Course Introduction. Health Assessment Across The Life Span. The Health History. Pain Assessment. Nutritional Assessment
n Infancy – birth to 1 year
n Toddler – 1 to 3 years
n Preschooler – 3 to 6 years
n School age – 6 to 12 years
n Adolescent – 12 to 20 years
n Early adult – 20 to 40 years
n Middle adult – 40 to 64 years
n Late adult – 65+ years
Developmental Considerations in Assessment
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Theorists
n Erikson – Psychodynamic theory
n Social environment combined with biological maturation provides each individual with a set of “crises” that must be resolved
n 8 stages based on age
n Each stage must be accomplished before moving into next stage
n Piaget – Cognitive theory
n How a person perceives and processes information
n 4 stages not based on age but in order
n Each stage represents a change in how children understand their environment
Infants
n Physical development
n Average term weight is 3.4 kg (7.5 lb). Triple birth weight by 1 year.
n Primitive reflexes that begin to disappear
n Grasp reflex disappears ~2 months
n Vision improves
n Posture, holding head up, sitting, crawling, and walking
n Behavioral and Cognitive
n Trust vs. Mistrust
n Language – crying, imitate sounds (9-10 months), first word!
Toddlers
Physical
n Rate of growth decreasing
n Upright posture
n Improvements in fine motor skills
Behavioral and Cognitive
n Autonomy vs. shame and doubt
n More autonomous
n Object permanence, mental representation
n Negativism – constant protests
n Ritualism – same order
n Parallel play – mimic other children
n Telegraphic speech – few words at a time, basic commands
Growth Charts
Preschoolers
Physical
n Growth of long bones
n Begin to lost baby fat
n Permanent teeth appear
Behavioral and Cognitive
n Initiative vs. guilt
n More autonomous
n Communicate more effectively
n Awareness of others’ needs and interests
n Develop gender roles
n Delayed imitation
n Egocentrism
School Age
Physical
n Muscles stronger and more coordinated
n Bones replace cartilage
Behavioral and Cognitive
n Industry vs. inferiority – a desire to achieve
n Reading and writing improve
n Manage feelings and impulses better
n Identify sex and gender roles
n Identify self as worthy individual
Adolescents
Physical
n Growth spurts in height and weight
n Menarche and thelarche in girls
Behavioral and Cognitive
n Ego identity vs. role confusion
n Formal operational thought
n Identity confusion
n May be embarrassed of own body
n Emotional independence
n More knowledgeable
Early Adulthood
Physical
n Maximum potential for growth and development
n Reduction in activity
Behavioral and Cognitive
n Intimacy vs. role isolation
n Achievements important, career
n Mate selection
Middle Adulthood
Physical
n Wrinkling of skin
n Graying or loss of hair
n Decrease in muscle mass and tone
n Vision and hearing decrease
n At risk populations develop
Behavioral and Cognitive
n Generativity vs. stagnation
n Many decisions about career, lifestyle, family – “midlife crisis”
n Empty nest syndrome
n Intelligence remains constant, more experience
Older Adulthood
Physical
n Many variations
n Chronic illnesses
n Changes in sensation
n Loss of lean body mass, increase in fat deposition.
n Posture deteriorates, wider gait
n Poor skin turgor, xerosis (drying)
n More prone to injury due to loss of bone mass.
Behavioral and Cognitive
n Ego identity vs despair
n Ego identity – acceptance of choices made in their lives
n Despair – Loss of spouse can be devastating
n Stereotyping by society – ageism
Developmental Considerations
n Infant – gentle, calm. Primary interaction with parents
n Preschooler – be direct. Let play with equipment. Only concrete explanation, don’t go into detail.
n School age – they are curious. Explain how and why. Talk to child first than parent.
n Adolescent – be respectful. Explain everything. Avoid silence.
n Older adults – slow down. Be respectful, patient. Like to tell stories.
Approach to Identifying Priorities
n Immediate priorities (ABCs)
n Airway
n Breathing
n Circulation
n Vital Signs
n Second-level priorities
n Mental status change
n Acute pain
n Urinary elimination problems
n Untreated medical problem (diabetic without insulin)
n Abnormal lab values
n Risks of infection, safety, security
n Third-level priorities
n Lack of knowledge
n Activity, rest, sleep
Wellness and Health Promotion
After you have successfully completed this chapter, you should be able to:
■ Define health
■ Identify the nurse’s role in promoting wellness
■ Identify factors that affect health
■ Identify normal sleep patterns for various age groups
■ Identify factors that can affect normal sleep patterns
■ Identify normal exercise patterns for various age groups
■ Identify factors that can affect normal exercise patterns
■ Identify stressors for various age groups
■ Identify risks for injury for various age groups
Health is a broad concept that is difficult to define. Older definitions viewed health as the absence of disease. But today health is seen as a goal, a dynamic process that involves the self and self-care ability; optimal functioning of body, mind, and spirit; the ability to adapt; feelings of well-being and wholeness; and growing and becoming.
People also have their own definitions of health, which are affected by gender, sociocultural factors, previous experience, age, and personal goals. These personal definitions influence their health promotion goals.
The three basic levels of prevention are primary, secondary, and tertiary.Primary prevention is essential to maintaining a state of wellness. At this level, the assessment process should include screening procedures, immunizations, and especially,prevention education.
How do you teach people to stay well? Follow these steps:
■ Set an example with a healthy lifestyle.
■ Motivate them to change unhealthy behaviors.
■ Propose strategies for behavior change.
■ Show them how to care for themselves more effectively.
■ Build on their strengths.
■ Help them find and use available resources.
■ Provide support through telephone, individual, and group counseling and continuing education.
Healthy People 2010 has identified leading health indicators that are used to measure the health of our nation over the next 10 years. These indicators were selected based upon the ability to motivate change, data availability to evaluate progress, and importance as public health issues (Healthy People 2010). The indicators are not disease specific, but rather, many are behavior specific. It is the unhealthy behaviors that increase the risk for disease, such as smoking increases the risk for lung disease (chronic obstructive pulmonary disease [COPD]) and lung cancer. As healthcare providers, you are in prime position to promote wellness.
The leading health indicators are:
■ Physical activity.
■ Overweight and obesity.
■ Tobacco use.
■ Substance abuse.
■ Responsible sexual behaviors.
■ Mental health.
■ Injury and violence.
■ Environmental quality.
■ Immunizations.
■ Access to healthcare.
These leading health indicators are addressed throughout this text. This chapter focuses on assessing four key areas fundamental to maintaining wellness—rest and sleep,exercise,stress management,and injury prevention—and suggests questions to ask at each developmental stage.
Factors Affecting Health Behaviors
Many factors influence a person’s choice to maintain healthy behaviors. Some of these factors include support systems, psychological state of mind, access to healthcare, and motivational level. Some of these factors may be beyond your patient’s control, and your influence on these factors could lead to a positive outcome. Referrals may be needed to facilitate healthy behaviors, and providing support for your patient can be crucial to his or her wellness.
Support Systems
The encouragement of friends and family can mean the difference between achieving personal health goals and falling short of them. Ask the person about her or his support systems, and then use these systems in the assessment process when needed. Other types of supports include organized religious groups, nurses and other caregiving professionals, and self-help groups such as Weight Watchers.
Psychological State
A person’s psychological state affects his or her physical state.For example,if a person knows that he or she needs to stop smoking, start eating more healthfully, and start exercising more, then why doesn’t he or she do it? Part of the assessment process is determining these reasons and working with people to change harmful behavior.
Access to Healthcare
People may be motivated to maintain or improve their state of wellness but be prevented from doing so because they lack access to healthcare. Causes include lack of finances or insurance coverage;rural location;lack of transportation;crowding at available healthcare resources; age,gender, ethnicity, and/or religion (possibly because of prejudice);and healthcare rationing based on these factors.
Motivational Level
Because people tend to resist change, convincing them to trade unhealthy behaviors for healthy ones can be difficult. Teaching them the importance of primary prevention does not ensure that they will practice what you preach. For example, people know that smoking, obesity, and lack of exercise are dangerous to their health, but they still have trouble changing long-standing behaviors unless they are truly motivated.
The wellness assessment entails asking the person and/or caregiver first general questions about health promotion behaviors and then specific questions about sleep and rest, exercise, stress management, and injury prevention. Health promotion behaviors and needs differ according to the person’s developmental stage.
General Questions to Ask at Each Developmental Stage
Tailor your assessment questions to the person’s developmental level—infant, toddler/preschool/school age, adolescent, young adult, middle age, or older adult. Include younger children in the interview as maturational level permits, and definitely include them by late school age. For young children, also assess health promotion behaviors for the family and the ability of the family to meet the child’s needs.
Infants/Toddlers/Preschoolers
Ask the parent(s) or caregiver(s): Has your child’s blood pressure been checked? Does the child brush her or his own teeth? How often? Are her or his immunizations (polio,diphtheria-tetanus-pertussis,measles-mumps-rubella, Haemophilus influenzae type B, hepatitis A and B, chickenpox, pneumococcal disease) up to date? Has she or he had a vision and hearing assessment? If so,when? If the assessment was abnormal, what follow-up has occurred? What are your child’s nutritional habits? Has she or he been tested for anemia or tuberculosis? What are your child care arrangements? Have you ever harmed your child or wanted to? Do you know what community resources are available related to child abuse?
Individualize your patient’s health promotion plan—it increases the chance of success.
Do not assume that people know how to stay well. We may be bombarded with health information in the media and on the Internet, but what seems simple and obvious to the healthcare professional may still seem complex to the layperson.
Assessing People’s Strengths
Knowing your patient’s strengths and weaknesses will help both of you set realistic goals and help you plan appropriate interventions. Ask some or all of the following questions:
■ What abilities do you possess to take care of your health?
■ What activities help you to maintain or improve your health?
■ What changes have you made in your lifestyle in the past 2 years to improve your health?
■ What goals have you set to improve your health? Do you have a plan for reaching them?
■ What changes in your life do you see in the future?
■ What people currently give you the most support?
■ What current activities make you feel happy?
■ When you were younger, what activities gave you strength, comfort, and support?
■ What helps you cope in a crisis?
■ What gives you direction in your life?
■ How do you spend a typical day?
■ What do you feel motivated to do in terms of a lifestyle change?
■ What barriers do you think will inhibit your lifestyle change?
■ What health problems have you successfully dealt with in the past?
Health Promotion Plan of Action
■ Identify the person’s healthcare goals.
■ Identify behavioral or health outcomes.
■ Develop a behavior change plan.
■ Reiterate benefits of change.
■ Address environmental and interpersonal facilitators and barriers to change.
■ Determine a time frame for implementation.
■ Ask the person to make a commitment to healthcare goals.
School-Age Children
Adapt the questions in the previous paragraph and also ask the following: Has your child been part of home, school, or community education programs related to alcohol,drugs, sexuality, acquired immunodeficiency disease syndrome (AIDS), birth control, or sexually transmitted diseases (STDs)? Does the child brush his or her teeth and practice other health promotion behaviors without being reminded? How is he or she doing in school?
Adolescents
Ask the adolescent the same questions as you asked about the school-age child, and also ask the following:
Who are your community role models?
All Adults
Ask adults of any age: What is your or your family’s definition of health? Do you believe you are healthy? Do other family members believe they are healthy? What health practices are included in your and your family’s lifestyle?
How is the family affected when someone is ill? Do you and your family have access to healthcare? Do you all have health insurance? Do you all receive regular physical and dental examinations? What religious or cultural beliefs do you all have that guide your purpose in life and your health practices?
Young Adults
Primary physical growth is completed during the 20s,and body systems usually reach peak functioning.
Although most young adults are healthy, some major threats include accidental injury, cancer, heart disease, suicide, AIDS, and homicide. Men are more likely to die than women, especially as a result of homicide involving handguns. Ask the following questions: Are your immunizations up to date? Do you visit a family doctor? Do you perform self-screening (e.g., breast or testicular selfexamination)?
How often? What do you eat in a 24-hour period? Are there behaviors affecting your health that you would like to change?
Middle-Aged Adults
At this stage, people are likely to be knowledgeable and assertive about their health and healthcare. However, they may not know what specific screening tests they should have.Middle-aged men are less likely to seek routine preventive care than women,which may be one reason why the life expectancy for women is approximately7 years longer than that of men.Ask the following questions:How do you care for your teeth? What screening tests have you had and when (e.g., mammograms and prostate-specific antigen blood tests)? What were the results? Do you keep a written record of your physician visits,immunizations,and screenings? Do you get a yearly flu shot? How about pneumonia vaccinations, tetanusdiphtheria, and hepatitis B injections?
Older Adults
Many older people begin to develop health problems,but they need to know that it is never too late to begin living more healthfully. Social support is the key in maintaining wellness in the later years. Research shows that older people who regularly attend religious services are less likely to require hospitalization, and when they do, have shorter hospital stays.Ask the same questions you asked the middle-aged person, but stress the importance of getting immunized, limiting medication use, eating nutritious foods, drinking enough fluids, interacting with family and friends, and keeping active in the church or community.
Assessing Areas of Wellness
The following four areas are critical to maintaining wellness: rest and sleep, exercise, stress management, and injury prevention.
Rest and Sleep
Sleep restores, rejuvenates, and sometimes, heals the body. Lack of sleep causes fatigue, stress, depression, and a decrease in lymphatic system functioning, which increases the risk of infection and disease. The following factors can directly affect how well and how long we sleep:
■ Circadian rhythms: Also called the biological clock, these rhythms help regulate the sleep/wake cycle, body temperature, and hormonal levels within a 24-hour period. Disruption affects muscle strength and coordination, attention, memory, and concentration.
■ Age: Infants sleep 16 to 20 hours a day; preschoolers, 10 to 12 hours a day;school-age children, 9 to 10 hours a day; adolescents 71⁄2 hours a day; and adults and older adults, 6 to 8 hours a day. Babies spend more time in rapid eye movement (REM) sleep than adults. Young children may experience sleep problems such as nocturnal enuresis (bedwetting), nightmares (bad dreams), night terrors (nightmare from which child awakens screaming), and somnambulism (sleepwalking). Older adults may take more time to fall asleep (sleep latency), may have a fragmented sleep pattern with less deep sleep, and may awaken early.
■ Exercise: Moderate exercise has little or no effect on sleep; however, vigorous exercise before retiring may inhibit sleep.
■ Nicotine, caffeine, alcohol: Smoking increases the time needed to fall asleep and causes lighter sleeping and more frequent awakening. Caffeine near bedtime can increase sleep latency and reduce total sleep time, especially in older adults. Alcohol affects REM sleep, causing a fragmented sleep pattern, and also exacerbates sleep apnea.
■ Diet and weight: Sleep apnea is more common in obese people. High-protein foods increase alertness; carbohydrates promote relaxation. People who are gaining weight usually sleep more; those who are losing weight sleep less.
■ Medical problems: COPD, congestive heart failure (CHF), and pain can affect sleep patterns.
■ Stress: Stress often increases arousal and inhibits sleep.
■ Medications: Some prescription and over-the-counter (OTC) drugs can affect the number of hours a person sleeps as well as the sleep process.
Questions to Ask at Each Developmental Stage
Infants
Ask the parent(s) or caregiver(s):Where does the infant sleep? In what position do you place her or him? Does the infant sleep through the night? Does she or he go to sleep with a bottle? If so,do you remove it once she or he is asleep? (Having a nipple drip milk into the mouth once the child is asleep can cause tooth decay and ear infections, in addition to being a choking hazard.)
Toddlers/Preschoolers/School-Age Children
Ask the parent(s) or caregiver(s): Where does the child sleep? How many hours does he or she sleep? Does the child take naps? Does he or she sleep through the night?If not, how do you console the child when he or she awakens? What bedtime rituals do you practice? Does the child act tired during the day?
Adolescents
Ask the adolescent:How many hours do you sleep? Are you tired during the day? Do you have trouble paying attention at school or at work because of fatigue? Do you have a regular time you go to bed, and do you stick to it? Do you usually sleep through the night? If not, what causes you to wake up? How do you get back to sleep?
Young Adults
Ask the young adult: How many hours of sleep do you need to feel rested? How many hours of uninterrupted sleep do you get each night? Do you usually sleep through the night? If not, what causes you to wake up? How do you promote sleep or get back to sleep? Do you have a bedtime routine? Do you take medications that interrupt a normal sleep cycle? Do you take medications to help you sleep? Do you maintain a physical fitness program? Do you have problems concentrating because of fatigue? What are your usual work hours?
Middle-Aged Adults
Ask the same questions as you asked the young adult, as well as the following:How would you describe your quality of sleep? What time do you usually go to bed? How long does it take you to go to sleep? What time do you usually wake up and get up? What do you do for relaxation and how often do you do it?
Older Adults
Adapt the questions you asked the young and middleaged adults, and add the following:What activities do you engage in during late afternoon or early evening? If you have trouble falling asleep, have you tried a light, warm snack at bedtime?
Exercise
Today, with so many people working at sedentary jobs,exercise needs to be planned for. Research shows that women are less active than men; people with lower incomes and less education are less active than those with higher incomes and education; people with disabilities are less active than people without disabilities; African Americans and Hispanics are less physically active than Caucasians; and many children and youth are overweight and exercising less, except for those active in organized sports. Major barriers to increasing physical activity are lack of time, access to convenient facilities,and safe environments in which to be active.
Questions to Ask at Each Developmental Stage
Infants
Keep in mind what gross and fine motor skills are normal at this age.Ask the parent(s) or caregiver(s):Does the infant play with her or his hands and feet and make noises? What kinds of toys do you give her or him? Which toys does the infant prefer? How often do you change her or his toys and play environment? Do you check toys regularly for loose parts and other safety hazards?
Toddlers/Preschoolers
Keep in mind what gross and fine motor skills are normalat this age. Ask the parents(s) or caregiver(s): Does the child have any physical limitations? Does he or she tire easily? What activities does he or she like? Does the child have a safe environment to explore and play? Whom does he or she play with? How many hours does your child watch TV or participate in other sedentary activities? What do you do to encourage physical activity during bad weather?
School-Age Children
Ask the same questions as you asked about the toddler/preschool child, as well as the following:
■ To the child: Do you play organized sports? What precautions do you take, and what protective equipment do you wear?
■ To the parent(s) or caregiver(s): Do you encourage physical activity? Do you engage in physical activities with your children?
Adolescents
Ask the adolescent: What competitive sports or other physical activities do you like? Do you schedule exercise during your week? How often and for how long? Do you exercise with friends? Do you have any physical limitations? Have you ever been injured during exercise? Does your school encourage participation in physical activities? What precautions do you take and what protective equipment do you wear? Do you gain satisfaction from exercising?
Young Adults
Ask the young adult: What physical activities do you include during an average week? How often and for how long? Do you have any physical limitations? Do you have any health conditions that should be evaluated before beginning an exercise program? Where do you exercise?Do you participate in activities that raise your heart rate? Do you include a warm-up and cool-down period? Do you participate in organized sports? What precautions do you take and what protective equipment do you wear?Have you had any exercise-related injuries? With whom do you exercise? Do you engage in physical activities as a family? Do you enjoy your exercise program?
Middle-Aged Adults
Ask the middle-aged adult:What kinds of exercise do you do? How often and for how long? Where do you exercise? With whom do you exercise? Do you warm up before and cool down after each exercise period? Have you had any unusual or uncomfortable feelings before,during, or after exercising? (If so, refer back to the person’s cardiovascular, respiratory, and musculoskeletal history data.)
Older Adults
Ask the same questions as you asked the middle-aged patient, but emphasize that the older adult should check with her or his doctor before starting a new exercise program.
Stress Management
Multiple stressors can occur at any age, even infancy,although different age groups are subject to different stressors.
Over time, stress can cause hypertension, cardiac arrhythmias, cardiovascular disease, gastrointestinal problems, headaches, and decreased immunological functioning, which can contribute to cancer and other diseases.
Questions to Ask at Each Developmental Stage
Infants
Keep in mind what social developmental milestones are normal for this age. Ask the parent(s) or caregiver(s) the following: What emotions have you seen the infant express? How does the infant calm himself or herself when crying? How do you calm the infant when he or she is unable to become calm? How would you describe his or her temperament? Does the infant entertain himself or herself when alone? How do you set limits for him or her? Does your home environment provide cognitive, physical, and psychosocial stimulation for the infant?
Who provides child care wheeeded? Does the caregiver stick to the infant’s usual routines?
Toddlers/Preschoolers
Adapt the preceding questions, and also ask the following:How does your child calm herself or himself after an emotional outburst? Children tend to regress when ill, so what do you do to support the child’s developmental level when she or he is ill? How do you show affection to your child, and how does she or he respond? How well does your child play with other children? What kinds of conflicts occur with other children? How do you set disciplinary guidelines for your child? How do you encourage her or his development of autonomy and initiative? How does she or he interact with siblings? How does she or he express positive (love,affection,happiness,joy) and negative emotions (hate, jealousy, anger, fear)? Do you actively model healthy expression of emotions in the home? Does your child enjoy child care experiences?
School-Age Children
■ To the child:Do you usually feel happy and contented?Do you like yourself? What do you do when you feel bored or sick? Do you like to compete with others in organized or informal activities? Do you enjoy learning new things? Do you feel confident as you begiew projects?Do you enjoy the challenge of solving new problems? Do you feel like your parents or caregivers support your activities and enjoy your successes? Do they support you even when you do not meet their expectations?Do you think of the consequences of your behavior before acting? Who are your friends? Do you feel included in most peer-group activities? If you have conflicts with friends,what is the source of the conflict, and how do you resolve it? Do you receive an allowance or have an opportunity to earn money? How do you manage your money? Do you feel good about your progress at school? What do you like most and least about school?How often do you miss school or other activities because you do not feel well? What types of physical activities do you do? How often and for how long?
■ To the parent(s) or caregiver(s): Do you give your child an allowance and provide general guidelines for money management? How do you display your interest in your child’s school work/progress? How do you support your child when he or she does not feel well? How would you describe your child’s friends? What stressmanagement techniques do you model or actively teach your child? How does your child act when he or she is tired or stressed out? How does he or she cope with emotional stress? What types of changes have affected your family and the child during the last year?
Adolescents
Adapt the questions for the school-age child, and also ask the following: Do you feel comfortable with the physical changes accompanying puberty? What accomplishmentsare most important to you? What stressors do you experience weekly? How do you reduce stress or the effects of stress? Are you able to be assertive when you need to be?
Can you give an example? What risks have you taken in the last year? Do you use tobacco, alcohol, or street drugs? What about OTC and prescription drugs? If so,what kinds,how often,and how much? How would you describe your peer group and your relationship with the group? How would you describe your relationships with the same sex, the opposite sex, and adults? How do you usually make decisions? What plans do you have once you leave or complete high school? Who are your role models for stress management? How do your parents support your efforts to be an independent person? What are the most common sources of conflict with your family and your peers? How do you resolve conflicts when they occur? Whom do you go to for support when you have a problem? What steps would you take if you were depressed or had thoughts of suicide or if you saw these characteristics in a friend? Have you ever been the victim of violence? Have you ever abused an animal or another person?
Young Adults
What stressors do you experience weekly? How do you reduce stress or the effects of stress? What risks have you taken in the last year? How do you make decisions? How would you describe your relationships with the same sex and the opposite sex? What are the most common sources of conflict with your family, friends, and coworkers? How do you resolve conflicts when they occur? Do you use tobacco, alcohol, or street drugs? What about OTC and prescription drugs? If so,what kinds,how often, and how much? Have you ever been the victim of violence? Have you ever wanted to hurt or abuse another person? Are you satisfied with your career choice? If not, what are your plans for a change? Do you have problems with time management?If you have children, what parenting rewards and challenges do you encounter? Do you feel confident and satisfied with your parenting skills?
Middle-Aged Adults
Ask the same questions that you asked the young adult.
Older Adults
Adapt the questions you asked the young adult and middleaged adult,and also ask the following:When do you plan to retire from a full-time position? Are your financial resources adequate? Do you plan to work part-time after retirement? What activities are you interested in (e.g., travel, hobbies,volunteer work in the community)?
Injury Prevention
Injuries can occur at any age, and most people have a significant injury at some time in their lives. Although most accidents are predictable and preventable, accidental injuries are the leading cause of death in the 1- to 34-year old age group. Additional millions are incapacitated by accidental injuries.
Questions to Ask at Each Developmental Stage
Infants
Ask the parent(s) or caregiver(s):What have you done tomake your home safe for the infant? Do you use an infant car seat? Is the infant regularly exposed to tobacco smoke? Has she or he been injured as a result of an accident in the home, in another’s home, or while riding in a motor vehicle? How often do you check equipment and toys for possible hazards? Are there guns in your home or in your caretaker’s home? If so, are they securely stored?
Toddlers/Preschoolers/School-Age Children
Adapt the preceding questions, and also ask the parent(s) or caregiver(s) the following: Have you taught your child personal safety guidelines? Does he or she use protective equipment when participating in physical activities like skating or bicycling? Who supervises your child when he or she is playing? Can he or she swim and does he or she know water safety guidelines?
Case Study Analysis and Plan
Adolescents
Ask the adolescent: Do you like to take risks? Have you completed a driver education course? What safe-driving behaviors do you practice? Do you talk on a cell phone while driving? Do you consider yourself well informed regarding the transmission, signs, symptoms, and treatment of STDs? Are you sexually active, and if so, do you practice safe sex? Do you know where to get confidential medical attention if you believe you have an STD or may be pregnant? Do you use alcohol, tobacco, or street drugs? What about OTC and prescription drugs? If so, what kinds, how often, and how much? Do you ever drive while under the influence of alcohol or drugs? Do you have guns in your home, and if so, are they securely stored? Have you ever been injured as a result of participation in physical activities? What protective measures do you take? Would you recognize signs and symptoms of depression in yourself or a peer? What would you do if you or a peer were depressed or had thoughts of suicide?
Young Adults
Adapt the preceding questions, and also ask: Have you evaluated your occupational health risks? What resources are available to you at work related to health maintenance or injury prevention? Do you have smoke and carbon monoxide detectors in your home,and do you check them frequently?
Middle-Aged Adults
Adapt the preceding questions, and also ask: Are you aware of environmental hazards in the home (e.g., loose rugs, electrical cords, stairways, steps)?
Older Adults
Adapt the questions for young and middle-aged adults,but focus on the prevention of falls.Ask:Can you describe any hazards in your home, especially in the bathroom,kitchen, or outside steps and sidewalks? Do you use an assistive device,such as a cane,walker,or wheelchair? Do you keep them in good repair? Have you made any modifications to your home, such as a wheelchair ramp or grab bars in the tub and by the toilet?
S U M M A R Y
■ There is no uniform definition of health as it applies to individuals, families, and communities. Yet, a definition forms the foundation for personal perceptions and is crucial in determining individual health promotion behaviors.
■ Some factors that affect health behaviors are the person’s motivation, support system, psychological state, and access to healthcare.
■ The key to assessing wellness is to identify the person’s perspective of health and any factors that affect health behaviors, and then work with him or her to develop a plan that promotes healthy living.
Cultural Considerations
With cultural and ethnic diversity come many challenges. As a health care professional, you are challenged with the responsibility to work with and care for individuals who may not have the same skin color, language, health practices, beliefs, and values as your own. When this occurs, the goal is not to force the client and his or her family to comply with your beliefs, values, and health practices but instead to meet the client where he or she is and to work with his or her belief and value system. The challenge occurs not when the client is of the same heritage and speaks the same language as the nurse, but when the cultures and languages are different. Consider the following scenario:
You are caring for a 72-year-old Hispanic woman, Rosa Martinez, who speaks Spanish as her primary language. Conversing in broken English, she tells you that she has injured her lower back and now has continuing aches and stiffness. She does not want to be at the clinic but is here because her daughter forced her to come. She says that she hasn’t seen a physician in years because Maria, her cuerandera, takes good care of her. When you inquire whether she has seen Maria for her back, she replies yes and then goes on to tell you that Maria had given her an herbal formula to take internally and had made herbal poultices to use at home. The client tells you that she believes that these remedies are working and she is not sure why her daughter made her come to the clinic.
The nurse caring for Mrs. Martinez is potentially challenged by three issues: (1) the language barrier; (2) an alternative health care provider, Maria the cuerandera, in whom Mrs. Martinez has much confidence; and (3) the use of alternative folk remedies—the herbal formulas and poultices. How the nurse interacts with this client and her family will depend partly on the nurse’s own heritage and culture and partly on her knowledge of and attitude toward other cultures and other cultural health beliefs and practices.
As health care professionals we are not responsible for knowing about the health beliefs, practices, and values of all of the cultural and racial groups other than our own, because the diversity among us is so great. We are responsible for asking the client about his or her health beliefs, practices, and values because knowing this information is essential for individualizing care. A person may be from one of the major racial and cultural groups, such as Native American, African American, Asian, white American, or Hispanic, or one of the often unrecognized cultural groups, such as the homeless, migrant workers, gay men, or lesbians. To improve cultural awareness and sensitivity, however, you can ask questions to gather information about the unique beliefs and value systems of individuals of other cultures and backgrounds.
Culture, ethnicity, and race are terms used to learn about cultural awareness. Culture is defined as all of the socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, life ways, and characteristics of a population that influence perception, behavior, and evaluation of the world. Ethnicity refers to a social group within a cultural and social system that shares a common social and cultural heritage, including language, history, lifestyle, and religion (Fig. 3-1). Cultural background is a fundamental component of one’s ethnic background. Ethnicity is indicative of some of the following characteristics that a group may share in some combination: common geographic origin; race; language and dialect; religious beliefs; shared tradition, values, and symbols; literature, folklore, and music; food preferences; settlement and employment patterns; and an internal sense of distinctiveness (Spector, 2000). Race is genetic in origin and includes physical characteristics such as skin color, bone structure, eye color, and hair color. The Human Genome Project provides evidence that all human beings share a genetic code that is more than 99% identical. Although less than 1% difference exists in genetic code, the differences are evident when performing health assessments. People from a given racial group do not necessarily share a common culture (Purnell & Paulanka, 2003).
To emphasize the importance of culturally and linguistically appropriate services in health care, the U.S. Department of Health and Human Services (USDHHS) Office of Minority Health (OMH) issued national standards to ensure that all people entering the health care system receive equitable and effective treatment (Fig. 3-2). These 14 standards provide for culturally and linguistically appropriate services (CLAS) to help eliminate racial and ethnic health disparities and to improve the health of all people who live in the
Become Culturally Competent
Cultural competence is the ability to communicate between and among cultures and to demonstrate skill in interacting with and understanding people from cultures other than your own. A culturally competent nurse communicates in a way that allows clients to explain what an illness means; respects the concepts of time, space, and contact of the client; and respects physical and social activities of clients. This nurse respects systems of social organization and provides as much of a sense of environmental control as is possible (McNaught, 2002).
describes ways to achieve cultural competence.
Every individual on this earth is unique. Regardless of a person’s skin color, physical features, cultural heritage, or social group, realize that individual’s uniqueness. Cultural heritage plays an important part in helping to identify the individual’s “roots” and perhaps helps to explain attitudes, beliefs, and health practices, but each major cultural group is made up of unique individuals and families who may have values and attitudes that differ from the cultural norm. Don’t assume that because individuals or families are Asian or Pacific Islander they all share culturally similar beliefs. For example, within the Asian or Pacific Islander people are Chinese, Filipino, Japanese, Asian Indian, Korean, Vietnamese, Cambodian, Thai, Bangladeshi, Burmese, Indonesian, Malayan, Laotian, Kampuchean, Pakistani, Sri Lankan, Hawaiian, Samoan, Tongon, Tahitian, Palauan, Fijian, and Northern Mariana Islanders, and each of these groups has a unique heritage and set of beliefs.
Personal beliefs and knowledge about other cultures in the
Some common misbeliefs and stereotyped images include the following:
• All African Americans have large families.
• All welfare recipients are minorities.
• All Asians excel in math and science.
• All Native Americans live on reservations.
• All Hispanics speak Spanish.
If you learothing else from this text, learn that we are all unique individuals deserving of a unique and personalized assessment of our beliefs, our values, and our culture.
To illustrate the fallacy of stereotyping, consider the analogy of assuming that all clients who have type 1 diabetes mellitus have renal failure, visual impairment, and an amputated extremity. You would assess those clients to determine their unique characteristics. Likewise, you do not assume that all people who are Catholics are opposed to divorce just because it is a belief of the religion (Dreher and MacNaughton, 2002). You would ask each client questions selected from a template for assessment that you thought were applicable.
Develop A Template For Assessment
When assessing the client and family, it is important to include a direct assessment of the client’s health beliefs and practices that may reflect his or her cultural heritage. Knowing the risks of stereotyping, perform a focused interview that will provide information about the client’s personal beliefs, values, and attitudes.
Introductory Questions
• Where were you born?
• With what particular cultural group (or groups) do you identify?
• What Is the Client’s Primary Language and Method of Communication?
• What is the language that is usually spoken in your home?
• How well do you speak, read, and write English?
• In what language do you think?
• Do you have to translate in your mind when communicating in English?
• Will you need the services of a translator during the time you are in this health care facility?
•Are there special rituals of communication in your family? (For example, is there someone special to whom questions should be directed?) Tell me about these.
• Are there unique customs in your culture that influence nonverbal or verbal communication? Tell me about them.
• What are some signs of indicating respect for others?
• What are appropriate ways to enter and leave situations?
What Are the Client’s Personal Beliefs About Health and Illness?
• How do you define health and illness?
• Do you believe that you have control over your health? If not, what or who do you believe controls your health?
• What are some of the practices or rituals that you believe will improve your health?
• Do you or have you used any of the alternative healing methods, such as acupuncture, acupressure, ayurveda, healing touch, or herbal products? If so, how effective was the treatment?
• Whom do you consult when you are ill?
• What are specific practices or rituals that you believe should be used to treat your health problem?
• What are your attitudes toward mental illness? Pain? Handicapping conditions? Chronic disease? Death? Dying?
• Who makes the health decisions in your family?
• What health topics do you feel uncomfortable talking about?
• What examination procedures do you feel modest about?
• What can the members of the health care team do to help you stay healthy (or become healthy again)?
What Religious Influences and Special Rituals Affect the Client?
• Is there a particular religion that you practice?
• Whom do you look to for guidance and support?
• Are there any special religious practices or beliefs that are likely to feel supportive when you are ill?
• What events, rituals, and ceremonies are considered important within your life cycle, such as birth, baptism, puberty, marriage, and death?
What Are the Roles of Individual People in the Family?
• Who makes the decisions in your family?
• What is the composition of your family? How many generations or family members live in your household?
• When the marriage custom is practiced, what is the attitude about separation and divorce?
• What is the role of and attitude toward children in the family?
• When the children are punished, how is it done, and who does it?
• What are the major important events in your family? How are they celebrated? Do you or the members of your family have special beliefs and practices surrounding conception, pregnancy, childbirth, lactation, and child rearing?
Does the Client Have Special Dietary Practices?
• What is the main type of diet eaten in your home?
• Are there special types of foods that are forbidden by your culture or foods that are a cultural requirement in observance of a rite or ceremony?
• Who in your family is responsible for food preparation?
• How is the food in your culture prepared?
• Are there specific beliefs or preferences concerning food, such as those believed to cause or cure illness?
Remember
The most important behaviors in cultural assessment are to be sensitive; to ask questions; to gather information specific to the individual client; to not stereotype; and to not assume that, just because you took care of a similar client last week, you know exactly how this client feels and what he or she believes.
Regardless of the client’s race or cultural heritage, each individual is unique. Before you become involved in the detailed task of a physical assessment, first take the time to get to know the client and his or her family.
Health History
The two primary components of health assessment are the health history and the physical examination. Collection of assessment data is the first step in the nursing process and an expectation of nurses in clinical nursing practice (American Nurses Association, 2004). Together, the nurse and client use this database to create a plan to promote health, prevent disease, resolve acute health problems, and minimize limitations related to chronic health problems. Accomplishing this purpose involves meeting both the clients’ expectations for health and the nurse’s expectations for the health of those clients.
The purpose of the health history is to obtain subjective data from the clients. Information to be gathered includes how clients define health, whether they believe they can attain and maintain health, whether they believe they are responsible for their health, what health behaviors they practice now, and what unhealthy behaviors they are willing to change. The clients’ expectations for health are based on their life experiences, the experiences of their families and friends, and the culture in which they live. The nurse has a broader view of health and compares a client’s current state of health to a standard needed to attain or maintain optimal health and then determines how far away the client is from the desired standard.
Purpose of the Health History
The purpose of the health history is to identify not only actual or potential health problems but also your patient’s strengths. It should also identify discharge needs. In fact, a successful discharge plan begins on admission with the health history. To create a successful plan of care, you must take a holistic view of your patient and all that affects her or him. Remember: The plan you develop will be successful only if your patient is able to follow through with it after discharge. The purpose of the health history is to:
■ Provide the subjective database.
■ Identify patient strengths.
■ Identify patient health problems, both actual and potential.
■ Identify supports.
■ Identify teaching needs.
■ Identify discharge needs.
■ Identify referral needs.
Types of Health Histories
A health history may be either complete or focused. A complete health history includes biographical data, reason for seeking care, current health status,past health status, family history, a detailed review of systems, and a psychosocial profile. A focused health history focuses on an acute problem, so all of your questions will relate to that problem.
Complete Health History. The complete health history begins with biographical data, including the patient’s name, age, gender, birth date, birthplace,marital status, race, religion, address,education, occupation, contact person, and health insurance/social security number. It should also include the source of the health history and his or her reliability, who referred the patient, and whether or not the patient has an advance directive. Once you have obtained this information, you should then identify the reason for seeking healthcare, followed by a description of current health status.
The past health history includes childhood illnesses, surgeries, injuries, hospitalizations, adult medical problems, medications, allergies, immunizations, travel, and military service. The family history will identify familial or genetically linked disorders. The review of systems provides a comprehensive assessment to determine your patient’s physiological status. Past or current problems may be identified and warrant further investigation.
The psychosocial profile gives you a picture of your patient’s health promotion and preventive patterns. It includes a description of health practices and health
beliefs, a typical day,nutritional patterns, activity/exercise patterns, recreational patterns, sleep/rest patterns, personal habits,occupational and environmental risk factors, socioeconomic status,developmental level, roles and relationships, self-concept, religious and cultural influences, supports, sexuality patterns, and finally, the emotional health status of your patient. Once you have completed the health history, summarize any pertinent data.
A complete health history provides a comprehensive, holistic picture of your patient. It screens for actual or potential problems and identifies your patient’s strengths and health promotion patterns. A complete health history may be obtained in a primary setting as a screening tool, in a secondary setting once your patient’s condition stabilizes, or in a tertiary setting to establish a baseline from which to develop your plan of care.
Focused Health History. A focused health history contains necessary biographical data, including the patient’s name, age, birth date, birthplace, gender, marital status, dependents, race, religion, address,education,occupation,contact person, and health insurance/social security number. It also includes the source of the health history and her or his reliability,who referred the patient,and whether or not the patient has an advance directive. You should then identify the reason for seeking care, followed by a complete symptom analysis.
In your past health history, address any areas that relate to the reason for seeking care, including diseases of high incidence in the United States, such as heart disease, hypertension, cancer, diabetes, and alcoholism. In your review of systems, ask questions about every system and how it relates to the presenting health problem. The questions in the psychosocial profile identify the impact of the presenting health problem on your patient’s life.
A focused health history may be indicated when your patient’s condition is unstable or when time constraints are an issue. Focused health histories may also be used for episodic follow-up visits for your patient. In this case,you have already obtained a detailed health history at an earlier point and have established the subjective database. During the follow-up visits, you need to obtain further subjective data to monitor and evaluate your patient’s progress. Once you have completed the focused health history, remember to document any pertinent findings.
Focused versus Comprehensive History. Deciding which type of health history to do depends on two factors: your patient’s condition and the amount of time you have.
Patient’s Condition. First, determine the condition of your patient. This condition may prohibit a detailed health history upon admission. For example, if you are working in the emergency department and John Harrison, a 49-year-old man, presents with acute chest pain, a comprehensive health history is not indicated. Instead,you should obtain a focused history while you perform a physical assessment, draw laboratory studies, obtain an electrocardiogram, and connect your patient to a cardiac monitor.When a patient is in acute distress, trying to obtain a complete health history not only is detrimental but also provides little valuable or accurate information. So ask key questions that focus on the acute problem; once your patient’s condition stabilizes, obtain a more detailed health history.
Amount of Time. Allot at least 30 minutes to an hour to obtain a complete health history. Be sure to let your patient know why you are asking these questions and that it will take time. If you do not have enough time to complete the history,do not rush. Instead, perform a focused history first, and then complete the history at later sessions.
Medical History versus Nursing History
The areas addressed and the questions asked during a medical health history are very similar to those in a nursing health history. However, some important differences exist. These differences are defined by the focus and scope of medical versus nursing practice. Although the history questions are similar, the underlying rationale differs. Remember: Physicians diagnose and treat illness. Nurses diagnose and treat the patient’s response to a health problem.
For example,Mary Johnson, an 81-year-old woman, is admitted to the hospital with a fractured right hip. The focus of the medical history would be to identify what caused the fracture in order to determine the extent of injury. The history would also try to identify any preexisting medical problems that might make her a poor surgical risk. The physician will use the data that he or she obtains to develop a treatment plan for the fracture.
Although the nursing health history also focuses on the cause of the injury, the purpose is to determine Mary Johnson’s response to the injury, or what effect it has on her. You will look at much more than the fractured hip. You will consider how the injury affects every aspect of her health and life. Your history will provide clues about the impact of the injury on her ability to perform her everyday activities and help you identify strengths she has that can be incorporated into her plan of care. You will also identify supports and begin your discharge plan. Then you will use the data to develop a care plan with Mary Johnson that includes not only her perioperative phase but also her discharge rehabilitative planning.
Setting the Scene Setting the Scene
Before you begin your assessment, look at your surroundings. Do you have a quiet environment that is free of interruptions? A private room is preferred,but if one is not available, provide privacy by using curtains or screens. Prevent interruptions and distractions so that both you and your patient can stay focused on the history.Make sure that the patient is comfortable and that the room is warm and well lit. If the patient uses assistant devices, such as glasses or a hearing aid, be sure that she or he uses them during the assessment to avoid any misperceptions.
Before you begin asking questions, tell your patient what you will be doing and why. Inform him or her if you will be taking notes, and reassure the patient that what he or she says will be confidential.However, avoid excessive note taking—it sends the message to your patient that the health history form is more important than he or she is. Also, if you are too preoccupied with writing and continually break eye contact, you may miss valuable nonverbal messages. Excessive note taking may also inhibit your patient’s responses, especially when discussing personal and sensitive issues such as sexuality or drug or alcohol use.
Be sure to work at the same level as your patient. Sit across or next to her or him.Avoid anything that may break the flow of the interview. If the interview is being recorded or videotaped, be sure to get your patient’s permission before starting. Position the equipment as unobtrusively as possible so that it does not distract you or your patient.
Your approach to your patient depends on his or her cultural background, age, and developmental level. Ask yourself,“Are there any cultural considerations that might influence our interaction?”“What approach is best, considering my patient’s age?”
Components of the Health History
A complete health history addresses health and illness patterns, health promotion and protective patterns, and roles and relationships.The parts of the health history that focus on health and illness patterns include the biographical data, reason for seeking healthcare,current health status, past health history, family history, and review of systems.You identify not only current health problems but also past health problems and any familial factors that place your patient at risk for health problems. Your patient’s health promotion activities, protective patterns, and role and relationship patterns are assessed through the psychosocial component of the health history. Here, you assess for risk factors that pose a threat to your patient’s health in every aspect of her or his life. Also, you need to consider your patient’s cultural and developmental status as it affects her or his health status.
Biographical Data. The biographical data provide you with direct information related to a current health problem, alert you to risk factors for health problems, and point out the need for referrals.Your patient’s ability to provide biographical data accurately reflects his or her mental status.
Biographical data include the patient’s name, address, phone number, contact person, age/birth date, place of birth, gender, race, religion,marital status, educational level, occupation, and social security number/health insurance. They also include the person who provided the history and her or his reliability as well as the person who referred the patient. Information on advance directives may also be obtained for hospital admissions. Also note any special considerations, such as the use of an interpreter.
Reason for Seeking Healthcare. Ask your patient why he or she is seeking healthcare; then document his or her direct quote. The patient’s reason for seeking care is usually related to the level of preventive healthcare —primary, secondary,or tertiary.
If the setting is a primary level of healthcare, there is usually no acute problem. The reason generally relates to health maintenance or promotion. For example, the patient states,“I am here for my annual physical examination.”
If there is an acute problem, ask the patient to state what the problem is and how long it has been going on. For example,“I have had chest pain for the last hour.” If your patient identifies more than one problem, she or he may be confusing associated symptoms with the primary problem. Help her or him clarify and prioritize the problems by asking questions such as, “Which problems are giving you the most difficulty?”. Usually, patients identify problems that affect their ability to do what they usually do. In an acute-care setting, the reason for seeking care is called the chief complaint. The chief complaint gives you the patient’s perspective on the problem, a view of the problem through his or her eyes.
At the tertiary level, the problem may be well defined, a chronic problem, or an acute problem that is resolving. In this case, the problem does not have the acuity or life-threatening urgency of an acute problem.
Current Health Status. Once you have identified the patient’s reason for seeking healthcare, assess her or his current health status. At a primary level of healthcare (no acute problem), the current health status should include the following:
■ Usual state of health.
■ Any major health problems.
■ Usual patterns of healthcare.
■ Any health concerns.
For example: Patient is Maryanne Weller, age 42, married,mother of three, full-time teacher.Usual state of health good.Has yearly physical with pelvic examination and dental examination. Last eye examination 1 year ago. Expresses concern regarding family history of hypertension and ovarian cancer.
Patients in secondary or tertiary healthcare settings have an existing problem. So you will need to perform a symptom analysis to assess your patient’s presenting symptoms thoroughly. Although many questions come to mind, your patient’s condition and time constraints may preclude you from going into too much detail. If so, you’ll need to zero in on several key areas to evaluate your patient’s symptoms. As you perform the symptom analysis, try to determine how disabling this problem is for your patient. Also ask if he or she has any medical problems related to the current problems and if he or she is taking any medications for this current problem.
The helpful mnemonic PQRST provides key questions that will give you a good overview of any symptom. Although you can ask additional questions, the following ones provide a thorough analysis of any presenting symptom:
■ Precipitating/Palliative Factors
Ask:What were you doing when the problem started? Does anything make it better,such as medications or certain positions? Does anything make it worse, such as movement or breathing?
■ Quality/Quantity
Ask: Can you describe the symptom? What does it feel like, look like,or sound like? How often are you experiencing it? To what degree does this problem affect your ability to perform your usual daily activities?
■ Region/Radiation/Related Symptoms
Ask: Can you point to where the problem is? Does it occur or spread anywhere else? (Take care not to lead your patient.) Do you have any other symptoms? (Depending on the chief complaint, ask about related symptoms. For example, if the patient has chest pain, ask if she or he has breathing problems or nausea.)
■ Severity
Ask: Is the symptom mild, moderate, or severe? Grade it on a scale of 0 to 10,with 0 being no symptom and 10 being the most severe. (Grading on a scale helps objectify the symptom.)
■ Timing
Ask:When did the symptom start? How often does it occur? How long does it last?
Past Health History. The past health history assesses childhood illnesses, hospitalizations, surgeries, serious injuries, adult medical problems (including serious or chronic illnesses), immunizations, allergies, medications, recent travel, and military service. The purpose is to identify any health factors from the past that may have a direct relationship to your patient’s current health status. For example, a history of rheumatic fever as a child may explain mitral valve disease as an adult.
The past health history also identifies any chronic preexisting health problems, such as diabetes or hypertension, which may directly affect the current health problem. For example, patients with diabetes often have poor wound healing.Also, even though the chronic disease may be well controlled, the current health problem may cause an exacerbation. For instance, a patient with well-controlled diabetes may need to adjust his or her medication when scheduled for surgery, because the stress of surgery can elevate blood glucose. In addition, the past health history can identify additional health risks caused by preexisting conditions.
The past health history may also explain your patient’s response to illness, healthcare, and healthcare workers. If she or he has a history of multiple medical problems requiring frequent hospitalizations, these experiences may affect her or his perception of healthcare either positively or negatively.
When obtaining the past health history, be sure to ask for dates, physicians’ names, names of hospitals, and reasons for hospitalizations or surgeries. This information is important if past records are needed.Also avoid using terms such as “usual,”“general,”or “routine.” For example, “usual” childhood illnesses vary depending on the age of your patient and available immunizations.
Family History. The family history provides clues to genetically linked or familial diseases that may be risk factors for your patient. Ask about the health status and ages of your patient’s family members. Family members include the patient, spouse, children, parents, siblings, aunts and uncles, and grandparents. Ask about genetically linked or common diseases, such as heart disease, high blood pressure, stroke, diabetes, cancer, obesity, bleeding disorders, tuberculosis, renal disease, seizures, or mental disease. If the patient’s family members are deceased, record the age and cause of death.
The family history may be recorded in one of two ways.You can list family members along with their age and health status (see Family History by Listing Family Members), or you can use a genogram (family tree). A genogram allows you to identify familial risk factors at a glance. When developing a genogram, use symbols to represent family members, and include a key to explain the symbols and abbreviations. Another tool that can be effective in taking a patient’s family history is an ecomap.
Review of Systems. The review of systems (ROS) is a litany of questions specific to each body system. The questions are usually about the most frequently occurring symptoms related to a specific system. The ROS is used to obtain the current and past health status of each system and to identify health problems that your patient may have failed to mention previously. Remember, if your patient has an acute problem in one area, every other body system will be affected, so look for correlations as you proceed with the ROS.Then perform a symptom analysis for every positive finding and determine the effect of,and the patient’s response to, this symptom.The ROS also provides clues to health promotion activities for each particular system. Identify health promotion activities and provide instruction as needed.
Developmental Considerations. The last part of your health history is taking a psychosocial profile, but before you do this, consider the developmental stage of your patient.A person’s development crosses the life span. Developmental assessments are often performed on children because the developmental changes that occur at this age are very observable and measurable.Yet adults also go through developmental changes that you need to consider during the assessment. Illness and hospitalization can have a major impact on a child’s growth and development, by either halting its progression or regressing it to an earlier stage. For example,when Johnny, age 4, is admitted to the hospital for a hernia repair, he begins wetting the bed during the night, even though his mother assures you that he has been “potty trained” since age 3.
Several developmental theories exist and will provide a framework for your psychosocial profile.These theories focus on specific areas of development, such as physical, psychosocial, cognitive, and behavioral.
Identifying your patient’s developmental stage will help you determine the relationship between the patient’s health status and his or her growth and development. Because many of these theories do not cross the life span, do not limit yourself to one developmental model. Each theorist views development from a different perspective. So be open and choose the theory or theories that will best help you assess your patient’s development.
Psychosocial Profile. The psychosocial profile is the last section of the health history. This section focuses on health promotion, protective patterns, and roles and relationships. It includes questions about healthcare practices and beliefs, a description of a typical day, a nutritional assessment, activity and exercise patterns, recreational activities, sleep/rest patterns, personal habits, occupational risks, environmental risks, family roles and relationships (see Assessing the Family), and stress and coping mechanisms.
In a primary healthcare setting, the psychosocial assessment enables you to identify how your patient incorporates health practices into every aspects of her or his life.You can then teach and reinforce health promotion activities that your patient can incorporate into her or his everyday life. If she or he has an acute problem, the psychosocial assessment helps you determine the impact of this illness on every facet of the patient’s life and assists you in determining discharge planning needs. For your plan of care to be successful, the patient must be able to follow through with it after discharge.Help ensure success by identifying clues as you perform the assessment and then making appropriate referrals.
Documenting Your Findings
Once you have completed the health history, summarize pertinent findings and share them with your patient to confirm their accuracy. Then document your findings and begin to formulate a plan of care. Documentation of history findings varies from one healthcare facility to another. Many acute-care facilities use computerized programs that enable you to enter the history directly into the computer. Standardized nursing admission assessment forms that combine both history and physical assessments are also commonly used.
Regardless of the system, here are some helpful hints for documenting a health history:
■ Be accurate and objective.Avoid stating opinions that might bias the reader.
■ Do not write in complete sentences. Be brief and to the point.
■ Use standard medical abbreviations.
■ Don’t use the word “normal.” It leaves too much room for interpretation.
■ Record pertinent negatives.
■ Be sure to date and sign your documentation.
Health History (Tips)
n Establishes a rapport – relationship, understanding, trust
n Helps to focus on the patient’s chief concern and sets the stage for the Physical Examination (PE)
n Less invasive than the PE
n Types of data
n Subjective data – what person says about himself or herself
n Objective – what you observe during a PE
Open-Ended Questions
n Broadly stated and encourage an open response
n Aim is to describe problem or symptoms
n “How are you feeling?”
Closed or Direct Questions
n Direct and specific questions to get details
n Aim is to focus on the problem. More specific.
n “When did the pain begin? Is the pain sharp, dull, or achy?”
Phases of an Interview
n Introduction phase
n Nurse introduces self to client
n Nurse describes purpose of interview
n Nurse describes the process of the interview so that client knows how long interview will take and what to expect
n Discussion phase
n Nurse helps discussion
n Discussion is client centered
n Nurse uses various communication techniques to collect data
n Summary phase
n Summarization of data
n Allows for clarification of data
n Provides validation to the client that nurse understands problem
Internal and External Factors of Communication
Sending Messages
n Appearance – clothing, hair, jewelry
n Nonverbal communication – body language (gestures, facial expressions, eye contact, touch)
n Verbal communication – empathy. Speech – is it clear? Can the patient understand you?
Receiving Messages
n Overall appearance of patient – neat? wet? orderly or rowdy?
n Nonverbal and verbal communication
n Listening actively – requires complete attention. What is the pt. not saying? Difficulty with language, pronunciation, or memory?
Enhancing Data Collection
n Facilitation – encouraging pt. to continue talking “uh-huh, go on, tell me more”
n Silence – giving attention to the pt. to allow her to speak. Do not interrupt.
n Reflection – repeating what the pt. has just told you. “So you’re saying you’ve been in pain for 5 days and it is worse when you walk?” Promotes trust from pt. Insures what you heard is accurate.
n Empathy – emotions. If pt. just found out he has cancer. “It must be so hard on you and your family.”
n Confrontation and Clarification – clarify inconsistencies of data. A story can change, especially with embarrassing issues.
n Interpretation – sharing with pt. the conclusions you have drawn.
n Explanation – inform. Could be about diet, medication use, etc.
n Summary – review of data gathered.
Traps to Avoid
n False assurances – everything’s not always ok
n Unwanted advice – sometimes must let pt. decide. Be objective. Give pt. all the facts.
n Avoiding the issues – be direct and honest
n Professional jargon
n Biased questions – “You don’t smoke, do you?”
n Talking too much and interrupting
n Don’t ask “why” when the pt. might not have answer – why didn’t you stop smoking when you knew it was bad for you?
n Answering personal questions – not necessary and might be uncomfortable.
Interviewing Special Populations
n Hearing Impaired
n Recognize clues such as staring at your mouth or face, speaking loudly
n Determine if there’s a better way to communicate such as writing or signing
n Acutely Ill
n If pt. is in an emergency situation, ask priority questions first. Use closed (direct questions).
n Drugs or Alcohol Influenced
n Ask simple and direct questions.
n Try not to appear threatening
n Sexually Aggressive People
n Very important to set professional boundaries
n Must make it clear you are a health professional and can best care for that person by maintaining a professional relationship
n Crying
n It’s ok if a pt. cries. It usually is a big relief to let out emotions.
n Do not move onto another topic. Talk about what’s bothering him or her.
n Anger and Threat of Violence
n Ask the pt. why they are angry and try to deal with the feelings
n If pt. becomes threatening, remember your safety comes first
n Leave the examining room and try to position yourself between the pt and the door
Domestic Violence Considerations
n Most common people to become victims of abuse are the intimate partner and the elderly.
n You must remember that reporting of abuse is one of the most important ways of preventing future occurrences
n Don’t be afraid to ask the pt. if you suspect abuse. You are an advocate for the patient.
n Abuse Assessment Screen (AAS)
n “Because domestic violence is so common in our society, we are asking all women the following questions”
n Document, Document, Document
n Write down direct quotes from pt. even if it includes swearing
AMA Definitions for Elder Abuse and Neglect
n Physical abuse
n Violent acts that result or could result in injury, pain, impairment, and/or disease
n Physical neglect
n Failure of family member or caregiver to provide basic goods and/or services such as food, shelter, health care, and medications
n Psychological abuse
n Behaviors that result in mental anguish. (Threats)
n Psychological neglect
n Failing to provide basic social stimulation
n Financial abuse
n Intentional misuse of elderly person’s financial resources without consent
n Financial neglect
n Failure to use the assets of the elderly person to provide necessary services
Abuse Terminology
n Abrasion
n A wound caused by rubbing the skin or mucous membrane
n Bruise (Contusion)
n Superficial discoloration due to hemorrhage into the tissues from ruptured blood vessels beneath the skin surface
n Ecchymosis
n A hemorrhagic spot, larger than petechia, in the skin or mucous membrane, forming a nonelevated, round, or regular, blue or purplish patch
n Hematoma
n A localized collection of extravasated blood, usually clotted in an organ, space, or tissue
n Hemorrhage
n An escape of blood from a ruptured vessel, which can be external, internal, and/or into the skin or other organ
Abuse Pictures
n Incision (Cut)
n A cut or wound made by a sharp instrument
n Laceration
n A wound produced by tearing and/or splitting of body tissue, usually from blunt impact over a bony surface.
n Lesion
n Any pathologic or traumatic discoloration of tissue or loss of function
n Patterned injury
n An injury caused by an object that leaves a distinct pattern on the skin and/or organ
n Petechiae
n Small red or purple spot on the body
n Disorders of coagulation. Strangulation.
n With bruising, should suspect abuse
n Puncture
n The act of piercing or penetrating with a pointed oubject
Components of Health History
n The general survey
n Fourteen cues to be observed
n Age
n Sex
n Race
n Vital Signs
n Apparent state of health
n Signs of distress
n Facial expressions
n Mood
n State of awareness
n Speech
n Dress, grooming, personal hygiene
n Nutrition
n Stature
n Posture and gait
n Reasons for seeking health care
n Health perception/Health management
n Present health or history of present illness
n Location
n Quality
n Quantity
n Timing
n Setting
n Aggravating/alleviating factors
n Associated factors
n Client’s perception
n Childhood illnesses
n Adult illnesses
n Accidents/injuries
n Hospitalizations
n Surgeries
n Obstetric history
n Immunizations
n Physical examinations/dental visits
n Allergies/reactions
n Current medications
n Health maintenance
n Knowledge of current and past health and illness
n Communicable disease
n Social history
n Family history/genogram
n Nutritional-metabolic pattern
n Elimination pattern
n Activity-exercise pattern
n Sleep-rest pattern
n Cognitive-Perceptual pattern
n Role-relationship pattern
n Sexuality-reproductive pattern
n Coping-stress-tolerance pattern
n Value-belief pattern
Functional Assessment (ADLs)
n Self esteem
n Activity and exercise
n Sleep patterns
n Nutritional assessment
n Spiritual and social supports
n Coping mechanisms
n Alcohol, smoking, and drug use
n Environmental hazards such as working conditions
n Domestic violence assessment
Pain Assessment
Introduction to Assessing Pain
Although pain is referred to as the fifth vital sign,pain is a symptom. Subjective iature, pain is “whatever the person says it is, whenever she or he says it does” (McCaffery, 1999). Pain has also been defined as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage” (International Association for the Study of Pain, 2006). It is the most common reason patients seek healthcare.
Far too often, not only the public but also healthcare providers undertreat pain owing to misconceptions surrounding it and its effective management. This is a serious issue,as undertreated pain can have serious physical, psychological, and financial consequences that affect the patient’s quality of life.
Accurate assessment of your patient’s pain is the first step in developing an effective treatment plan to deal with pain. Because pain is subjective, no two patients experience pain the same way. Since pain has physiological, psychological, sociocultural, behavioral, and affective components, assessment must address each component as it relates to your patient.
Structure and Function of Pain
Understanding the process of pain will help you to accurately assess and develop a plan of care to manage your patient’s pain.The process by which a painful stimulus is transmitted to the central nervous system (CNS) and perceived as pain is referred to as nociception (Fig. 4.1).
The process of pain includes transduction, transmission, perception, and modulation. However, the exact mechanism of pain is unknown, and this process does not explain all types of pain, such as phantom limb. Also, not all nociception results in the perception of pain.
Transduction. Transduction begins with a response to a noxious (painful) stimulus that results in tissue injury. The noxious stimuli can be mechanical, thermal,or chemical. The noxious stimuli are then converted into a nerve impulse by sensory receptors called nociceptors.
Nociceptors are receptors found in the skin, subcutaneous tissue, joints,walls of arteries, and most internal organs (with the highest concentration found in the skin and the least in internal organs) that respond to painful stimuli. In response to tissue injury, cells break down and release byproducts and inflammation mediators (bradykinin, prostaglandins, substance P, histamine, serotonin,and cytokines).These substances activate or sensitize the nociceptors.Bradykinin also acts as a potent vasodilator, triggering the inflammatory response of redness, swelling, and pain. The inflammatory response is the greatest cause of pain.However,all pain that originates from the periphery is not nociceptive pain. Damaged peripheral nerves can result in peripheral neuropathic pain.
Transmission. Once the nociceptors are activated, the nerve impulse is transmitted to the spinal cord and brain. The sensory nerve impulses travel via afferent neurons to the dorsal horn of the spinal cord. Primary afferent nerve fibers travel along C-fibers,unmyelinated, slow-conducting fibers that transmit dull,aching pain,or A-delta fibers,myelinated, fast-conducting fibers that transmit sharp, localized pain. C-fibers transmit slow, constant pain from mechanical, thermal,and chemical stimuli.A-delta fibers transmit fast, intermittent pain from mainly mechanical stimuli. Excitatory amino acids (e.g., glutamine, aspartate) and neuropeptides (e.g., substance P) facilitate transmission of impulse to the dorsal horn at the synapses from the primary afferent neuron to a second-order neuron in the dorsal horn. Inhibitory aminoacids (e.g., γ-aminobutyric acid [GABA]) and neuropeptides (e.g., endogenous opioids) inhibit transmission of impulse.Once in the dorsal horn, the impulse can be transmitted to the brain or inhibited.Neuroregulators, neurotransmitters, or neuromodulators either inhibit or facilitate nociception.
From the dorsal horn, the impulses are then transmitted from (1) the spinothalamic tract to the thalamus, (2) the spinoreticular tract to the reticular formation, (3) the spinomesencephalic tract to the mesencephalon, and (4) the spinohypothalamic tract to the hypothalamus. Most impulses are transmitted to the thalamus from which they are directed to three areas: the somatosensory cortex, which perceives and interprets physical sensation; the limbic system, which allows for emotional response to stimuli; and the frontal cortex, which involves thought and reason and perception of pain.
Perception. Perception is an awareness of pain and involves both the cortical and the limbic system structures.Realize that pain threshold, the point at which a painful stimulus is perceived as painful, is consistent from one person to the next; however, pain tolerance, the amount of pain one is able to endure, varies greatly.Psychosocial and cultural factors and past experiences influence pain perception, thereby accounting for such individual differences in pain perception even with similar painful stimuli.
Modulation. Nerve transmission from the dorsal horn is modulated by descending inhibitory input. Inhibition can also occur at the peripheral, spinal, and supraspinal levels. Inhibition occurs by analgesia or the gate-control theory of pain modulation. Inhibitory substances (e.g., GABA and neuropeptides [endogenous opioids, serotonin, norepinephrine]) bind to primary afferent receptors and dorsal horeurons to inhibit transmission of impulse. Endogenous opioids include enkephalins, dynorphins, and beta endorphins.
Endogenous opioids can also be produced through exercise, meditation, visualization, and music therapy. The brain also sends descending inhibitory input that modulates the transmission of nociceptive transmission in the dorsal horn.
The gate-control theory of pain modulation (Fig. 4.2) proposes that impulses can be blocked by non-painful somatic stimuli. Impulses compete for transmission. Since two impulses cannot be transmitted at the same time, one goes through while the other is blocked.
For example, if you stub your toe, you automatically rub your toe.The rubbing sensation is transmitted by the fast, A-delta fibers, while the impulse from stubbing the toe travels along the slow C-fiber and is blocked.
Sensitization. Sensitization to pain can be peripheral or central. Peripheral sensitization occurs with prolonged exposure to noxious stimuli.The result is a lower threshold of pain, leading to hyperalgesia (increased response to painful stimuli) and allodynia (painful response to nonpainful stimuli). Central sensitization also occurs with prolonged exposure to noxious stimuli with spinal neuron hyperexcitability and results in hyperalgesia and allodynia as well as persistent pain and referred pain. Sensitization can act as a protective mechanism during healing,but when it persists, chronic pain can develop.
Classification of Pain
Pain can be categorized by duration, site of pain, cause,or other qualities.
Acute Pain. Pain is defined as acute when it lasts the expected recovery time. Acute pain serves as a protective mechanism in response to an actual or potential threat to injury, such as when you withdraw your hand from a hot surface. Injury also activates the “stress hormone response,” which, if left untreated, can produce negative physiological and psychological effects resulting in chronic pain. Acute pain is seen with injury and surgery and may last up to 6 months.
Chronic Pain. Chronic pain is defined as pain enduring for 6 months or longer.More specifically, chronic pain endures beyond expected recovery time. Chronic pain may be in response to a progressive illness or result from no apparent injury, as with neuropathic pain. Chronic pain often serves no adaptive purpose, and frequently results in depression. Chronic pain can be further classified as cancer/malignant pain or chronic noncancer pain.
Cancer/Malignant Pain. Pain associated with cancer may be categorized separately. Cancer or malignant pain may be acute pain or chronic pain that is associated with an underlying malignancy, diagnostic procedure, or disease treatment. The level of pain strongly correlates with the degree of pathology. Intractable pain, pain resistant to treatment, is often seen with advanced metastatic disease.
Chronic Noncancer Pain. Persistent paiot associated with malignancy may be categorized as chronic noncancer pain, a subtype of chronic pain. Pain levels and pathology have a weak link and may have no discernable cause.The pain becomes the disease. Any body system or region can be affected, with intensity ranging from mild to severe. Chronic noncancer pain has a major effect on every aspect of the patient’s daily life and is referred to as chronic pain syndrome. In this syndrome, the patient cao longer function and her or his entire life is centered on finding pain relief.
Nociceptive/Neuropathic Pain
Pain can also be classified by underlying pathology.
Nociceptive Pain. Nociceptive pain results from exposure to noxious (painful) stimuli. The painful stimuli can occur in the viscera, resulting in visceral pain, or tissue, resulting in somatic pain.
Visceral pain results from overdistension, spasms, ischemia, inflammation, or traction of organs such as colic, appendicitis, peptic ulcer disease, and bladder distension. The pain can be localized or diffuse or referred. Referred pain is felt at a site other than at the site of origin. Referred pain occurs when internal organs and structures share nerve pathways within the CNS (Fig. 4.3). Pain can also radiate. Radiating pain begins in one area and extends to others, such as chest pain associated with myocardial infarction may be in the chest and radiate to the jaw or arm. The quality of visceral pain is deep aching or sharp stabbing. Visceral pain is often accompanied by nausea, vomiting, malaise, sweating, tenderness, and muscle spasm.
Somatic pain can be superficial or deep. Superficial somatic pain originates in the skin or mucous membranes from external stimuli such as sunburn; chemical and thermal burns; or injury to the skin, such as lacerations or contusions.The pain is very localized and described as sharp, pricking, or burning. Cutaneous tenderness, hyperalgesia (increased sensitivity to pain), hyperesthesia (increased sensitivity to sensory stimuli), and allodynia (painful response to nonpainful stimulus) may be associated with superficial somatic pain.
Deep somatic pain originates in muscles, bones, and joints from overuse, injury ischemia, cramping, or inflammation such as arthritis, tendinitis, and sprains. The pain can be localized or diffuse and radiating and described as dull, achy, or cramping. Tenderness and muscle spasm with an autonomic response (increase pulse,blood pressure, and respiratory rate; sweating; pallor; dilated pupils; nausea; vomiting; dry mouth; and increased muscle tension) are often associated with deep somatic pain.
Neuropathic Pain. Neuropathic pain results from injury to the peripheral or central nervous system. Neuropathic pain serves no adaptive purpose and therefore is “pathological” pain.
Neuropathic pain can be classified as mono/polyneuropathies, deafferentation, sympathetically maintained pain, and central pain (
Mono/Polyneuropathies. Mono/polyneuropathies involve pain along one or more damaged peripheral nerves. Neuropathies may be caused by metabolic disorders (diabetic neuropathy), toxins (alcoholic neuropathy or chemotherapy), infections (human immunodeficiency virus [HIV], postherpetic neuralgia), trauma, compression (compartment syndrome, carpal tunnel syndrome), and autoimmune and hereditary diseases. The pain associated with neuropathies may be described as continuous,deep,burning, aching or bruised, paroxsymal shocklike,or abnormal skin sensitivity.
Deafferentation. Deafferentation pain occurs with loss of afferent input from damage to a peripheral nerve, ganglion, or plexus, or the CNS. Phantom limb and postmastectomy pain are examples of deafferentation pain. The pain is often described as burning, cramping, crushing, aching, stabbing, or shooting. The patient may experience hyperalgesia (excessive sensitivity to pain),hyperpathia (hypersensitivity to sensory stimuli), dysesthesia (abnormal sensations of the skin such as numbness, tingling, burning, or cutting), or other abnormal sensations. Phantom limb pain, pain that is experienced in a missing limb or body part, is the result of sensory representations of the missing limb that are still present in the brain.
Sympathetically Maintained Pain. Sympathetically maintained pain is a pain mechanism that results from sympathetic nervous stimulation. Peripheral nerve damage, sympathetic efferent innervation, or circulating catecholamines can result in sympathetically maintained pain. Chronic pain syndrome, phantom limb pain, postherpetic neuralgia, and some metabolic neuropathies can trigger sympathetically maintained pain.
Central Pain. Central pain results from a primary lesion or dysfunction of the CNS. Ischemia (stroke), tumors, trauma, syrinx (a pathological cavity in the spinal cord or brain), or demyelination (multiple sclerosis) can cause central pain. The quality of the pain varies from a burning, numbing, tingling to a shooting sensation.Onset may be spontaneous, steady, or reactive with positive or negative sensory loss, allodynia, and hyperalgesia (
Developmental, Cultural, and Ethnic Variations
A common misconception is that infants, young children, and older adults or cognitively impaired adults do not experience pain. Just because the patient cannot verbally describe pain, that does not negate its presence. Although self-report is the most reliable indicator of pain, if this is not possible, physiological and behavioral indicators are used to assess pain.The challenge then is to accurately assess for pain in all patients at any age and to develop an effective treatment plan.
Infants. At one time, it was believed that infants did not experience pain, but research has refuted that idea. The process of pain is intact even though the emotional response is unclear. Since the infant cannot verbalize pain, physiological and behavioral indicators are used to assess for pain in the infant.
Infant physiological changes associated with pain include (Wong & Hockenberry-Eaton, 2001):
■ Integumentary system: Pallor or flushing,diaphoresis, palmar sweating.
■ Cardiovascular: Increased heart rate, increased blood pressure.
■ Respiratory: Rapid, shallow respirations, decreased arterial oxygen saturation, and transcutaneous oxygen saturation.
■ Musculoskeletal: Increased muscle tone.
■ Neurological: Increased intracranial pressure, dilated pupils, decreased vagal nerve tone.
■ Endocrine (hormonal release): Increased catecholamines, growth hormones, glucagon, cortisol, corticosteroids, and aldosterone.
■ Metabolism: Increased plasma lactate, pyruvate, ketone bodies, and fatty acids.
■ Laboratory values: Increased blood glucose (hyperglycemia) and corticosteroid levels and decreased pH.
Infant behavioral changes associated with pain include:
■ Vocalization: Intense, sustained crying, whimpering, and groaning.
■ Facial expression: Eye squeeze, brow bulge, open mouth, taut tongue, chin quivering, and grimaces.
■ Body movements: Limb withdraw, thrashing, rigidity or flaccidity, and fist clenching.
■ Sleep/wake cycle: Increased wakefulness and irritability.
■ Feeding: Loss of appetite, vomiting, loss of interest and/or energy in sucking.
■ Activity level: Decreased activity level; fussiness, irritability, and listlessness.
Children. Depending on the age of the child, assessing pain in children can be a challenge. The mnemonic QUESTT is helpful in assessing pain in children (Wong & Hockenberry-Eaton, 2001).QUESTT stands for:
■ Question the child.
■ Use a pain rating scale.
■ Evaluate behavioral and physiological changes.
■ Secure parents’ involvement.
■ Take the cause of pain into account.
■ Take action and evaluate results.
Question the Child. Self-report is the most accurate means for assessing pain, so ask the child to describe the pain. Self-report is more accurate than the child’s behavior.
Use a Pain Rating Scale. Various pain rating scales are available for assessing pain in children. Be sure to select one that is age appropriate for your patient.These scales are discussed later in this chapter.
Evaluate Behavioral and Physiological Changes. If the child is nonverbal and unable to describe pain, detecting behavioral and/or physiological changes is essential. Physiological changes that may be seen with acute pain include increase in blood pressure, increased or decreased heart rate, increased respirations, flushing, sweating, dilated pupils. Behavioral changes can vary depending on the child’s developmental level. Behavioral changes for a young child include crying, screaming, vocalizing hurt, thrashing of arms and legs, pushing away, clinging to parents, and increasing restlessness and irritability. Behavioral changes for a school-age child include crying, muscle rigidity, clenched fists, white knuckles, clenched teeth, closed eyes, and stalling techniques when anticipating a painful procedure. Behavioral changes for an adolescent include verbalization of pain and muscle tension.
Secure Parents’ Involvement. Parents know their child, so rely on their assessment. Parents are more attuned to subtle changes in their child’s behavior. Parents also usually know what will best comfort their child.Ask the parent:
■ What is the child’s past experience with pain?
■ What is the child’s response to pain?
■ How do you know your child is having pain?
■ What relieves the child’s pain?
Take the Cause of Pain Into Account. Consider the pathophysiology of the underlying problem when you evaluate the child’s pain.
Take Action and Evaluate Results. After assessing the pain, develop a plan to treat the pain. After treating pain, you need to assess the child to evaluate the effectiveness of the treatment and revise the plan as needed.
Older Adults. Assessing pain in the older patient can be challenging because of the misconceptions both patients and healthcare providers have surrounding pain and the elderly.
It is important to realize that the elderly do experience pain both acute and chronic. Untreated pain increases the risk for complications such as pneumonia, constipation, deep vein thrombosis, impaired immune function, sleep disturbances, weight loss, social isolation, and depression. Often, the older patient experiences chronic pain and does not exhibit the typical signs of pain.Answers to questions about the patient’s functional level and quality of life are good indicators of the effects of pain.
If the patient is cognitively impaired, assessing for pain becomes a greater challenge.The degree of impairment will determine the use of pain scales. Keep questions simple, specific, and in the here and now. If the patient is unable to verbally communicate, rely on physiological signs associated with pain, such as increased blood pressure, heart rate, and respirations; diaphoresis; and behavioral changes, such as agitation, restlessness, facial expression of pain, and vocal sounds (moaning and groaning) of pain.
Family members or caregivers should be included in the assessment process.They can provide invaluable data of the patient’s pain-related behavior and effective methods for relieving pain.
People of Different Cultures and Ethnic Groups. Although the physiological response to pain is consistent across cultures, your patient’s cultural or ethnic background influences his or her psychological and behavioral responses to pain. (See Cultural and Ethnic Variations in Response to Pain.)
Performing the Pain Assessment
Pain assessment includes a history and physical examination. As with any assessment,always begin with a history. Since pain is subjective iature, the history component of the pain assessment is the most important.
Health History. Self-report is the most accurate indicator of pain. Because pain is subjective, the patient’s health history provides the best assessment of pain. The history also allows you to assess past experiences with pain,effective pain treatments, and the effects pain has on every aspect of the patient’s life.
Biographical Data. Review your patient’s biographical data. As described previously, your patient’s age,ethnicity,and religion may affect her or his perception and behavioral response to pain. Even the patient’s gender may influence her or his perception of pain. Also, your patient’s occupation may be a direct cause of the pain, such as back pain related to heavy lifting; the presence of pain may prohibit a return to work.
Current Health Status. When your patient presents with pain, perform a symptom analysis. The mnemonic PQRST provides a thorough description of pain. Ask:
■ Precipitating/Palliative/Provocative Factors
■ What were you doing when the pain started?
■ Does anything make it better, such as medication ora certain position?
■ Does anything make it worse, such as movement or breathing?
■ Quality/Quantity
■ What does it feel like?
■ Superficial somatic pain is sharp, pricking, or burning.
■ Deep somatic pain is dull or aching.
■ Visceral pain is dull, aching, or cramping.
■ Neuropathic pain is burning, shocklike, lancing, jabbing, squeezing, or aching.
■ How often are you experiencing it?
■ To what degree is the pain affecting your ability to perform your usual daily activities?
■ Region/Radiation/Related Symptoms
■ Can you point to where it hurts?
■ Does the pain occur or spread anywhere else?
■ Localized pain is confined to the site of origin, such as cutaneous pain.
■ Referred pain is referred to a distant structure, such as shoulder pain with acute cholecystitis or jaw pain associated with angina.
■ Projected (transmitted) pain is transmitted along a nerve, such as with herpes zoster or trigeminal neuralgia.
■ Dermatomal pattern as with peripheral neuropathic pain.
■ Nondermatomal pattern as with central neuropathic pain, fibromyalgia.
■ No recognizable pattern as with complex regional pain syndrome.
■ Do you have any other symptoms? (e.g., nausea, dizziness, shortness of breath)
■ Visceral pain–related symptoms include sickening feeling, nausea, vomiting, and autonomic symptoms.
■ Neuropathic pain–related symptoms include hyperalgesia and allodynia.
■ Complex regional pain syndrome–related symptoms include hyperalgesia, hyperesthesia, allodynia, autonomic changes, and shin, hair, and nail changes.
■ Severity
■ Use appropriate pain scale. (See Pain Scales, below.)
■ Timing
■ When did the pain begin?
■ How long did it last?
■ Brief flash: Quick pain as with needle stick.
■ Rhythmic pulsation: Pulsating pain as with migraine or toothache.
■ Long-duration rhythmic: As with intestinal colic.
■ Plateau pain: Pain that rises then plateaus such as angina.
■ Paroxysmal: Such as neuropathic pain.
■ How often does it occur?
■ Continuous fluctuating pain: As with musculoskeletal pain.
■ Do you have times when you are pain free?
When taking a patient’s current health status, pay attention to the words that the patient uses to describe her or his current pain level. They can provide important clues to her or his status.
Pain Scales. Various instruments are available to assess pain. Consider the patient’s age and developmental status along with his or her cultural background when selecting a pain scale. Select the one that will best meet your patient’s needs.
Pain Scales for Adults. Unidimensional and multidimensional pain scales are available.The unidimensional scale assesses one dimension, usually intensity of pain, and is often used to assess acute pain. Multidimensional scales provide additional information about pain, such as the pain’s characteristics and the effects on the patient’s daily life.A multidimensional scale is useful in assessing chronic pain.
Unidimensional Scales. These scales generally use numeric, verbal, or visual descriptors to quantify pain. Examples include the Numeric Rating Scale, Visual Analogue Scale, and categorical scales.
Numeric Rating Scale. The Numeric Rating Scale rates pain on a scale of 0 (no pain) to either 5 or 10 (worst pain) by asking the patient to rate her or his current pain level.
Visual Analogue Scale. The Visual Analogue Scale utilizes a vertical or horizontal 10-cm line with anchors. One end of the line is labeled “No pain” and the opposite end of the line is labeled “Worst pain.”The patient marks his or her current pain level on the line.
Categorical Scales. Categorical scales use verbal or visual descriptors to identify pain intensity. The patient selects the descriptor that she or he feels best represents the current pain level. Verbal descriptors include:
■ Mild, discomforting, distressing, horrible, excruciating.
■ No pain, mild pain, moderate pain, severe pain, very severe pain,worst possible pain.
Visual descriptors include the Faces Pain Scale for Adults and Children (FPS), which utilizes illustrated faces with facial expressions ranging from happy (no pain) to sad and crying (worst pain). The FPS has eight faces to select current pain level.The patient is asked to select the face that best represents his or her current pain level.
Multidimensional Pain Scales. These scales assess pain characteristics and its effects on patient’s activities of daily living and include such scales as the Initial Pain Assessment Inventory (IPAI), Brief Pain Inventory (BPI), McGill Pain Questionnaire (MPQ), and the Neuropathic Pain Scale.
Initial Pain Assessment Inventory. The IPAI is used for initial assessment of pain. It assesses characteristics of pain; effects of pain on the patient’s life, such as daily activities, sleep, appetite, relationships, and emotions; and the patient’s expression of pain. This assessment tool includes a diagram to note pain location, a scale to rate pain intensity,and space to document additional comments and the treatment plan.
Brief Pain Inventory. The BPI is used to quantify pain intensity and associated disability. It assesses pain intensity, location, effects on life, type, and effectiveness of treatment over the last 24 hours. Benefits of the BPI include that it is quick and easy to use and available in multiple languages.
McGill Pain Questionnaire. The MPQ uses descriptive words to assess pain on three levels: sensory, affective, and evaluative. It can be used with other tools and is available in short and long forms.
Neuropathic Pain Scale. The Neuropathic Pain Scale assesses the type and degree of sensations associated with neuropathic pain. The patient rates eight common qualities of neuropathic pain (sharp, dull, hot, cold, sensitive, itchy, deep, or surface pain) on a scale of 0 (no pain) to 10 (worst pain). This scale is still in the developmental stages,but early testing holds diagnostic and therapeutic promise.
Pain Scales for Children. Many pain scales are available to assess a child’s pain. Many of the pain scales are age specific. Instruments may also be specified by your institution since pain assessment forms are common use.
FACES Pain Rating Scale. The FACES Pain Rating Scale assesses pain for children ages 3 years and up.The Wong-Baker has five faces from which the child can select her or his current pain level (Fig. 4.4).
Oucher. The Oucher scale assesses pain for children ages 3 to 13 years with photos or a numeric scale.The photographic scale uses six photographs of children ranging from a child with “no hurt” to a child with “a lot of hurt.”The photographs are arranged vertically from 0 to 5, with 0 (no hurt) on the bottom and 5 (lot of hurt) on the top. This scale also has photographs of black and Hispanic children available.
Numeric Scale. The numeric scale ranges vertically from 0 to 100,with 0 being “no hurt” and 100 being “biggest hurt” (Beyer, Denyes,& Villaruel, 1992):
■ 0 = no hurt.
■ 1–29 = little hurt.
■ 30–69 = middle hurt.
■ 70–99 = big hurt.
■ 100 = biggest hurt.
Poker Chip Tool. The Poker Chip Tool assesses pain in children 4 years of age and up. The nurse places red poker chips horizontally in front of the child, with the poker chips denoting “pieces of hurt.” She then asks the child to select how many pieces of hurt he or she has (Hester et al., 1998).
Word-Graphic Rating Scale. The Word-Graphic Rating Scale assess pain in children ages 4 to 17 years. It uses words on a horizontal linear scale to assess pain. The child is asked to identify her or his current pain level on the scale (Tesler et al., 1991).
Numeric Scale. The Numeric Scale assesses pain for children ages 5 years and older. It uses a horizontal linear scale with numbers from 0 to 5 or 10, with 0 being “no pain” and 5 or 10 being “worst pain.”The child is asked to identify his or her current pain level on the scale. Although similar to a scale used for adults, this provides the child with a visual to help assess his or her pain.
Visual Analogue Scale. The Visual Analogue Scale, which assesses pain in children ages 41⁄2 and older, is similar to that used for adults. The child is asked to identify her or his pain level by marking the line in the area that represents her or his level of pain (Cline et al., 1992).
Color Tool. The Color Tool assesses pain for children as young as 4 years by having the child create a body outline using colored markers or crayons. The child selects four colors. The first color represents “most hurt,” the second represents “little hurt,” the third represents “least hurt,”and the last represents “no hurt.” Using all four colors, the child identifies areas and degree of hurt on the body outline (Eland & Banner,1999).
Past Health History. The past health history can identify factors that may affect the patient’s pain, response to pain, and treatment plan. When conducting the past health history, make sure to identify:
■ Cause of pain.
■ Past and present medical problems that may influence pain and its management.
■ Past psychiatric illnesses and chemical dependence.
■ Past and present pain management strategies.
■ Past experiences with pain.
■ Chronic vs. acute pain.
Family History. The family history may identify genetically linked causes of pain, such as sickle cell anemia and cancer. The family history also identifies familial history of chronic pain or illness. Ask the patient about hereditary or familial health problems.
Review of Systems. If there is a problem in one system, eventually other systems will be affected.The underlying cause of the pain determines the effect the pain will have on other systems.
Psychosocial Profile. Assessing the psychosocial history identifies the effects that pain has on every aspect of the patient’s life and evaluates quality of life.
Physical Assessment. The initial purpose of the physical examination is to identify the underlying cause of pain. As you perform the examination, assess the effects of physical movements (e.g., deep breathing, position changes) on the patient’s pain level.The physical examination may also reveal complications associated with untreated pain. The history findings should direct the physical exam.Be alert for physical, behavioral, and psychological responses to pain.
The autonomic response of the sympathetic nervous system to painful stimuli accounts for many of the physiological changes that are seen. This response is acute and cannot be sustained for prolonged periods of time, as the body adapts and physical indicators are no longer apparent in patients with prolonged pain or chronic pain. Again, physical signs are not as reliable of an indicator as self-report, the most reliable indicator of pain. However, when patients are unable to verbally communicate or who are cognitively impaired, you must rely on physical and behavioral indicators obtained by a head-to-toe assessment to evaluate your patient’s pain. (See Performing a Head-to-Toe Physical Assessment.)
Behavioral Pain Assessment Scales. Although the patient’s self-report of pain is the most accurate means to assess pain, there are times when the patient’s age or condition does not permit self-report, such as when the patient is confused or very young. Pain scales have been developed to objectively assess pain by scoring behavioral and physiological responses to pain. A variety of objective pain scales are available. The scales are mainly geared for the infant and young child. You need to consider the age of your patient in selecting a scale that will best assess your patient’s pain.
Behavioral Pain Assessment Scales for Infants. Since an infant cannot verbalize feelings of pain, physiological and behavioral changes need to be used to assess pain. Many scales are available to help you assess your patient’s pain. Identify the scale that is most appropriate in assessing your patient.
CRIES. CRIES (crying, requiring increased oxygen, increased vital signs, expression, sleeplessness) assesses postoperative pain from 32 weeks’ gestation to 20 weeks’ post-term. Each of the five categories is scored from 0 to
Postoperative Pain Score. The Postoperative Pain Scale (POPS) assesses postoperative pain in infants ages 1 to 7 months. It scores each of its 10 categories (sleep, facial expression, quality of cry, spontaneous motor activity, spontaneous excitability, flexion of fingers and toes, tone, consolability, and sociability) on a scale of 0 to
Neonatal Infant Pain Scale. The Neonatal Infant Pain Scale (NIPS) is used to assess infants at an average gestational age of 33.5 weeks. It grades six categories: facial expression (0 to 1), cry (0 to 2), breathing pattern (0 to 1), arms (0 to 1), legs (0 to 1), and state of arousal (0 to 1).A final score of 0 identifies no pain while a score of 7 identifies worst pain (Lawrence et al., 1993).
Pain Assessment Tool. The Pain Assessment Tool (PAT) assesses pain from a gestational age of 27 weeks to full term. It grades 10 different categories:posture/tone (1 to 2), sleep pattern (0 to 2), expression (1 to 2), color (0 to 2), cry (0 to 2), respirations (1 to 2),heart rate (1 to 2), saturations (0 to 2), blood pressure (0 to 2), and nurse’s perception (0 to 2). A final score of 4 identifies no pain,while a score of 20 identifies worst pain (Hodgkinson et al., 1994).
Pain Rating Scale. The Pain Rating Scale (PRS) assesses pain for infants ages 1 to 36 months.The infant is given a grade of 0 (no pain) through 5 (worst pain) based on the following guidelines. For a score of 0, the infant exhibits smiling, sleeping, and no change when moved or touched. Behaviors associated with a score of 1 include taking small amounts orally, restlessness, moving, and crying. A score of 2 includes behaviors of not eating or drinking and short periods of crying but distracted with rocking or use of pacifier. With a score of
Premature Infant Pain Profile (PIPP). The Premature Infant Pain Profile (PIPP) assesses pain for gestational ages 28 to 40 weeks. It grades seven categories on a scale of 0 (no pain) to 3 (worst pain).The categories are gestational age, behavioral stage, heart rate, oxygen saturation, brow bulge, eye squeeze, and nasolabial furrow. A final score of 0 identifies no pain, while a score of 21 identifies worst pain (Stevens, 1996).
Modified Behavioral Pain Scale. The Modified Behavioral Pain Scale (MBPS) assesses pain for children ages 4 to 6 months. It assesses three categories: facial expression (0 to 3), cry (0 to 4), and movements (0 to 3). A final score of 0 identifies no pain, while a score of 10 identifies worst pain (Taddio et al., 1995).
Behavioral Pain Assessment Scales for Children. Several behavioral pain assessment scales have been developed to assist in assessing paiot only for the infant but also for the older child. Brief descriptions are provided below.Again, you need to select the instrument most appropriate to meet your patient’s needs.
Objective Pain Score. The Objective Pain Scale (OPS) assesses pain for infants and children from ages 4 months to 18 years. It assesses five categories, each on a scale of 0 (no pain) to 2 (worst pain). The categories are blood pressure, crying, moving, agitation, and verbal evaluation/body language. A final score of 0 identifies no pain, and a score of 10 identifies worst pain (Hannallah et al., 1987).
Children’s
Nurses Assessment of Pain Inventory. The Nurses Assessment of Pain Inventory (NAPI) assesses pain for infants and children from birth to age 16 years. It assesses three categories: body movement (0 to 2), facial (0 to 3),and touching (0 to 2). A final score of 0 identifies no pain,while the higher score identifies the worst pain (Stevens, 1990).
Behavioral Pain Score. The Behavioral Pain Score (BPS) assesses pain for children ages 3 to 36 months. It assesses three categories: facial expression (0 to 2), cry (0 to 3), and movements (0 to 3). A final score of 0 identifies no pain, while a score of 8 identifies worst pain (Robieux et al., 1991).
Riley Infant Pain Scale. The Riley Infant Pain Scale (RIPS) assesses pain in children younger than 36 months and children with cerebral palsy. It assesses five categories on a scale of 0 (no pain) to 3 (worst pain).
FLACC Postoperative Pain Tool. The FLACC Postoperative Pain Tool assesses pain for children ages 2 months to 7 years. It assesses five categories using a scale of 0 (no pain) to 2 (worst pain).A final score of 0 indicates no pain,while a score of 10 indicates worst pain.
Behavioral Pain Assessment Scales for Older Adults. Since a confused patient may not be able to verbalize feelings of pain, physiological and behavioral changes need to be used to assess pan.
Pain Assessment in Advanced Dementia Scale. The Pain Assessment in Advanced Dementia Scale (PAINAD) can be used to assess pain levels in patients with advanced dementia. It assesses five categories on a scale of 0 to 2.The higher the score, the greater the pain.
Reassessment of pain
Reassessment of pain is imperative to determine the effectiveness of treatment. Self-report and physical findings will help you evaluate the effectiveness of treatment. Compare the patient’s responses to the expected outcomes.Have the patient grade his or her current pain level and compare the grade with the previous rating. If relief has not been obtained, revise your plan and implement alternative interventions. Current recommendations for pain reassessment include:
■ Within 30 minutes after parenteral administration of pain medication.
■ Within 1 hour after oral administration of pain medication.
■ After each and every report of new or changes in pain.
The frequency of reassessment depends on the patient, type of pain, and setting. In acute care settings, reassessment of pain frequently occurs when vital signs are obtained. Outpatients or long-term healthcare residents should be instructed to report any changes in pain or ineffective pain control. Patients with chronic pain should have periodic pain reassessments to ensure effective pain control.
SUMMARY
■ Pain is referred to as the fifth vital sign. Subjective iature, self-report is the most accurate assessment indicator of pain.
■ Pain assessment includes a detailed history and symptom analysis and physical examination. The history is the most important piece of the assessment.
■ Realize that pain threshold, the point at which a painful stimulus is perceived as painful, is consistent from one person to the next; however, pain tolerance, the amount of pain one is able to endure, varies greatly.
■ Developmental, psychosocial, and cultural factors and past experiences influence pain perception, thereby accounting for such individual differences in pain perception even with similar painful stimuli.
■ The initial purpose of the physical examination is to identify the underlying cause of pain. The physical examination also identifies physical, behavioral, and psychological nonverbal responses to pain.
■ Although self-report is the most accurate assessment tool of pain, the age and mental status of the patient may prevent self-report. Assessment then becomes dependent on assessing physical, behavioral, and psychological nonverbal responses to pain.
■ Various pain scales are available to assess pain. Select the one best suited to meet your patient’s needs.
■ Be sure to document your findings,evaluate the effects of treatment, and revise the plan of care as needed to ensure pain relief for your patient.
Nutritional Assessment
Nutrition is the relative state of balance betweeutrient intake and physiological requirements for growth and physical activity. Optimal nutrition helps protect against disease, facilitates recovery, and decreases complications during illness. Good nutrition helps people stay healthy.
Malnutrition has traditionally been defined as a deficit of appropriate nutrients.However, it literally means bad nutrition and can encompass any situation that contributes to an imbalance iutrient intake relative to actual needs.Therefore,malnutrition can mean a nutrient deficit or excess. Although nutritional deficits remain a significant health problem in Third World countries, the major problem in the
As a nurse, you are in a unique position to assess people’s nutritional status and provide information on proper nutrition. You can reinforce positive nutritional patterns, identify people at risk for malnutrition, and encourage more healthful eating habits.
Assessing nutritional status achieves the following:
■ Identifies actual nutritional deficiencies.
■ Illuminates dietary patterns that may contribute to health problems.
■ Provides a basis for planning for more optimal nutrition.
■ Establishes baseline data for evaluation.
Review of Nutrients
The goal of eating is to supply body cells with necessary nutrients. Ingestion, digestion, absorption, and metabolism are the processes that normally accomplish this goal. Interference with any of these functions can contribute to nutritional problems.
Primary Nutrients. Nutrients are substances contained in food that are essential for optimal body functioning. The primary nutrients are carbohydrates, proteins, fats, vitamins, minerals, and water. Carbohydrates, protein, and fat are the body’s major energy sources. Carbohydrates and protein each supply 4 calories per gram, and fat provides 9 calories per gram. Vitamins are essential to specific functions in the body. Minerals are inorganic elements that are essential to cell structure and physiological functions in the body.Water makes up 50 to 60 percent of the adult weight. It is required for many functions, and humans cannot survive for more than a few days without it.
Carbohydrates. Carbohydrates are the body’s major energy source. Foods that contain the most carbohydrates are grains, legumes, potatoes, corn, fruits, and vegetables. Adult carbohydrate intake should range from 50 to
Protein. Protein is the primary building block of all tissues and organs and serves an important function in cell structure and tissue maintenance. Integrity of the skin, internal organs, and muscles depends on adequate protein intake and metabolism.The body can synthesize most of the necessary amino acids from nonprotein dietary sources. However, there are nine essential amino acids that the body cannot synthesize and that must be obtained through dietary sources. For this reason, adults require 0.8 g/kg per day of protein (about 10 to 20 percent of the daily caloric intake). Primary sources of protein include meat, milk and milk products (e.g., cheese and yogurt),nuts, and legumes.
More protein is needed during tissue building—for example, in pregnancy and lactation, childhood, adolescence, postoperative recovery, tissue damage, and long-term illness. Athletes also require additional protein to build and maintain muscle. Animal products are the most common source of protein in industrialized countries. However,well-planned vegetarian diets can also provide ample dietary protein.
Fats. Lipids or fats are insoluble in water and soluble in alcohol, ether, and chloroform. They include true fats, lipids, and sterols, such as cholesterol. Fat supplies twice as much energy as carbohydrates or proteins. It provides essential fatty acids (linoleic and linolenic acids) and promotes the absorption of the fat-soluble vitamins A, D, E, and K. The typical American diet usually contains adequate fat, and recommended daily allowances in grams do not exist.
Triglycerides and cholesterol are major contributors to heart disease,diabetes mellitus (DM), and obesity. The U.S. Department of Agriculture (USDA) and the American Heart Association recommend that fat intake not exceed 20 to 30 percent of a person’s total daily calories.
Highly saturated fat (solid at room temperature) significantly contributes to elevated serum triglyceride and cholesterol levels. So USDA/U.S. Department of Health and Human Services (USDHHS) guidelines recommend that no more than 10 percent of daily calories be derived from saturated fats. Unsaturated and polyunsaturated fats are recommended because of their inverse relationship with heart disease.
Cholesterol occurs naturally and exclusively in all animal food products.The body needs cholesterol for cell structure, as a precursor for certain hormones and vitamins, and to aid in the digestive process. But even if no cholesterol were consumed in the diet, the body would synthesize the needed supply.
Lipoproteins. Serum cholesterol and lipids attach to proteins and are transported throughout the body as lipoproteins. The relative ratio of lipid to protein determines the density of the molecule.A low lipid-to-protein ratio results in a high-density lipoprotein (HDL).HDLs are produced during cellular metabolism. They lower serum cholesterol by transporting it from the cell to the liver for metabolism and excretion. Conversely, a high lipid-to-protein ratio produces a larger and low-density lipoprotein (LDL). LDLs are produced in the gastrointestinal wall after eating and transport dietary cholesterol and triglycerides to the cells.
Thus, HDLs guard against heart disease by lowering cholesterol, and LDLs contribute to heart disease by raising cholesterol.The risk for heart disease is particularly high when total serum cholesterol exceeds 200 mg/dL. The risk also increases as the HDL level decreases. An HDL less than 35 mg/dL is considered a major risk factor for heart disease, and an HDL above or equal to 60 mg/dL is a negative risk factor.
Vitamins and Minerals. Vitamins are organic compounds that play a major role in enzyme reactions associated with the metabolism of carbohydrate, protein, and fat. Although vitamins are required in small amounts, the body does not synthesize them, so they must be present in the diet. Vitamins are classified as water soluble or fat soluble. The body does not store water-soluble vitamins (B complex and C vitamins), so any surplus in daily intake is excreted in the urine. Fat-soluble vitamins (A, D, E, and K) are obtained through dietary fat and are stored in adipose tissue,where they can accumulate and become toxic.Toxicity generally results from self-administered large doses of a vitamin or excessive intake of foods that contain the vitamin.
Minerals are inorganic compounds found iature. They play a wide variety of roles in human nutrition. Minerals are required in varying amounts and are divided into major and trace elements. Major minerals are required in excess of 100 mg per day and include calcium, chloride, magnesium, phosphorus, potassium, sodium, and sulfur. The remaining minerals are known as trace elements (e.g. aluminum, bromine, chromium, cobalt, copper, fluorine, iron, iodine, magnesium, nickel, silicon, zinc, and other rare minerals).
Water. We usually do not think of water as being related to nutria tion. But without it, humans cannot survive more than a few days.Water helps regulate body temperature; serves as a solvent for vitamins, minerals, and other nutrients; acts as a medium for chemical reactions; serves as a lubricant; and transports nutrients to and wastes from the cells.
Adults consume about 6 cups of water per day through beverages; another 4 cups are obtained through food; and about 1 cup is produced as a byproduct of metabolism. Sensible water loss occurs through excessive perspiration, urine, and gastrointestinal secretions. Evaporative or insensible water loss occurs via the lungs and skin. More than half of the body’s weight is composed of water, and therefore rapid weight changes are usually a reflection of fluid balance. This is especially true for infants who have a greater proportion of water weight and proportionately more extracellular fluid. Thirst is not an accurate indicator of hydration status because it does not occur until about 10 percent of the intravascular volume is lost, or 1 to 2 percent of the intracellular volume is depleted. Assessment of hydration and signs and symptoms of dehydration are discussed later in this chapter.
Nutritional Guidelines and Standards. Early guidelines addressed the nutritional needs of the entire population, so they exceed the needs of most normal, healthy people. A diet that meets roughly two-thirds of the Recommended Daily Allowances (RDAs) for each nutrient is considered adequate.
Dietary Guidelines and the Food Guide Pyramid The RDAs provide guidelines for specific nutrient quantities for clinical applications. The six-group Food Guide Pyramid was developed to make these recommendations easier for the public to understand and follow. The pyramid can be used to evaluate individual nutritional status and to educate people about nutrition.
How a Nutritional Deficiency Develops
Nutritional deficiencies have characteristics that are relatively unique to the specific nutrient that is lacking in the diet. For example, diminished night vision is a classic symptom of vitamin A deficiency, and fetal deformities are associated with folic acid deficiencies in pregnancy. A thorough nutritional assessment can identify deficiencies long before actual clinical symptoms occur. The following section describes the four stages of nutritional deficiency.
Stage 1: Nutritional Deficiency Occurs. Malnutrition occurs when the nutrient in question is not available for digestion, absorption, and metabolism. Primary malnutrition results when a specific nutrient is lacking in the diet. Iron-deficient diets that result in anemia in infants and young children and calcium-deficient diets that cause osteoporosis in postmenopausal women are examples. Secondary malnutrition results from impaired bioavailablity of nutrients to the body. Intake of nutrients may be adequate, but physiological processes prevent them from being digested, absorbed, or metabolized, such as with malabsorption syndrome. Primary and secondary malnutrition can occur together.
Stage 2: Tissue Reserves Decrease. When a nutritional deficiency occurs, the body mobilizes tissue reserves to sustain metabolic processes. Nutrient levels in the blood generally will remain withiormal limits as long as there are tissue reserves that the body can depend on.However, if the intake deficiency persists, tissue reserves become depleted and blood levels of nutrients drop, causing biochemical abnormalities.
Stage 3: Biochemical Lesions Occur. Biochemical lesions are changes in serum values that signal depletion of tissue reserves. Biochemical testing is a valuable adjunct to nutritional assessment and may reveal nutrient deficiencies well before clinical signs and symptoms occur.
Stage 4: Clinical Lesions Occur. Clinical lesions are physical changes that result from an inadequate supply of one or more nutrients necessary for tissue growth and maintenance.
Developmental, Cultural, and Ethnic Variations. As people grow and develop, their nutritional needs change. Developmental groups especially at risk for nutritional problems include pregnant and lactating women, infants and children, adolescents, and older adults.
Infants, Children, and Adolescents. The growth and development that occur in infancy, childhood, and adolescence determine nutritional needs. For example, brain development is at its peak from birth through the second year of life, but after this, improved nutrition will not enhance brain growth. Growth charts are the standard against which infant and child growth is evaluated (see Appendix B).The following tables list indications of good nutrition in school-age children and summarize pertinent growth and developmental factors and corresponding nutritional needs of infants, children, and adolescents.
Pregnant Women. Good nutrition is critical to the developing fetus. Women who fail to receive adequate nutrition before and during pregnancy are at risk for premature birth, low-birth-weight (LBW) infants, or infants who are small for gestational age (SGA).These infants are at higher risk for mental and physical disabilities and other congenital anomalies. In addition, pregnant women who are poorly nourished endanger their own health because maternal nutrients are sacrificed to compensate for the increasing demands of the growing fetus.
Pregnant womeeed an additional 300 calories a day, and lactating women an additional 500 calories a day. Development of the placenta, amniotic fluid, and fetal tissues, and increases in maternal blood volume during pregnancy require
Older Adults. Older adulthood begins at age 65. The senses become less acute, and diminished taste of sweet and salty foods may cause people to compensate by increasing sugar and salt. Decreased gastric acidity can impede vitamin B12 absorption. Antacid use impedes it further. Skin changes associated with aging impair vitamin D synthesis; so does spending less time outdoors. Diminished physical strength and decreased activity predispose older adults to bone demineralization and loss. This problem is especially common in women who do not consume adequate calcium and in postmenopausal women who have lost the protective advantage of estrogen. In addition, loss of urinary sphincter muscle tone in women and urination difficulty associated with prostate changes in men may discourage fluid intake. Confusion, a common consequence of dehydration, may impair mental status. Decreased income, loss of the social context for eating (e.g., death of spouse), and lack of accessibility to food markets are social and economic aspects of aging that may adversely affect nutrition.
The RDA amounts beginning in early adulthood change only moderately through the middle adult years. The most significant changes beginning in midlife and extending into older adulthood are related to the physical changes associated with aging. Energy requirements are thought to decrease by about 5 percent per decade after age 40. However, without dietary modifications, weight gain will occur, with the risk for obesity-related diseases. The RDAs reflect a 200-mg increase in calcium and a twofold increase for vitamin D to 10 µg after age 50. Unless fluid intake is restricted for medical reasons, older adults still need to drink 6 to 8 glasses of water daily.
People of Different Cultural/Ethnic Groups. Sociocultural patterns of food intake also influence nutritional status. Cultural patterns of eating are learned and reinforced early in life and are difficult to change without conscious efforts and external support. Many cultures have healthy eating habits. For example, the traditional Asian diet provides adequate nourishment and is associated with lower rates of the chronic diseases that plague Western populations. However, now that Asians are beginning to adopt Western food preferences, chronic diseases are on the rise in these countries. In contrast, diets in Western industrialized cultures are high in meat, sugar, and fat.
Performing the Nutritional Assessment
One of the first steps in assessing nutrition is screening the patient for possible nutritional risks. At the very least, you should evaluate the health history for symptoms and situations related to nutritional problems,perform a basic physical examination, and obtain laboratory data associated with malnutrition. A comprehensive nutritional assessment involves a detailed dietary history, focused anthropometry, and evaluation of laboratory values. It is recommended for people with any of the following nutritional risks:
■ Weight less than 80 percent or more than 120 percent of ideal body weight (IBW).
■ History of unintentional weight loss (>
■ Serum albumin concentration lower than 3.5 g/dL.
■ Total lymphocyte count lower than 1500 cells/mm3.
■ History of illness, surgery, trauma, or stress.
■ Symptoms associated with nutritional deficiency or depletion.
■ Factors associated with inadequate nutritional intake or absorption.
Health History. Nutritional health risks and problems are not always obvious to the patient or the nurse. So during the health history, stay alert for clues. The following sections summarize health history data that may signal nutritional problems warranting further investigation.
Biographical Data. Scan the biographical data for clues that may affect the patient’s nutritional status.Note age to determine normal dietary requirements.Nutritional needs also vary according to gender. Religion and cultural background may influence dietary preferences. Financial status may also affect the person’s ability to maintain a healthy diet.
Current Health Status. Inadequate nutrition is often discovered indirectly during a routine health history and physical examination. For instance, diminished growth and delayed development related to inadequate nutrition may be identified during a routine well-child checkup. Patient concerns that result from malnutrition usually present as a specific symptom or functional problem rather than a focused nutritional problem.For example,a person with iron deficiency anemia may complain of a lack of energy and an inability to concentrate.
Ask your patient if his or her health status has changed. If so, consider the potential influence of the health change outrition.Acute and chronic illnesses, debilitating conditions, medications, surgery, and trauma all affect nutrition. Illness and trauma stimulate the stress response and increase nutritional requirements. Vomiting and diarrhea can cause fluid and electrolyte loss. Febrile illnesses accelerate metabolic processes and insensible fluid loss. Energy and fluid requirements are also greater during infections and febrile illnesses. Certain diseases, such as DM, cystic fibrosis, and celiac disease, are linked to specific nutritional deficits.
Ask about changes in diet or weight. Diet changes may be a result of physical,economic,or other factors that could contribute to malnutrition.Weight gains can occur with certain endocrine problems, and weight loss may accompany cancer, DM, and hyperthyroidism. Sudden weight changes are more likely to be related to fluctuations in hydration status caused by such conditions as congestive heart failure (CHF) or severe diarrhea.
Ask about prescription and over-the-counter (OTC) medications. Many of these drugs adversely affect nutrition.Note the patient’s use of diuretics because they can cause non-nutritional weight changes.
Past Health History. Ask the person if she or he has experienced a major illness, surgery, or trauma. These are usually associated with increased nutritional needs, and depending on how recently they occurred and the person’s recovery status, they may continue to pose a nutritional risk. Also ask if she or he has any chronic conditions, such as cancer, that could affect utilization of nutrients. In addition, inquire about dental or oral problems. Loss of teeth or pain and health problems, such as Crohn’s disease, DM, or cystic fibrosis; or anemias, such as thalassemia. Inquire about a family history of cardiovascular disease, atherosclerotic disease, or obesity.
Review of Systems. The review of systems (ROS) provides a focused screening for past and present problems related to or affecting each of the physical systems. It may also identify problems or symptoms that indicate a nutritional risk.
Psychosocial Profile. Because physical problems are frequently assumed to have a physical origin, nurses may underestimate the relationship of everyday life to health. Taking a psychosocial profile can yield valuable clues about a person’s nutritional status. Helping the person change unhealthy lifestyle behaviors may also be the most viable avenue of intervention.
Comprehensive Nutritional History. If the person has one or more knowutritional risks, perform a comprehensive nutritional history. If there is no time to perform a comprehensive history, perform a focused history. Although nutritional patterns are learned early in life and are hard to break,weight and nutrition are major health issues in Western cultures. Information on dieting, exercise, and nutrition pervades the news media, along with the message that people should take responsibility for making healthy changes. Consequently, many people worry that they will be scolded for poor nutritional practices, so they withhold or embellish information. So remember to convey an attitude of acceptance and caring, and never be authoritarian or paternalistic. Two dietary analysis techniques are discussed—24-hour recall and food intake records. You can use either technique as part of your comprehensive history.
24-Hour Recall. Ask the person to write down what he or she ate and drank during the previous 24 hours. Then use the Food Guide Pyramid to sort and categorize the foods and determine the general quality of his or her diet. People often have trouble accurately recalling what they ate, so prompt them by saying, “Start with the first thing you had when you got out of bed.” Also ask them to record between-meal drinks and snacks, desserts, bedtime snacks, condiments (e.g., mayonnaise, butter, sugar, or cream), and food preparation items (e.g., cooking oil or lard).Water is critical to nutritional metabolic processes, so ask them to record water intake, too. Last, be sure to have them record the amount of each food or liquid they consumed, and translate these into standard servings according to the Food Pyramid. A person’s typical serving may actually equal several servings.
The 24-hour recall is a valuable screening and assessment tool only if it represents the person’s typical daily intake. If a person is ill or has a change in routine, her or his intake will vary from normal. So be sure to ask if what she or he recorded represents a typical day. If she or he says no, ask her or him to substitute foods typically eaten.
Use the Food Pyramid to categorize 24-hour-recall data. Then tabulate food items alongside each corresponding Pyramid group, and document them in the person’s health record.
Food Intake Records. Food intake records are typically done on people who are debilitated, have severe burns, or are on chemotherapy. A food intake record is a quantitative listing of all food and fluid consumed within a designated time frame—usually 3 to 5 days.Because food intake patterns often change on weekends and holidays, records kept during outpatient or home-care situations should reflect one atypical day for a 3-day period and one weekend for a 5-day period. Again, be sure to clarify serving sizes.
To analyze the data, reduce the recorded food items into their constituent nutrients, using USDA food composition tables. To get a daily average intake for each nutrient, add up the total nutrients and divide by the number of days the record was kept. Evaluate the averages against the RDAs. Two-thirds of the RDAs is considered adequate for the general healthy population. However, acceptable levels may vary in disease, risk, or deficiency situations and will be reflected in therapeutic treatment decisions.
A less specific but more practical approach involves analyzing the patient’s food intake record using food labels on packages. Once you have determined the total number of calories consumed, calculate the total grams of carbohydrate, protein, and fat and the percentage of caloric intake contributed by each of these.
Protein should compose 10 percent of the diet; fat, 20 to 30 percent, and carbohydrates, the remaining calories.
Physical Assessment. Now proceed to the objective part of the assessment. Findings from the health history will determine the depth and scope of your physical examination. As you perform the examination, be alert to findings in various body systems that might signal malnutrition. Remember, determination of malnutrition cannot be made on physical findings alone.Many diseases and disorders mimic nutritional deficiencies. Always corroborate your physical findings with the health history and the results of laboratory assessments.The assessment includes performing a head-to-toe scan and taking various anthropometric measurements.
Approach. You will mainly use the techniques of inspection and palpation. Examining the skin and mucous membranes is crucial, but additional data are derived from assessment of other body systems.
Optimal nutrition cannot occur without adequate hydration.Therefore, evaluate the person’s hydration status simultaneously. Red flags include reports of minimal fluid intake, excessive thirst or excessive fluid intake, increased urination, diarrhea, or diuretic use. Very young infants, very frail older adults, and chronically ill and debilitated people are less tolerant of fluid loss and are at particular risk for dehydration from vomiting and/or diarrhea.
Performing a Head-to-Toe Physical Assessment. Look for changes in every system that might signal a nutritional problem.
Anthropometry. Anthropometry literally means human measurement. It includes measuring overall body mass (particularly growth, fat reserves, and somatic protein stores) and evaluation of related laboratory values. Growth charts that plot height, weight, and head growth are used for children up to age 18. By adulthood, growth has stabilized and ratio measurements of body mass are used. The following sections describe common anthropometric techniques for assessing nutrition in children and adults.
Growth Charts
Children. Growth charts for height, weight, and head circumference are excellent indicators of nutrition in children because they allow you to visualize the child’s growth progress. Two sets of charts are commonly used: one for birth to 36 months (includes head circumference) and one for age 2 to 18 (does not include head circumference because cerebral growth is complete by age 2).New charts have also been developed to track the unique growth patterns of premature infants.
Until age 2, take growth measurements with the child nude or wearing only a diaper and lying supine. For children age 2 to 18, take a standing height without shoes, with the patient dressed in usual examination clothing. Record measurements on the corresponding axes of the chart at the point that intersects with the child’s current age. To visualize a growth pattern, take serial measurements.The important factor is the relative consistency of the child’s growth within the norms of the curve.
As long as a child receives adequate nutrition,his or her growth largely reflects genetic heritage. If a child shows a consistent decline into a lower percentile or falls below the fifth percentile, suspect undernutrition. Suspect overnutrition in children who begin to deviate into higher percentiles or who fall above the 95th percentile. Growth chart abnormalities can also signify problems of a non-nutritional nature, such as endocrine disorders. If your history does not support a nutritionally related growth problem, a medical referral is warranted.
Adults. By age 18, growth is largely complete and weight-for height tables replace growth charts. The Metropolitan Life Insurance Company’s height and weight tables, revised in 1983, are the standard, although they do not reflect ideal weights. Instead, they represent the weights of people with the most longevity in each height category and recommend weight ranges based on height and skeletal frame size. Figures 8.2 and 8.3 illustrate height and weight measurement.
Body Mass Index. Body mass index (BMI) is an accurate indicator of fat in adults.The most commonly used BMI is Quetelet’s Index, which is obtained by dividing weight in kilograms by height in meters squared.BMIs between 20 and 25 kg/m2 are associated with the least mortality; BMIs under 16 kg/m2 are associated with eating disorders. The relatively larger proportion of muscle in athletes and body builders and the greater blood and tissue volume in pregnant and lactating women make BMI measurements inappropriate for these groups. It is also not recommend for growing children or frail and sedentary older adults.
Arm Measurements. Triceps skin fatfold (TSF) estimates body fat using a double fold of skin and subcutaneous adipose tissue from the patient’s dominant arm. With the patient’s arm at his or her side and elbow flexed at 90 degrees, measure and mark the midpoint overlying the triceps muscle between the elbow and the shoulder. Tell the patient to relax the arm.Then use your thumb and index finger to compress a symmetrical fold of skin and adipose tissue 1⁄2 inch above the marked site. Use calipers to measure in the middle of the skin fold at the marked site, about 1⁄2 inch below your fingers. Release the calipers, and wait 4 seconds before reading the measurement. To ensure reliability, take two to three additional measurements at least 15 seconds apart. They should not vary by more than
Compare fatfold measurements with equivalent age- and gender-specific percentiles. Values below the 10th percentile or above the 90th percentile indicate diminished or extensive fat reserves, respectively. Figure 8.4 illustrates TSF measurement.
Midarm circumference (MAC) provides a crude estimate of muscle mass and is most useful when combined with TSF. Measure the circumference of the patient’s dominant arm at the same site where you obtained the TSF. Wrap the measuring tape firmly around the patient’s arm without compressing the skin. Take two or three more measurements to ensure reliability. They should not vary by more than
Midarm muscle circumference (MAMC) is mathematically derived using TSF and MAC values. As an indirect measurement of muscle mass, it provides an index of protein stores. To calculate MAMC, multiply the TSF (in centimeters) by 3.143 and subtract the result from the MAC. Because MAMC estimates skeletal muscle reserves, it should generally fall within 90 percent of standard. Values falling between 60 and 90 percent suggest moderate protein deficiency and those less than 60 percent indicate severe malnutrition. Compare MAMC measurements with equivalent age- and gender-specific percentiles.
Waist-to-Hip Ratio. The waist-to-hip ratio (WHR) estimates obesity by evaluating the amount of abdominal fat. People with a greater proportion of upper body fat are at greater risk for HTN, DM, elevated triglycerides, and other atherosclerotic risk factors.WHR is calculated simply by dividing the waist circumference by the hip circumference. A WHR of 1.0 or greater in men and 0.8 or greater in women indicates upper body obesity.
Nursing Diagnoses. Consider all of the data you have collected during your assessment of Mr.Thomas, and then use this information to develop a list of nursing diagnoses.Some possible ones are listed. Cluster the supporting data.
1. Nutrition: imbalanced, less than body requirements, related to inadequate iron intake
2. Fluid Volume, deficient, related to medications and poor intake
3. Knowledge, deficient, related to nutrition
Identify any additional nursing diagnoses and any collaborative nursing diagnoses.
SUMMARY
■ Throughout the health assessment process, the nurse should be attuned to data related to nutrition.
■ Nutrition is influenced by a myriad of factors. Basic information in the health history can identify the need to more thoroughly investigate nutritional status.
■ Assessment of nutritional status involves eliciting data that are both directly and indirectly related to nutrition.
■ Comprehensive nutritional assessment will provide specific data to enable the nurse to determine potential or actual nutritional health problems, to devise an appropriate plan of intervention, and to determine criteria for evaluation.
