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What are the phases in the nursing process
- Outcome Identification
What is a nursing diagnoses?
Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state. The most recently approved North American Nursing Diagnosis Association (NANDA) 2009-2011 list includes (1) actual diagnoses, existing problems that are amenable to independent nursing interventions; (2) risk diagnoses, potential problems that an individual does not currently have but is particularly vulnerable to developing; and (3) wellness diagnoses, which focus on strengths and reflect an individual's transition to a higher level of wellness. Throughout this book, appropriate diagnoses from this list are presented and developed as they pertain to related content in each chapter.
In the hospitalized, acute care setting, the initial problems are usually related to the reason for admission. however, the acuity of the illness often determines the order of priorities of the person's problems.
Describe second-level priority problems
those that are next in urgency—those requiring your prompt intervention to forestall further deterioration, for example, mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security.
What is one way to determine a priority?
Make a complete list of current medications, medical problems, allergies, and reasons for seeking care. Refer to them frequently because they may affect how you set priorities.
What are the steps to setting priorities?
- 1 Assign high priority to First-level priority problems (immediate priorities): Remember the “ABCs plus V”:
- • Airway problems
- • Breathing problems
- • Cardiac/circulation problems
- • Vital sign concerns (e.g., high fever)
- Exception: With cardiopulmonary resuscitation (CPR) for cardiac arrest, begin chest compressions immediately. Go online to www.americanheart.org for the most current CPR guidelines.
- 2 Next, attend to Second-level priority problems:
- • Mental status change (e.g., confusion, decreased alertness)
- • Untreated medical problems requiring immediate attention (e.g., a diabetic who has not had insulin)
- • Acute pain
- • Acute urinary elimination problems
- • Abnormal laboratory values
- • Risks of infection, safety, or security (for the patient or for others)
- 3 Address Third-level priority problems (later priorities):
- • Health problems that do not fit into the above categories (e.g., problems with lack of knowledge, activity, rest, family coping)
Describe Evidence Based Assessment
EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinician's experience, as well as the patient preferences and values, to make decisions about care and treatment
What are the four different types of data?
- Complete (Total Health) Database
- Focused or problem-centered database
- Follow-up database
- Emergency database
Describe the complete (total health) database
- This includes a complete health history and a full physical examination. It describes the current and past health state and forms a baseline against which all future changes can be measured. It yields the first diagnoses.
- In primary care, the complete database is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, women's health care agency, visiting nurse agency, or community health agency. When you work in these settings, you are the first health professional to see the patient and have primary responsibility for monitoring the person's health care. This is the opportunity to build and strengthen your relationship with the patient. For the well person, this database must describe the person's health state, perception of health, strengths or assets such as health maintenance behaviors, individual coping patterns, support systems, current developmental tasks, and any risk factors or lifestyle changes. For the ill person, the database also includes a description of the person's health problems, perception of illness, and response to the problems.
- For well and ill people, the complete database must screen for pathology as well as determine the ways people respond to that pathology or to any health problem. You must screen for pathology because you are the first, and often the only, health professional to see the patient. You will screen for pathology in order to refer the patient to another professional, to help the patient make decisions, and to perform appropriate treatments. But this database also notes the human responses to health problems. This factor is important because it provides additional information about the person that leads to nursing diagnoses.
- In acute hospital care, the complete database also is gathered after admission to the hospital. In the hospital, data related specifically to pathology may be collected by the admitting physician. You will collect additional information on the patient's perception of illness, functional ability or patterns of living, activities of daily living, health maintenance behaviors, response to health problems, coping patterns, interaction patterns, and health goals. This approach completes the database from which the nursing diagnoses are made.
Describe focused or problem-centered databases
This is for a limited or short-term problem. Here, you collect a “mini” database, smaller in scope and more targeted than the complete database. It concerns mainly one problem, one cue complex, or one body system. It is used in all settings—hospital, primary care, or long-term care. For example, 2 days after surgery, a hospitalized person suddenly has a congested cough, shortness of breath, and fatigue. The history and examination focus primarily on the respiratory and cardiovascular systems. Or, in an outpatient clinic, a person presents with a rash. The history and examination follow the direction of this presenting concern, such as whether the rash had an acute or chronic onset, was associated with a fever, and was localized or generalized. History and examination must include a clear description of the rash.
describe follow up databases
The status of any identified problems should be evaluated at regular and appropriate intervals. What change has occurred? Is the problem getting better or worse? What coping strategies are used? This type of database is used in all settings to follow up short-term or chronic health problems.
describe emergency databases
This calls for a rapid collection of the data, often compiled concurrently with lifesaving measures. Diagnosis must be swift and sure. For example, in a hospital emergency department, a person is brought in with suspected substance overdose. The first history questions are “What did you take?,” “How much did you take?,” and “When?” The person is questioned simultaneously while his or her airway, breathing, circulation, level of consciousness, and disability are being assessed. Clearly, the emergency database requires more rapid collection of data than the episodic database.
Define holistic health
Consideration of the whole person is the essence of holistic health. Views the mind, body and spirit as interdependent and functioning as a whole within the environment
All behavior has meaning
Describe electronic health recording or EHR
- Direct computer recording of the patient health record has moved into many outpatient offices and hospital rooms in the twenty-first century. This eliminates handwritten clinical data as well as provides access to patient education materials and Internet searches. Although computer entry facilitates data retrieval from numerous locations, this new technology poses problems for the provider-patient relationship. In the worst case scenario, the patient sits idly by while the examiner interacts silently with the computer.29
- If this technology is used in your setting, do not let the computer screen become a barrier between you and the patient. Begin the interview as you usually would by greeting the person, establishing rapport, and collecting the person's narrative story in a direct face-to-face manner. Only after the narrative is fully explored should you type data into the computer. Ask the person if you may now type some notes into the computer, and position the monitor so the patient can see it. Typing directly into the computer may ease entry of some sections of history such as past health occurrences, family history, and review of systems (see Chapter 4). However, be aware that the patient narrative, emotional issues, and complex health problems can only be addressed by the reciprocal communication techniques and patient-centered interviewing presented in this chapter.
Comparison of open ended and closed ended questions
Described facilitation communication
These responses encourage the patient to say more, to continue with the story (“mm-hmm, go on, continue, uh-huh”). Also called general leads, these responses show the person you are interested and will listen further. Simply maintaining eye contact, shifting forward in your seat with increased attention, nodding “Yes,” or using your hand to gesture, “Yes, go on, I'm with you,” encourage the person to continue talking.
Describe reflection communication
This response echoes the patient's words. Reflection is repeating part of what the person has just said. In this example, it focuses further attention on a specific phrase and helps the person continue in his own way
A physical symptom, condition, or illness often has accompanying emotions. Many people have trouble expressing these feelings, perhaps because of confusion or embarrassment. In the reflecting example above, the person already had stated her feeling and you echoed it. But in the following example, he has not said it yet. An empathic response recognizes a feeling and puts it into words. It names the feeling and allows the expression of it. When the empathic response is used, the patient feels accepted and can deal with the feeling openly.
describe clarification communication
Use this when the person's word choice is ambiguous or confusing (e.g., “Tell me what you mean by ‘tired blood.’ ”). Clarification also is used to summarize the person's words, simplify the words to make them clearer, and then ask if you are on the right track. You are asking for agreement, and the person can then confirm or deny your understanding.
Describe summary communication
This is a final review of what you understand the person has said. It condenses the facts and presents a survey of how you perceive the health problem or need. It is a type of validation in that the person can agree with it or correct it. Both you and the patient should participate. When the summary occurs at the end of the interview, it signals that termination of the interview is imminent.
Describe nonverbal skills
Learn to listen with your eyes as well as with your ears. Nonverbal modes of communication include physical appearance, posture, gestures, facial expression, eye contact, voice, and touch. Nonverbal messages are very important in establishing rapport and in conveying information, especially about feelings. Nonverbal messages provide clues to understanding feelings. When nonverbal and verbal messages are congruent, the verbal is reinforced. When they are incongruent, the nonverbal message tends to be the true one, because it is under less conscious control.
What would be a good way to close an interview?
- The session should end gracefully. An abrupt or awkward closing can destroy rapport and leave the person with a negative impression of the whole interview. To ease into the closing, ask the person:
- “Is there anything else you would like to mention?”
- “Are there any questions you would like to ask?”
- “Are there any other areas I should have asked about?”
- “We have covered a number of concerns today. What would you most like to accomplish?”
You must alter your interview based on the age of the client.
How can objective data be measured?
What is the order of the health history sequence?
- 1 Biographic data (55 y/o caucasian male for example)
- 2 Reason for seeking care
- 3 Present health or history of present illness
- 4 Past history
- 5 Family history
- 6 Review of systems
- 7 Functional assessment or activities of daily living (ADLs)
describe the review of systems
- The purposes of this section are (1) to evaluate the past and present health state of each body system, (2) to double-check in case any significant data were omitted in the Present Illness section, and (3) to evaluate health promotion practices. The order of the examination of body systems is roughly head-to-toe. The items within each system are not inclusive, and only the most common symptoms are listed. If the Present Illness section covered one body system, you do not need to repeat all the data here. For example, if the reason for seeking care is earache, the Present Illness section describes most of the symptoms listed for the auditory system. Just ask now what was not asked in the Present Illness section.
- Medical terms are listed here, but they need to be translated for the patient. (Note that symptoms and health promotion activities are merely listed here. These terms are repeated and expanded in each related physical examination chapter, along with suggested ways to pose questions and a rationale for each question.)
- When recording information, avoid writing “negative” after the system heading. You need to record the presence or absence of all symptoms; otherwise, the reader does not know about which factors you asked.
- A common mistake made by beginning practitioners is to record some physical finding or objective data here, such as “skin warm and dry.” Remember that the history should be limited to patient statements, or subjective data—factors that the person says were or were not present.
Lengthy explanation of review of systems
- Significant gain or loss of weight, failure to gain weight appropriate for age, frequent colds, ear infections, illnesses, energy level, fatigue, overactivity, and behavior change (irritability, increased crying, nervousness).
- Birthmarks, skin disease, pigment or color change, mottling, change in mole, pruritus, rash, lesion, acne, easy bruising or petechiae, easy bleeding, and changes in hair or nails.
- Headache, head injury, dizziness.
- Strabismus, diplopia, pain, redness, discharge, cataracts, vision changes, reading problems. Is the child able to see the board at school? Does the child sit too close to the television?
- Health Promotion
- Use of eyeglasses, date of last vision screening.
- Earaches, frequency of ear infections, myringotomy tubes in ears, discharge (characteristics), cerumen, ringing or crackling, and whether parent perceives any hearing problems.
- Health Promotion
- How does the child clean his or her ears?
- Nose and Sinuses
- Discharge and its characteristics, frequency of colds, nasal stuffiness, nosebleeds, and allergies.
- Mouth and Throat
- History of cleft lip or palate, frequency of sore throats, toothache, caries, sores in mouth or tongue, tonsils present, mouth breathing, difficulty chewing, difficulty swallowing, and hoarseness or voice change.
- Health Promotion
- Child's pattern of brushing teeth and last dental checkup.
- Swollen or tender glands, limitation of movement, or stiffness.
- For preadolescent and adolescent girls, when did they notice that their breasts were changing? What is the girl's self-perception of development? For older adolescents, does the girl perform breast self-examination? (see Chapter 17 for suggested phrasing of questions.)
- Respiratory System
- Croup or asthma, wheezing or noisy breathing, shortness of breath, chronic cough.
- Cardiovascular System
- Congenital heart problems, history of murmur, and cyanosis (what prompts this condition). Is there any limitation of activity, or can the child keep up with peers? Is there any dyspnea on exertion, palpitations, high blood pressure, or coldness in the extremities?
- Gastrointestinal System
- Abdominal pain, nausea and vomiting, history of ulcer, frequency of bowel movements, stool color and characteristics, diarrhea, constipation or stool-holding, rectal bleeding, anal itching, history of pinworms, and use of laxatives.
- Urinary System
- Painful urination, polyuria/oliguria, narrowed stream, urine color (cloudy, dark), history of urinary tract infection, whether toilet trained, when toilet training was planned, any problems, bedwetting (when the child started, frequency, associated with stress, how child feels about it).
- Male Genital System
- Penis or testicular pain, whether told if testes are descended, any sores or lesions, discharge, hernia or hydrocele, or swelling in scrotum during crying. For the preadolescent and adolescent boy, has he noticed any change in the penis and scrotum? Is the boy familiar with normal growth patterns, nocturnal emissions, and sex education? Screen for sexual abuse. (see Chapter 24 for suggested phrasing of questions.)
- Female Genital System
- Has the girl noted any genital itching, rash, vaginal discharge? For the preadolescent and adolescent girl, when did menstruation start? Was she prepared? Screen for sexual abuse. (see Chapter 26 for suggested phrasing of questions.)
- Sexual Health
- What is the child's attitude toward the opposite sex? Who provides sex education? How does the family deal with sex education, masturbation, dating patterns? Is the adolescent in a relationship involving intercourse? Does he or she have information on birth control and sexually transmitted infections? (See Chapters 24 and 26 for suggested phrasing of questions.)
- Musculoskeletal System
- In bones and joints: arthritis, joint pain, stiffness, swelling, limitation of movement, gait strength and coordination. In muscles: pain, cramps, and weakness. In the back: pain, posture, spinal curvature, and any treatment.
- Neurologic System
- Numbness and tingling. (Behavior and cognitive issues are covered in the sections on development and interpersonal relationships.)
- Hematologic Systems
- Excessive bruising, lymph node swelling, and exposure to toxic agents or radiation.
- Endocrine System
- History of diabetes or thyroid disease; excessive hunger, thirst, or urinating; abnormal hair distribution; and precocious or delayed puberty.
What is a functional assessment?
Questions to ask about current medications
For each medication, record the name, purpose, and daily schedule. Does the person have a system to remember to take the medicine? Does medicine seem to work? Are there any side effects? If so, does the person feel like skipping medicine because of them?
Defining mental status
- Mental status is a person's emotional (feeling) and cognitive (knowing) function. Optimal functioning aims toward simultaneous life satisfaction in work, in caring relationships, and within the self. Mental health is relative and ongoing. Everyone has “good” days and “bad” days. Usually, mental status strikes a balance, allowing the person to function socially and occupationally.
- The stress surrounding a traumatic life event (death of a loved one, serious illness) tips the balance, causing transient dysfunction. This is an expected response to a trauma. Mental status assessment during a traumatic life event can identify remaining strengths and can help the individual mobilize resources and use coping skills.
Describe a mental disorder
A mental disorder is apparent when a person's response is much greater than the expected reaction to a traumatic life event. A mental disorder is defined as a significant behavioral or psychological pattern that is associated with distress (a painful symptom) or disability (impaired functioning) and has a significant risk of pain, disability, or death or a loss of freedom.2 Mental disorders include organic disorders (due to brain disease of known specific organic cause [e.g., delirium, dementia, alcohol and drug intoxication and withdrawal]) and psychiatric mental illness (in which an organic etiology has not yet been established [e.g., anxiety disorder or schizophrenia]). Mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life.
Currently, we understand pain to develop by two main processes: nociceptive and/or neuropathic processing. It is important to understand how these two types of pain develop because patients will present with distinguishing sensations and respond differently to analgesics. When we are better able to assess the type(s) of pain, clinicians can more accurately select effective pharmacologic and nonpharmacologic strategies to interrupt the pain processing along multiple points within the pain messaging system and ultimately provide improved pain relief
Specialized nerve endings called nociceptors are designed to detect painful sensations from the periphery and transmit them to the CNS.
The pain signals then cross over to the other side of the spinal cord and ascend to the brain by the anterolateral spinothalamic tract. Pain researchers are demonstrating that when pain is poorly controlled over an extended period, cells within the dorsal horn become altered in size and function and this damage ultimately turns future pain signals into more exaggerated or hypersensitive processing
describe nociceptive pain
- Nociceptive pain develops when nerve fibers in the periphery and in the central nervous system are functioning and intact. Nociceptive pain starts outside of the nervous system from actual or potential tissue damage. Nociception can be divided into four phases: (1) transduction, (2) transmission, (3) perception, and (4) modulation
describe neuropathic pain
Neuropathic pain is pain that does not adhere to the typical and rather predictable phases in nociceptive pain. Neuropathic pain implies an abnormal processing of the pain message from an injury to the nerve fibers. It is this type of pain that is most difficult to assess and treat. Pain is often perceived long after the site of injury heals and can start 2 to 3 years after an initial injury.
Describe referred pain
Pain that is felt at a particular site but originates from another location
Describe acute pain
Acute pain is short-term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals. Examples of acute pain include surgery, trauma, and kidney stones. Acute pain serves a self-protective purpose; acute pain warns the individual of actual or potential tissue damage. Incident pain is an acute type that happens predictably when certain movements take place. Examples include pain in the lower back upon standing or shoulder pain when arms are raised.
Describe chronic or persistent pain
persistent (or chronic) pain is diagnosed when the pain continues for 6 months or longer. It can last 5, 15, or 20 years and beyond. Persistent pain can be further divided into malignant (cancer-related) and nonmalignant. Malignant pain often parallels the pathology created by the tumor cells. The pain is induced by tissue necrosis or stretching of an organ by the growing tumor. The pain fluctuates within the course of the disease. Chronic nonmalignant pain is often associated with musculoskeletal conditions, such as arthritis, low back pain, or fibromyalgia.
Describe breakthrough pain
pain that starts again or escalates before the next scheduled analgesic dose. Pain breaks through when it is expected to be controlled by pain medications
Infants and pain
Infants have the same capacity for pain as adults
Aging adult and pain
No evidence exists to suggest that older individuals perceive pain to a lesser degree or that sensitivity is diminished. Although pain is a common experience among individuals 65 years of age and older, it is not a normal process of aging. Pain indicates pathology or injury. Pain should never be considered something to tolerate or accept in one's later years.
acute pain behaviors
Because acute pain involves autonomic responses and has a protective purpose, individuals experiencing moderate to intense levels of pain may exhibit the following behaviors: guarding, grimacing, vocalizations such as moaning, agitation, restlessness, stillness, diaphoresis, or change in vital signs. This list of behaviors is not exhaustive because they should not be used exclusively to deny or confirm the presence of pain. For example, in a postoperative patient, pulse and blood pressure can be altered by fluid volume, medications, and blood loss.
Define nutritional status
Nutritional status refers to the degree of balance between nutrient intake and nutrient requirements. This balance is affected by many factors, including physiologic, psychosocial, developmental, cultural, and economic.
describe optimal nutritional status
Optimal nutritional status is achieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands due to growth, pregnancy, or illness. Persons having optimal nutritional status are more active, have fewer physical illnesses, and live longer than persons who are malnourished.
Undernutrition occurs when nutritional reserves are depleted and/or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demands. Vulnerable groups—infants, children, pregnant women, recent immigrants, persons with low incomes, hospitalized people, and aging adults—are at risk for impaired growth and development, lowered resistance to infection and disease, delayed wound healing, longer hospital stays, and higher health care costs.
- Overnutrition is caused by the consumption of nutrients—especially calories, sodium, and fat—in excess of body needs. A major nutritional problem today, overnutrition can lead to obesity and is a risk factor for heart disease, type 2 diabetes, hypertension, stroke, gallbladder disease, sleep apnea, certain cancers, and osteoarthritis.
- An estimated 17% of children and adolescents (ages 2 to 19 years) are overweight, and 66% of adults in the United States are either overweight or obese. For children, overweight is a body mass index (BMI) equal to or greater than the 95th percentile based on age- and gender-specific BMI charts. For adults, overweight is a BMI of 25 or greater and obesity is a BMI of 30 or greater.7 Although obesity rates in both children and adults seem to be leveling off after several years of increases, these data are alarming. Being overweight during childhood and adolescence is associated with increased risk for becoming overweight during adulthood
The easiest and most popular method for obtaining information about dietary intake is the 24-hour recall. The individual or family member completes a questionnaire or is interviewed and asked to recall everything eaten within the last 24 hours. An advantage of the 24-hour recall is that it can elicit specific information about dietary intake over a specific period of time. However, there are several significant sources of error: (1) the individual or family member may not be able to recall the type or amount of food eaten; (2) intake within the last 24 hours may be atypical of usual intake; (3) the individual or family member may alter the truth for a variety of reasons; and (4) snack items and use of gravies, sauces, and condiments may be underreported.
what are food diaries?
Food diaries or records ask the individual or family member to write down everything consumed for a certain period of time. Three days—two weekdays and one weekend day—are customarily used. A food diary is most complete and accurate if you teach the individual to record information immediately after eating. Potential problems with the food diary include (1) noncompliance, (2) inaccurate recording, (3) atypical intake on the recording days, and (4) conscious alteration of diet during the recording period.
what are some guides used to assess adequate diet?
MyPyramid, Dietary Guidelines and the Daily Reference Intakes (DRIs)
Clinical signs for nutrition
The general appearance—obese, cachectic (fat and muscle wasting), or edematous—can provide clues to overall nutritional status. More specific clinical signs of nutritional deficiencies can be detected through a physical examination. Because clinical signs are late manifestations of malnutrition, only in areas of rapid turnover of epithelial tissue—skin, hair, mouth, lips, and eyes—are the deficiencies readily detectable. These signs may also be non-nutritional in origin. Therefore laboratory testing is required to make an accurate diagnosis
Body mass index
Body mass index is a practical marker of optimal weight for height and an indicator of obesity or undernutrition
- Weight (kg)/height (meters)^2
- Weight (pounds) / height (inches) x 703
weight in infants, children and adolescents
During infancy, childhood, and adolescence, height, weight, and head circumference should be measured at regular intervals, because longitudinal growth is one of the best indices of nutritional status over time.
weight in pregnant women
- Measure weight monthly up to 30 weeks' gestation, then every 2 weeks until the last month of pregnancy, when weight should be measured weekly.
- Consider the expectant mother at nutritional risk if her weight is 10% or more below ideal or 20% or more above the norm for her height and age-group.
Keys to a healthy diet
- • Eat a variety of foods from all the basic food groups to ensure nutrient adequacy.
- • Consume the recommended amounts of fruits/vegetables, whole grains, and fat-free or low-fat milk products or equivalents.
- • Limit intake of foods high in saturated or trans fats, added sugars, starch, cholesterol, salt, and alcohol.
- • Match calorie intake with calories expended.
- • Be physically active for at least 30 minutes almost every day of the week.
- • Follow food safety guidelines for handling, preparing, and storing foods.
The Obesity Epideminc
The CDC has identified obesity as a major health risk for obesity-related diseases and a health problem of epidemic proportions. Obesity-related diseases include coronary heart disease; type 2 diabetes; endometrial, breast, and colon cancers; hypertension; stroke; dyslipidemia; liver and gallbladder disease; sleep apnea and respiratory problems; osteoarthritis; and gynecologic problems, including abnormal menses and infertility. On its homepage, the CDC invites health care providers and the public to view a state-by-state breakdown of obesity statistics, trends, and economic impact on the U.S. health system, as well as an interactive map illustrating the growth of obesity in the United States since 1985 to its current epidemic proportions
MetS is associated with increased risk for cardiovascular disease, type 2 diabetes mellitus, and mortality, and its prevalence is estimated to be 28% among adolescents and 22% among adults
Sample of a mini-mental state examination (MMSE)
- ORIENTATION TO TIME
- “What is the date?”
- “Listen carefully, I am going to say three words. You say them back after I stop.
- Ready? Here they are …
- HOUSE (pause), CAR (pause), LAKE (pause). Now repeat those words back to me.”
- (Repeat up to five times, but score only the first trial.)
- “What is this?” (Point to a pencil or pen.)
- “Please read this and do what it says.” (Show examinee the words on the stimulus forms.)
- CLOSE YOUR EYES
an acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness (e.g., pneumonia, alcohol/drug intoxication), and is usually resolved when the underlying cause is treated.
a gradual progressive process, causing decreased cognitive function, even though the person is fully conscious and awake, and is not reversible. Alzheimer disease accounts for about two thirds of cases of dementia in older adults
Levels of consciousness
- (1) Alert
- Awake or readily aroused, oriented, fully aware of external and internal stimuli and responds appropriately, conducts meaningful interpersonal interactions.
- (2) Lethargic (or Somnolent)
- Not fully alert, drifts off to sleep when not stimulated, can be aroused to name when called in normal voice but looks drowsy, responds appropriately to questions or commands but thinking seems slow and fuzzy, inattentive, loses train of thought, spontaneous movements are decreased.
- (3) Obtunded
- (Transitional state between lethargy and stupor; some sources omit this level.)
- Sleeps most of time, difficult to arouse—needs loud shout or vigorous shake, acts confused when is aroused, converses in monosyllables, speech may be mumbled and incoherent, requires constant stimulation for even marginal cooperation.
- (4) Stupor or Semi-Coma
- Spontaneously unconscious, responds only to persistent and vigorous shake or pain; has appropriate motor response (i.e., withdraws hand to avoid pain); otherwise can only groan, mumble, or move restlessly; reflex activity persists.
- (5) Coma
- Completely unconscious, no response to pain or to any external or internal stimuli (e.g., when suctioned, does not try to push the catheter away), light coma has some reflex activity but no purposeful movement, deep coma has no motor response.
- Acute Confusional State (Delirium)
- Clouding of consciousness (dulled cognition, impaired alertness); inattentive; incoherent conversation; impaired recent memory and confabulatory for recent events; often agitated and having visual hallucinations; disoriented, with confusion worse at night when environmental stimuli are decreased.
causes of delirium
- Delirium may be due to a general medical condition: systemic infections, metabolic disorders (e.g., hypoxia, hypercarbia, hypoglycemia), fluid or electrolyte imbalances, liver or kidney disease, thiamine deficiency, postoperative states, hypertensive encephalopathy, or following seizures or head trauma.
- Delirium also may be substance-induced (i.e., due to a drug of abuse, a medication, or toxin exposure).
obsessions vs compulsions
- obsessions are recurrent and persistent thoughts or impulses
- compulsions are repetitive behaviors
how we use our senses
You will use your senses—sight, smell, touch, and hearing—to gather data during the physical examination. You always have perceived the world through your senses, but now they will be focused in a new way. The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order.
Palpation follows and often confirms points you noted during inspection. Palpation applies your sense of touch to assess these factors: texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain. Different parts of the hands are best suited for assessing different factors
- Percussion is tapping the person's skin with short, sharp strokes to assess underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ. Why learn percussion when an x-ray study is so much more accurate? It's because your percussing hands are always available, are easily portable, and give instant feedback. Percussion has the following uses:
- • Mapping out the location and size of an organ by exploring where the percussion note changes between the borders of an organ and its neighbors.
- • Signaling the density (air, fluid, or solid) of a structure by a characteristic note.
- • Detecting an abnormal mass if it is fairly superficial; the percussion vibrations penetrate about 5 cm deep—a deeper mass would give no change in percussion.
- • Eliciting a deep tendon reflex using the percussion hammer.
Auscultation is listening to sounds produced by the body, such as the heart and blood vessels and the lungs and abdomen. Likely you already have heard certain body sounds with your ear alone—for example, the harsh gurgling of very congested breathing. However, most body sounds are very soft and must be channeled through a stethoscope for you to evaluate them. The stethoscope does not magnify sound but does block out extraneous room sounds. Of all the equipment you will use, the stethoscope quickly becomes a very personal instrument. Take time to learn its features and to fit one individually to yourself.
Choose a stethoscope with two endpieces—a diaphragm and a bell (Fig. 8-4). You will use the diaphragm most often because its flat edge is best for high-pitched sounds—breath, bowel, and normal heart sounds. Hold the diaphragm firmly against the person's skin—firm enough to leave a slight ring afterward. The bell endpiece has a deep, hollow, cuplike shape. It is best for soft, low-pitched sounds such as extra heart sounds or murmurs. Hold it lightly against the person's skin—just enough that it forms a perfect seal.
A nosocomial infection (an infection acquired during hospitalization) is a hazard because hospitals have sites that are reservoirs for virulent microorganisms. Some of these microorganisms are resistant to antibiotics, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), or multidrug-resistant tuberculosis, or are microorganisms for which there is currently no known cure, such as human immunodeficiency virus (HIV).
- The general survey is a study of the whole person, covering the general health state and any obvious physical characteristics. It is an introduction for the physical examination that will follow; it should give an overall impression, a “gestalt,” of the person (see Sample Charting on p. 153). Objective parameters are used to form the general survey, but these apply to the whole person, not just to one body system.
- Consider these four areas: physical appearance, body structure, mobility, and behavior.
normal temperature ranges
The various routes of temperature measurement reflect the body's core temperature. The normal oral temperature in a resting person is 37° C (98.6° F), with a range of 35.8° to 37.3° C (96.4° to 99.1° F). The rectal temperature measures 0.4° to 0.5° C (0.7° to 1° F) higher.
normal temperature changes
- • A diurnal cycle of 1° to 1.5° F, with the trough occurring in the early morning hours and the peak occurring in late afternoon to early evening.
- • The menstruation cycle in women. Progesterone secretion, occurring with ovulation at midcycle, causes a 0.5° to 1.0° F rise in temperature that continues until menses.
or fever, is caused by pyrogens secreted by toxic bacteria during infections or from tissue breakdown such as that following myocardial infarction, trauma, surgery, or malignancy. Neurologic disorders (e.g., a cerebral vascular accident, cerebral edema, brain trauma, tumor, or surgery) also can reset the brain's thermostat at a higher level, resulting in heat production and conservation.
usually due to accidental, prolonged exposure to cold. It also may be purposefully induced to lower the body's oxygen requirements during heart or peripheral vascular surgery, neurosurgery, amputation, or gastrointestinal hemorrhage.
Take a rectal temperature only when the other routes are not practical—for example, for comatose or confused persons, for persons in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, wired mandible, or other facial dysfunction or if no tympanic membrane thermometer equipment is available. Wear gloves and insert a lubricated rectal probe cover on an electronic thermometer only 2 to 3 cm (1 in) into the adult rectum, directed toward the umbilicus. (For a glass thermometer, leave in place for minutes.) Disadvantages to the rectal route are patient discomfort and the time-consuming and disruptive nature of the activity.
tympanic membrane thermometer (TMT)
- The tympanic membrane thermometer (TMT) senses infrared emissions of the tympanic membrane (eardrum). The tympanic membrane shares the same vascular supply that perfuses the hypothalamus (the internal carotid artery); thus it is an accurate measurement of core temperature.
- The tympanic membrane thermometer is a noninvasive, nontraumatic device that is extremely quick and efficient. The probe tip has the shape of an otoscope, the instrument used to inspect the ear. Gently place the covered probe tip in the person's ear canal and aim the infrared beam at the tympanic membrane
temperature ranges in C and F
104.0 ° F = 40.0 ° C; 98 .6 ° F = 37 .0 ° C; 95 .0 ° F = 35 .0 ° C
In the adult at physical and mental rest, clinical evidence shows the normal heart range at 50 to 90 beats per minute (bpm).34 This differs from the conventional rate limits—60 to 100 bpm—that were established by consensus in the 1950s and never formally examined.
less than 50 bpm
over 90 bpm
Force with pulse
- The force of the pulse shows the strength of the heart's stroke volume. A “weak, thready” pulse reflects a decreased stroke volume (e.g., as occurs with hemorrhagic shock). A “full, bounding” pulse denotes an increased stroke volume (e.g., as with anxiety, exercise, and some abnormal conditions). The pulse force is recorded using a three-point scale:
- 3+—Full, bounding
- 1+—Weak, thready
- Some agencies use a four-point scale; make sure your system is consistent with that used by the rest of your staff. Either scale is somewhat subjective. Experience will increase your clinical judgment.
normal respiratory rates
- 1 yr
- 2 yr
- 8-10 yr
- 12-14 yr
- 16 yr
Blood pressure (BP) is the force of the blood pushing against the side of its container, the vessel wall. The strength of the push changes with the event in the cardiac cycle. The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood exerts constantly between each contraction. The pulse pressure is the difference between the systolic and diastolic pressures and reflects the stroke volume
Factors that can effect blood pressure
- • Emotions. The BP momentarily rises with fear, anger, and pain as a result of stimulation of the sympathetic nervous system.
- • Stress. The BP is elevated in persons feeling continual tension because of lifestyle, occupational stress, or life problems.
orthostatic (or postural) vital signs
- Take serial measurements of pulse and blood pressure when (1) you suspect volume depletion; (2) when the person is known to have hypertension or is taking antihypertensive medications; or (3) when the person reports fainting or syncope. Have the person rest supine for 2 or 3 minutes, take baseline readings of pulse and BP, and then repeat the measurements with the person sitting and
- then standing. For the person who is too weak or dizzy to stand, assess supine and then sitting with legs dangling. When the position is changed from supine to standing, normally a slight decrease (less than 10 mm Hg) in systolic pressure may occur.
a drop in systolic pressure of more than 20 mm Hg or orthostatic pulse increases of 20 bpm or more occurs with a quick change to a standing position. These changes are due to abrupt peripheral vasodilation without a compensatory increase in cardiac output. Orthostatic changes also occur with prolonged bedrest, older age, hypovolemia, and some drugs.
head circumference in infants
Measure the infant's head circumference at birth and at each well-child visit up to age 2 years and then yearly up to 6 years (Fig. 9-14). Use a retractable plastic tape rather than a paper tape measure. Circle the tape around the head aligned with the eyebrows at the prominent frontal and occipital bones; the widest span is correct. Plot the measurement on standardized growth charts. Compare the infant's head size with that expected for age. A series of measurements is more valuable than a single figure to show the pattern of head growth.
pulse in infants
Palpate or auscultate an apical rate with infants and toddlers. (See Chapter 19 for location of apex and technique.) In children older than 2 years, use the radial site. Count the pulse for a full minute to take into account normal irregularities, such as sinus dysrhythmia. The heart rate normally fluctuates more with infants and children than with adults in response to exercise, emotion, and illness.
The pulse oximeter is a noninvasive method to assess arterial oxygen saturation (Spo2). A sensor attached to the person's finger or earlobe has a diode that emits light and a detector that measures the relative amount of light absorbed by oxyhemoglobin (Hbo2) and unoxygenated (reduced) hemoglobin (Hb). The pulse oximeter compares the ratio of light emitted with light absorbed and converts this ratio into the percentage of oxygen saturation. Because it only measures light absorption of pulsatile flow, the result is arterial oxygen saturation. A healthy person with no lung disease and no anemia normally has an Spo2 of 97% to 98%.
In many situations, pulse and BP measurement are enhanced by using an electronic device, the Doppler ultrasonic flowmeter. The Doppler technique works by a principle discovered in the nineteenth century by an Austrian physicist, Johannes Doppler. Sound varies in pitch in relation to the distance between the sound source and the listener; the pitch is higher when the distance is small, and the pitch lowers as the distance increases. Think of a railroad train speeding toward you; its train whistle sounds higher the closer it gets, and the pitch of the whistle lowers as the train fades away.
less than 95/60 mm Hg