHIC
DOCUMENTATION
Patterned, punch-like abrasion to the mid
forehead from an assailant wearing a
ring with a stone; sutured laceration to
the left
eyebrow; sutured partial- avulsion injury
to the nose, punch-like contusion to the
left eye involving the sclera, and manual
strangulation- related abrasion to the
neck
PHOTOGRAPHIC
DOCUMENTATION
Patterned, defensive posture-like bruises
to the
right forearm
DOCUMENTATION
• Documentation of IPV and elder
abuse must include detailed, nonbiased
progress notes
• Use of injury maps
• Photographic documentation
• Written documentation of histories
of IPV and elder abuse need to be
verbatim but within reason
• Critical to document exceptionally
poignant statements made by victim that
identify perpetrator and severe threats of
harm
made by perpetrator
DOCUMENTATION
• Detailed, nonbiased progress notes
• Other aspects of abuse and reports of
past abuse can be paraphrased using
partial direct quotations
• When quoting or paraphrasing
history, do not sanitize the words
reportedly heard by victim
• Verbatim documentation of reported
perpetrator’s threats interlaced with
curses and expletives can be extremely
useful in
future court proceedings
• Also, be careful to use the exact
terms an abused patient may use to
describe sexual organs or sexually
assaultive behaviors
ASSESSING FOR RISK OF
HOMICIDE
• Women more often killed by husband,
boyfriend, or ex- husband than by
anyone else
• About three-fourths of these women
have been abused by man who
subsequently killed them
• In recent study of intimate partner
homicide of women, 42% of women
killed had been seen in health care
system in year before she was killed
• These encounters were missed
opportunities for health care
professionals to identify IPV and
intervene to decrease danger
ASSESSING FOR RISK OF
HOMICIDE
• Danger Assessment (DA), is a 19-
item yes/no instrument used extensively
by nurses in health care system
• Starts with a calendar so women can
more accurately see how frequent and
severe violence has become over the past
year
• This is also an excellent assessment
of frequency and severity of violence for
health care provider
• The more yes answers, the more
serious the danger of the woman’s
situation
WHEN SHE SAYS NO TO AAS BUT
THERE ARE OTHER IPV
INDICATORS
• Suspect IPV when she says “No” to
AAS, but there are other indicators
associated with IPV
• In addition, providers need to be alert
for conditions associated with IPV
including:
• Gynecological problems, especially
STIs, pelvic pain, and complaints of
sexual dysfunction
• Chronic irritable bowel syndrome,
back pain, depression, symptoms of
PTSD, problems sleeping, panic attacks,
or nerves
WHEN THERE ARE OTHER IPV
INDICATORS
• When these problems occur, and
especially when they persist, a thorough
and repeated assessment for domestic
violence is needed.
• In this case, an instrument such as the
WEB scale might be used in addition to
the AAS, or gentle indirect queries
• “I am concerned about your health
conditions; is there any chance that
stress at home is contributing to these
problems?”
CULTURAL COMPETENCE
• Domestic violence occurs cross-
culturally
• It may be more difficult to determine
in many cultural groups
• Serious psychological distress
among persons 18 years of age and over
was 3.0% for the general population,
3.0% for whites, 7.1% for American
Indians, and 3.0% for blacks
• Heavy alcohol use by persons 12 years
of age and older for the white population
was 7.5%, blacks 4.4%, and American
Indians 8.7% of population
HEALTH ASSESSMENT
ASSESSING CULTURE,
SPIRITUALITY AND RELIGIOUS
PRACTICES
MODULE 8
OVERVIEW/INTRODUCTION:
 Religion provides things that are
good for health and wellbeing, including
social support, existential meaning, a
sense of purpose, a coherent belief
system and a clear moral code. But these
benefits can also come from other
sources.
 Conversely, religion is shaped by
its social context in ways that affect its
social role. Religion is no panacea when
it comes to improving health.
 Religion’s role in health needs to be
examined in a broad context, especially
the ways in which culture influences
religion’s expression of the spiritual.
 A large number of Filipinos profess
a belief in God, pray on a regular basis,
and frequently use spiritual resources
during times of high stress, but how
clients use and view spirituality and
religion varies immensely.
 It is important to consider
spirituality within the context of client
care, but in whatever form spirituality is
incorporated into an assessment, the
nurse must remain respectful and open.
LEARNING OUTCOMES:
At the end of the module, students
should be able to:
1. Describe culture and its basic
characteristics, the role of cultural
competence of the caregiver in nursing
assessment.
2. Demonstrate how the assessment
interview needs to be modified to
consider cultural variations.
3. Explain how understanding
spirituality can assist the nurse in
identifying the client’s coping responses
and support systems.
4. Discuss why it is important that nurses
be aware of their own spiritual beliefs
and biases as they relate to health care.
5. Analyze data from the client
interview and physical assessment of the
client’s culture and spiritual status.
CULTURAL DIVERSITY AND
NURSINGCULTURE AND NURSING
 Nurses provide health care to
culturally diverse client populations in a
variety of settings.
 Knowledge of culturally relevant
information is vital in the delivery of
competent nursing care.
CULTURE
 Dynamic and integrated structures of
knowledge, beliefs, behaviors, ideas,
attitudes, values, habits, customs,
languages, symbols,
rituals, ceremonies, and practices that are
unique to a particular group of people.
ETHNICITY
 A cultural group’s perception of
itself,
or a group identity.
RACE
 The grouping of people based on
biological similarities.
RACE VS ETHNICITY
 For example, people might identify
their race as Aboriginal, African
American or Black, Asian, European
American or White, Native American,
Native Hawaiian or Pacific Islander,
Māori, or some other race. Ethnicity
refers to shared cultural characteristics
such as language,
ancestry, practices, and beliefs.
CULTURAL DIVERSITY
 The differences among people that
result from racial, ethnic, and cultural
variables.
IMPORTANT TERMS IN CULTURAL
DIVERSITY
 Ethnocentrism: assumption of
cultural
superiority
 Oppression: result of ethnocentrism
 Stereotyping: the belief that all
members of
a cultural group act alike
 Dominant culture: prevailing group
within a
given society
 Minority group: those of fewer
numbers
 Cultural assimilation: the absorption
of the
minority into the dominant culture
COMPONENTS OF CULTURAL
Culture is composed of beliefs about:
 Activity - how people organize and
value
work.
 Social relations - structure of
friendships,
gender roles and class.
 Motivation - the value and methods
of
achievement.
 Perception of the world -
interpretation of
life events and religious beliefs.
 Perception of self - refers to
personal
identity, value, and respect for
individuals.
CHARACTERISTICS OF CULTURAL
 Culture is learned
 Culture is not inherited or innate,
but
integrated throughout all interrelated
components
 Culture is shared by all who belong
to the
cultural group
 Culture is tacit (unspoken) and
understood
by all in the cultural group
 Culture is dynamic
CULTURAL & HEALTH CARE
How different cultures view the
following
variables affect health care in significant
ways.
 Definition of health: what is it?
 Etiology: what are the origins of
disease?
 Health Promotion and Protection:
how is
health achieved and maintained?
 Practitioners and Remedies: who
and what
can heal a person?
CULTURAL ROOTS
 Unlike opinions, preferences, and
attitudes, which can change, cultural
characteristics are deeply rooted and
difficult to change.
 Clients reflect their cultural and ethnic
heritage every time they interact with the
world around them.
CULTURAL & RACIAL
INFLUENCES ON CLIENT CARE
Culture and race influence client care in
the
areas of:
1. Communication
2. Orientation to Space and Time
3. Social Organization
COMMUNICATION
 Language differences can lead to
misunderstandings and frustration.
 Alternative methods of
communication,
such as flash cards and gestures, may
have
to be used.
 Family members or staff interpreters
may
also be necessary to intercede.
ORIENTATION TO SPACE AND
TIME
 Issues around personal space and
future orientation varies from culture to
culture and impact the effective delivery
of health care.
SOCIAL ORGANIZATION
Social organization refers to how
different cultural groups determine rules
of acceptable behavior.
Examples include:
 Family Structure.
 Gender Roles.
 Religion.
RELIGION
 Culture is influenced by religion,
which in turn affects beliefs and
practices about health and illness.
 Spiritual and religious beliefs are
important in many people’s lives. They
can influence lifestyle, attitudes, and
feelings about illness and death.
BIOLOGICAL VARIATION
 Biological variations distinguish one
cultural or racial group from another.
 Biological variations include skin
color, hair
texture, body structure, eye shape, etc.
 Enzymatic differences account for
diverse
responses of some groups to dietary
therapy and drugs.
CULTURAL ASPECTS & THE
NURSING PROCESS
 Cultural aspects affect all significant
areas of the nursing process:
1. assessment,
2. nursing diagnosis,
3. planning/outcome identification,
4. implementation, and
5. evaluation.
 Some areas are more affected than
others.
PERSONAL CULTURAL
ASSESSMENT
Five areas to be examined in assessing
one’s own culture and the influence it
may have on personal beliefs about
health care are:
 Influences from own ethnic/racial
background.
 Typical verbal and non-
communication
patterns.
 Cultural values and norms.
 Religious beliefs and practices.
 Health beliefs and practices.
CLIENT CULTURAL ASSESSMENT
Six categories of information necessary
for a comprehensive cultural assessment
of a client are:
 Ethnic or racial background.
 Language and communication
patterns.
 Cultural values and norms.
 Biocultural factors.
 Religious beliefs and practices.
 Health beliefs and practices.
CULTURALLY APPROPRIATE CARE
 Respect clients for their different
beliefs.
 Be sensitive to behaviors and
practices
different from your own.
 Accommodate differences if they
are not
detrimental to health.
 Listen for cues in the client’s
conversation
that relay a unique ethnic belief about
etiology, transmission, prevention, etc.
 Teach positive health habits if
client’s
practices are deleterious to good health.
NURSING ASSESSMENT
FOR SPIRITUAL/RELIGIOUS
PRACTICES
WHY A SPIRITUAL
ASSESSMENT?
 Faith is already a factor affecting
the lives and healthcare choices of many
of our patients.
 Most patients and their families
already use faith- based/ religious
practices (like prayer, diet, ritual, etc.) to
complement treatment modalities.
 Healthcare practitioners need to
assess how faith impacts individual
treatment choices.
 A spiritual assessment is less about
WHAT a
person believes and more about HOW
their
faith/ belief system functions as a source
of
support.
GUIDELINES FOR SPIRITUAL
ASSESSMENTS
 A spiritual assessment should, at a
minimum,
determine the patient’s religious beliefs
(if
any), as well as any values or practices
important to the patient.
 The main goal of a spiritual
assessment should be to identify the
patient’s needs, hopes,
resources, and possible outcomes
regarding their spirituality.
OTHER BENEFITS OF A SPIRITUAL
ASSESSMENT
 Acknowledging spirituality can
positively affect the clinician-patient
relationship.
 Addressing spiritual concerns with
your patient and their family can provide
comfort and increase trust- building.
 In itself the assessment becomes a
therapeutic intervention.
IMPORTANT CONSIDERATIONS
 Respect the privacy of patients with
regard to their unique spirituality.
 Do not impose your own beliefs and
practices on others.
INITIAL SPIRITUAL ASSESSMENT
 A Spiritual History collects
information on
spirituality and religious practice that
may
help them cope with their present health
crisis.
 A Spiritual Assessment involves an
informed
judgment concerning treatment options –
including referral to a chaplain for a
more in-
depth assessment.
FACT
 SPIRITUAL HISTORY
 FAITH – beliefs
 ACTIVE ACCESS – availability
 CONFLICT/ CONCERNS –
coping
 SPIRITUAL ASSESSMENT
 TREATMENT PLAN
NURSING INTAKE SPIRITUAL
ASSESSMENT QUESTIONS
 The following questions are part of
a new
spiritual assessment process.
 Positive answers trigger instant
referrals for follow-up pastoral care,
such as:
 Communion requests
 Communication with the patient’s
religious
congregation
 Consultation on issues of religious/
cultural
sensitivity
 In-depth spiritual assessment by a
chaplain
 General emotional or spiritual
support by a chaplain
FAITH
 Can you confirm your religious
affiliation that I have recorded from your
admission documents? (Check patient's
ID band for
religious affiliation).
 I see you are (religious affiliation).
Is
this correct?
 Contact admissions office to update /
correct this information.
FAITH
 If patient is Catholic, would he/she
like to receive communion?
 SCRIPT: “Eucharistic Ministry
volunteers
are available daily to distribute
communion
to Catholic patients and their families.”
 Generates an automatic referral to
pastoral
care.
ACTIVE ACCESS
 Do you participate in a religious
congregation?
 SCRIPT: “Our pastoral care team will
help
you contact them. I’ll let the team know
of
this request.”
 Generates an automatic referral to
pastoral
care.
ACTIVE ACCESS
 Pastoral care is offered to all
patients. Would you like me to expedite
a visit from one of the pastoral care team
members?
 Call chaplain on duty if there
is an
emergent need for pastoral support.
 “Yes” generates an automatic
referral to pastoral care.
CONFLICT/ CONCERNS
 What cultural, spiritual, or religious
practices/ values are important for us to
know?
 SCRIPT: “I’ll work with my
colleagues to
make sure we work with you on these
concerns.”
 Consult with Pastoral Care as
appropriate.
CONFLICT/ CONCERNS
 Do any of your religious practices
conflict
with or affect how we will need to treat
you
while you are here? (Example: diet,
medication, visitors, privacy, rituals.)
 SCRIPT: “I’ll work with my
colleagues to make sure we work with
you on these concerns.”
 Update plan of care as
appropriate.
 Dietary or Pastoral Care
Departments are automatically referred.
CONFLICT / CONCERNS
 Do you have any particular concerns
or
fears about your stay in the hospital?
 Address those fears / concerns that
you are
able to.
 SCRIPT: “Our chaplains are also
here to help address many of these
concerns. Would you like me to
expedite a visit from one of the
chaplains?”
 Generates an automatic referral to
pastoral
care.
TREATMENT PLAN
 Does the patient appear to be
coping
well and have adequate social/ emotional
/ spiritual support?
 Call chaplain on duty if there
is an
emergent need for pastoral support.
 Non-emergent needs (“no”
answers)
generate an automatic referral to pastoral
care.
FINAL THOUGHTS
 If questioned on the role of pastoral
care
and chaplains refer the patient / family to
facility guides. Or, contact pastoral care
for assistance.
FINAL THOUGHTS
 Referrals to pastoral care generated
by
the assessment will be completed in 24
hours. A chaplain will visit to further
assess ongoing issues and pastoral care
needs.
 Urgent pastoral care needs
(emergency
sacraments, family crises, death/ dying
issues) should be referred to the chaplain
on duty for immediate response.