Health Assessment Unit 1

Culture and Genetics

Cultural Considerations on Gender Violating cultural norms related to appropriate male-female relationships may jeopardize a professional relationship. Among some Arab Americans an adult male is never alone with a female (except his wife) and is generally accompanied by at least one other male when interacting with females. This behavior is culturally very significant; a lone male could be accused of sexual impropriety. Ask the person about culturally relevant aspects of male-female relationships at the beginning of the interview. When gender differences are important to the patient, try strategies such as offering to have a third person present. Cultural Considerations on Sexual Orientation Simple, basic changes in your communication and nursing practice can help avoid heterosexism. • Instead of asking marital status or referring to a spouse, husband, or wife, use the term partner, and make sure that all forms have this as an option. • Do not marginalize a homosexual relationship. Ask the same questions of a homosexual couple that you would of a heterosexual couple as long as the questions are applicable. • Know your state laws. Every state differs; therefore it is important that you know applicable laws in your state. For example, some states allow both same-sex parents to be listed on the birth certificate, whereas others do not. • Use appropriate health teaching materials, including those that depict same-sex couples. • Do not make assumptions about a person's sex based on his or her appearance. • Avoid heterosexist assumptions. Make sure that you ask all appropriate questions while avoiding assumptions that heterosexism is the norm. For example, ask a sexually active woman, "Have you ever used birth control?" instead of, "Which type of birth control measures have you used?" The latter question assumes that the woman has had the need for birth control, which assumes that she has engaged in relations with a man. • Make sure that registration and admitting forms allow for identification of a same-sex partner by using terms such as "partner" or "significant other" while avoiding terms such as "marital status." • Be nonjudgmental, and make sure that your workplace has adopted policies to avoid discrimination. Most important, be aware of your personal bias and baggage. Being familiar with considerations for treatment of the LGBT community is the first step in providing culturally competent care. Working With (and Without) an Interpreter Over 60.5 million people in the United States speak a language other than English at home.33 One of the greatest challenges in cross-cultural communication occurs when you and the client speak different languages (Fig. 3-8). After assessing the language skills of non-English-speaking people, you may find yourself in one of two situations: trying to communicate 44effectively through an interpreter or trying to communicate effectively when there is no interpreter. Either way, it is important that you consider not only the meaning of the spoken language, but also nonverbal communication.

Functional Assessment (Including Activities of Daily Living)

Functional assessment measures a person's self-care ability in the areas of general physical health or absence of illness; ADLs such as bathing, dressing, toileting, eating, walking; instrumental ADLs (IADLs) or those needed for independent living such as housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances; nutrition; social relationships and resources; self-concept and coping; and home environment. Self-Esteem, Self-Concept. Education, financial status, value-belief system (religious practices and perception of personal strengths). Activity/Exercise. A daily profile reflecting usual daily activities. Ask, "Tell me how you spend a typical day." Note ability to perform ADLs: independent or needs assistance with feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, or climbing stairs. Is there any use of wheelchair, prostheses, or mobility aids? Sleep/Rest. Sleep patterns, daytime naps, any sleep aids used. Nutrition/Elimination. Record the diet by a recall of all food and beverages taken over the past 24 hours. Indicate any food allergy or intolerance. Record daily intake of caffeine (coffee, tea, cola drinks). Describe eating habits and current appetite. Interpersonal Relationships/Resources. Social roles: Ask, "How would you describe your role in the family? How would you say you get along with family, friends, and co-workers?" Ask about support systems composed of family and significant others: "To whom could you go for support with a problem at work, your health, or a personal problem?" Include contact with spouse, siblings, parents, children, friends, organizations, workplace. "Is time spent alone pleasurable and relaxing, or is it isolating?" Spiritual Resources. Many people believe in a relationship between spirituality and health, and they may wish to have spiritual matters addressed in the traditional health care setting. Use the Faith, Influence, Community, and Address (FICA) questions to incorporate the person's spiritual values into the health history Coping and Stress Management. Types of stresses in life, especially in the past year; any change in lifestyle or any current stress; methods tried to relieve stress and whether these have been helpful. Personal Habits. Tobacco, alcohol, street drugs: Ask, "Do you smoke cigarettes (pipe, use chewing tobacco)? At what age did you start? How many packs do you smoke per day? How many years have you smoked?" Record the number of packs smoked per day (PPD) and duration (e.g., 1 PPD × 5 years). Then ask, "Have you ever tried to quit?" and "How did it go?" to introduce plans about smoking cessation. Alcohol. When was your last drink of alcohol? How much did you drink that time? In the past 30 days, about how many days would you say that you drank alcohol? Has anyone ever said that you had a drinking problem?" You may wish to use a screening questionnaire to identify excessive or uncontrolled drinking such as the Cut down, Annoyed, Guilty, and Eye-opener (CAGE) test. Illicit or Street Drugs. Ask specifically about prescription painkillers such as OxyContin or Vicodin, cocaine, crack cocaine, amphetamines, heroin, and marijuana. Indicate frequency of use and how use has affected work or family. Environment/Hazards. Housing and neighborhood (living alone, knowledge of neighbors), safety of area, adequate heat and utilities, access to transportation, and involvement in community services. Intimate Partner Violence. Begin with open-ended questions: "How are things at home?" and "Do you feel safe?" "Have you ever been emotionally or physically abused by your partner or someone important to you? Within the past year, have you been hit, slapped, kicked, pushed, or shoved or otherwise physically hurt by your partner or ex-partner?" If yes, ask: "By whom? How many times? Does your partner ever force you into having sex? Are you afraid of your partner or ex-partner? Occupational Health. Ask the person to describe his or her job. Ever worked with any health hazard such as asbestos, inhalants, chemicals, repetitive motion? Wear any protective equipment? Any work programs in place that monitor exposure? Aware of any health problems now that may be related to work exposure?

Patients interactions with nurses

Personal Questions Occasionally people will ask you questions about your personal life or opinions such as, "Are you married?" "Do you have children?" or "Do you smoke?" You do not need to answer every question, but you may supply information that you think is appropriate. Beware that there may be an ulterior motive to the questions such as anxiety or loneliness. Sexually Aggressive People On some occasions personal questions extend to flirtatious compliments, seductive innuendo, or sexual advances. Some people see illness as a threat to their self-esteem and sexual adequacy; this feeling creates anxiety that makes them act out in sexually aggressive ways. Your response must make it clear that you are a health professional who can best care for the person by maintaining a professional relationship. It is important to communicate that you cannot tolerate sexual advances, but you should also communicate that you accept the person and understand his or her need to be self-assertive. This may be difficult, considering that the person's words or gestures may have left you shocked, embarrassed, or angry. Crying A beginning examiner usually feels horrified when the client starts to cry, but crying is a big relief to a person. Health problems come with powerful emotions, and it takes a good deal of energy to keep worries about illness, death, or loss bottled up. When you say something that "makes the person cry," do not think you have hurt the person. You have just broached a topic that is important. Do not go on to a new topic. Anger Occasionally you will try to interview a person who is already angry. Don't take the anger personally; it typically doesn't relate to you. The person is showing aggression as a response to his or her own feelings of anxiety or helplessness. Do ask about the anger and hear the person out. Deal with the angry feelings before you ask anything else. An angry person cannot be an effective participant in a health interview. Threats of Violence The health care setting is not immune to violent behavior, and an individual may act in such a way that you believe that your personal safety is being threatened. Red-flag behaviors 43of a potentially disruptive person include fist clenching, pacing back and forth, a vacant stare, confusion, statements out of touch with reality or that do not make sense, a history of recent drug use, or perhaps a recent history of intense bereavement (loss of partner, loss of job). If you sense any suspicious or threatening behavior, act immediately to defuse the situation or obtain additional support from other staff or security. Make sure that you leave the door to the examination room open, and never turn your back to a potentially aggressive person. Anxiety Finally take it for granted that nearly all sick people have some anxiety. This is a normal response to being sick. It makes some people aggressive and others dependent. Appearing unhurried and taking the time to listen to all of the client's concerns can help diffuse some anxiety. Avoiding the traps to interviews and using therapeutic responses are other ways to help diffuse anxiety.

The Health History—The Adult

Record the date and time of day of the interview. Biographic Data Biographic data include name, address, and phone number; age and birth date; birthplace; gender; marital partner status; race; ethnic origin; and occupation (both usual and present; an illness or disability may have prompted a change in occupation). Record the person's primary language. Try to find a language-concordant provider to collect the history or a medical interpreter fluent in the patient's language. Evidence supports that language-concordance providers increase accuracy of communication and patient satisfaction. Source of History 1. Record who furnishes the information—usually the person himself or herself, although the source may be an interpreter or caseworker. Less reliable is a relative or friend. 2. Judge how reliable the informant seems and how willing he or she is to communicate. What is reliable? A reliable person always gives the same answers, even when questions are rephrased or repeated later in the interview. 3. Note if the person appears well or ill; a sick patient may communicate poorly. Reason for Seeking Care This is a brief, spontaneous statement in the person's own words that describes the reason for the visit. Think of it as the "title" for the story to follow. It states one (possibly two) symptoms or signs and their duration. A symptom is a subjective sensation that the person feels from the disorder. A sign is an objective abnormality that you as the examiner could detect on physical examination or in laboratory reports. The reason for seeking care is not a diagnostic statement. Avoid translating it into the terms of a medical diagnosis. For example, Mr. J.S. enters with shortness of breath, and you ponder writing "emphysema." Even if he is known to have emphysema from previous visits, it is not the chronic emphysema that prompted this visit but, rather, the "increasing shortness of breath" for 4 hours. Present Health or History of Present Illness For the well person, this is a short statement about the general state of health: "I feel healthy right now." "I am healthy and active." For the ill person, this section is a chronologic record of the reason for seeking care, from the time the symptom first started until now. Isolate each reason for care identified by the person and say, for example, "Please tell me all about your headache, from the time it started until the time you came to the hospital" (Fig. 4-2). If the concern started months or years ago, record what occurred during that time and find out why the person is seeking care now. 1. Location. Be specific; ask the person to point to the location. If the problem is pain, note the precise site. "Head pain" is vague, whereas descriptions such as "pain behind the eyes," 2. Character or Quality. This calls for specific descriptive terms such as burning, sharp, dull, aching, gnawing, throbbing, shooting, viselike. Use similes: Does blood in the stool look like sticky tar? 3. Quantity or Severity. Attempt to quantify the sign or symptom such as "profuse menstrual flow soaking five pads per hour." Quantify the symptom of pain using the scale shown on the right. 4. Timing (Onset, Duration, Frequency). When did the symptom first appear? Give the specific date and time or state specifically how long ago the symptom started prior to arrival (PTA). 5. Setting. Where was the person or what was the person doing when the symptom started? What brings it on? 6. Aggravating or Relieving Factors. What makes the pain worse? Is it aggravated by weather, activity, food, medication, standing bent over, fatigue, time of day, or season? What relieves it (e.g., rest, medication, or ice pack)? What is the effect of any treatment? Ask, "What have you tried?" or "What seems to help?" 7. Associated Factors. Is this primary symptom associated with any others (e.g., urinary frequency and burning associated with fever and chills)? Review the body system related to this symptom. 8. Patient's Perception. Find out the meaning of the symptom by asking how it affects daily activities (Fig. 4-3). "How has this affected you? Is there anything you can't do now that you could do before?" Also ask directly, "What do you think it means?" Past Health Past health events are important because they may have residual effects on the current health state. The previous experience with illness may also give clues about how the person responds to illness and the significance of illness for him or her. Including: Childhood illnesses Injury or accidents Serious or chronic illnesses Hospitalizations Operations Obstetric history ( Recorded as: Grav 3 Term 2 Preterm 1 Ab 0 Living 3) immunizations last examination date Allergies Current medications (frequency, dose, OTC medicines, herbal medicines.) Family History The most fruitful way to compile a complete family history is to send home a detailed questionnaire before the health care/hospital encounter because the information takes time to compile and often comes from multiple family members. Then you can use the health visit to complete the pedigree. A pedigree or genogram is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations such as parents, grandparents, and siblings Review of Systems The purposes of this section are (1) to evaluate the past and present health state of each body system, (2) to double-check in case any significant data were omitted in the Present Illness section, and (3) to evaluate health promotion practices. The order of the examination of body systems is roughly head to toe. The items within each system are not inclusive, and only the most common symptoms are listed When recording information, avoid writing "negative" after the system heading. You need to record the presence or absence of all symptoms. A common mistake made by beginning practitioners is to record some physical finding or objective data here such as "skin warm and dry." Remember that the history should be limited to patient statements or subjective data—factors that the person says were or were not present.

General Overall Health State.

Skin. History of skin disease (eczema, psoriasis, hives), pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion. Hair. Recent loss, change in texture. Nails: change in shape, color, or brittleness. Health Promotion. Amount of sun exposure; method of self-care for skin and hair. . Head. Any unusually frequent or severe headache; any head injury, dizziness (syncope), or vertigo. Eyes. Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts. Health Promotion. Wear glasses or contacts; last vision check or glaucoma test; how coping with loss of vision if any. Ears. Earaches, infections, discharge and its characteristics, tinnitus or vertigo. Health Promotion. Hearing loss, hearing aid use, how loss affects daily life, any exposure to environmental noise, and method of cleaning ears. Nose and Sinuses. Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smell. Mouth and Throat. Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste. Health Promotion. Pattern of daily dental care, use of dentures, bridge, and last dental checkup. Neck. Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter. Breast. Pain, lump, nipple discharge, rash, history of breast disease, any surgery on breasts. Health Promotion. Performs breast self-examination, including its frequency and method used; last mammogram. Axilla. Tenderness, lump or swelling, rash. Respiratory System. History of lung diseases (asthma, emphysema, bronchitis, pneumonia, TB), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure. Health Promotion. Last chest x-ray study, TB skin test. Cardiovascular. Chest pain, pressure, tightness or fullness, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion [e.g., walking one flight of stairs, walking from chair to bath, or just talking]), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary heart disease, anemia. Health Promotion. Date of last ECG or other heart tests, cholesterol screening. Peripheral Vascular. Coldness, numbness and tingling, swelling of legs (time of day, activity), discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet and ankles), varicose veins or complications, intermittent claudication, thrombophlebitis, ulcers. Health Promotion. Does the work involve long-term sitting or standing? Avoid crossing legs at the knees. Wear support hose? Gastrointestinal. Appetite, food intolerance, dysphagia, heartburn, indigestion, pain (associated with eating), other abdominal pain, pyrosis (esophageal and stomach burning sensation with sour eructation), nausea and vomiting (character), vomiting blood, history of abdominal disease (liver or gallbladder, ulcer, jaundice, appendicitis, colitis), flatulence, frequency of bowel movement, any recent change, stool characteristics, constipation or diarrhea, black stools, rectal bleeding, rectal conditions (hemorrhoids, fistula). Health Promotion. Use of antacids or laxatives. (Alternatively, diet history and substance habits can be placed here.) Urinary System. Frequency, urgency, nocturia (the number of times the person awakens at night to urinate, recent change); dysuria; polyuria or oliguria; hesitancy or straining, narrowed stream; urine color (cloudy or presence of hematuria); incontinence; history of urinary disease (kidney disease, kidney stones, urinary tract infections, prostate); pain in flank, groin, suprapubic region, or low back. Health Promotion. Measures to avoid or treat urinary tract infections, use of Kegel exercises after childbirth. Male Genital System. Penis or testicular pain, sores or lesions, penile discharge, lumps, hernia. Health Promotion. Perform testicular self-examination? How frequently? Female Genital System. Menstrual history (age at menarche, last menstrual period, cycle and duration, any amenorrhea or menorrhagia, premenstrual pain or dysmenorrhea, intermenstrual spotting), vaginal itching, discharge and its characteristics, age at menopause, menopausal signs or symptoms, postmenopausal bleeding. Health Promotion. Last gynecologic checkup and last Pap test. Sexual Health. Begin with: "I usually ask all patients about their sexual health." Then ask: "Are you presently in a relationship involving intercourse? Are the aspects of sex satisfactory to you and your partner? Are condoms used routinely? Is there any dyspareunia (for female) or are there any changes in erection or ejaculation (for male)? Are contraceptives used? Is the contraceptive method satisfactory? Are you aware of contact with a partner who has any sexually transmitted infection (gonorrhea, herpes, chlamydia, venereal warts, HIV/acquired immunodeficiency syndrome (AIDS), or syphilis)?" Musculoskeletal System. History of arthritis or gout. In the joints: Pain stiffness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion? In the muscles: Any muscle pain, cramps, weakness, gait problems, or problems with coordinated activities? In the back: Any pain (location and radiation to extremities), stiffness, limitation of motion, or history of back pain or disk disease? Health Promotion. How much walking per day? What is the effect of limited range of motion on ADLs such as grooming, feeding, toileting, dressing? Are any mobility aids used? Neurologic System. History of seizure disorder, stroke, fainting, blackouts. Motor function: Weakness, tic or tremor, paralysis, or coordination problems? Sensory function: Numbness, tingling (paresthesia)? Cognitive function: Memory disorder (recent or distant, disorientation)? Mental status: Any nervousness, mood change, depression, or history of mental health dysfunction or hallucinations? Health Promotion. Alternatively, data about interpersonal relationships and coping patterns are placed here. Hematologic System. Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, exposure to toxic agents or radiation, blood transfusion and reactions. Endocrine System. History of diabetes or diabetic symptoms (polyuria, polydipsia, polyphagia), history of thyroid disease, intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, tremors, and need for hormone therapy.

Developmental Competence Children

The health history is adapted to include information specific for the age and developmental stage of the child (e.g., the mother's health during pregnancy, labor and delivery, the perinatal period, and the family unit) Biographic Data Include the child's name, nickname, address and phone number, parents' names and work numbers, child's age and birth date, birthplace, sex, race, ethnic origin, and information about other children and family members at home. Source of History 1. Person providing information and relation to child 2. Your impression of reliability of information 3. Any special circumstances (e.g., the use of an interpreter) Reason for Seeking Care Record the parent's spontaneous statement. Because of the frequency of well-child visits for routine health care, there will be more reasons such as "time for the child's checkup" or "she needs the next baby shot." Reasons for health problems may be initiated by the child, the parent, or a third party such as a classroom teacher or social worker. Sometimes the reason stated may not be the real reason for the visit. A parent may have a "hidden agenda," such as the mother who brought her 4-year-old child in because "she looked pale." Further questioning revealed that the mother had heard recently from a former college friend whose 4-year-old child had just been diagnosed with leukemia. Present Health or History of Present Illness If the parent or child seeks routine health care, include a statement about the usual health of the child and any common health problems or major health concerns. Describe any presenting symptom or sign, using the same format as for the adult. Some additional considerations include: • Severity of pain: "How does your child behave when he or she is in pain?" (e.g., pulling at ears alerts parent to ear pain). Note the effect of pain on usual behavior (e.g., does it stop child from playing?). • Associated factors such as relation to activity, eating, and body position. • The parent's intuitive sense of a problem. As the constant caregiver, this intuitive sense is very accurate. Even if proved otherwise, this factor gives you an idea of the parent's area of concern. • Parent's coping ability and reaction of other family members to child's symptoms or illness. Past Health Prenatal Status. Start with an open-ended question: "Tell me about this pregnancy." Then ask: "How was this pregnancy spaced? Was it planned? What was the mother's attitude toward the pregnancy? What was the father's attitude? Labor and Delivery. Parity of the mother, duration of the pregnancy, name of the hospital, course and duration of labor, use of anesthesia, type of delivery (vertex, breech, cesarean section), birth weight, Apgar scores, onset of breathing, any cyanosis, need for resuscitation, and use of special equipment or procedures. Postnatal Status. Any problems in the nursery, length of hospital stay, neonatal jaundice, whether the baby was discharged with the mother, whether the baby was breastfed or bottle-fed, weight gain, any feeding problems, "blue spells," colic, diarrhea, patterns of crying and sleeping (Fig. 4-7), the mother's health postpartum, the mother's reaction to the baby, placement on back when sleeping. Childhood Illnesses. Age and any complications of measles, mumps, rubella, chickenpox, whooping cough, strep throat, and frequent ear infections; any recent exposure to illness. Serious Accidents or Injuries. Age of occurrence, extent of injury, how the child was treated, and complications of auto accidents, falls, head injuries, fractures, burns, and poisonings. Serious or Chronic Illnesses. Age of onset, how the child was treated, and complications of meningitis or encephalitis; seizure disorders; asthma, pneumonia, and other chronic lung conditions; rheumatic fever; scarlet fever; diabetes; kidney problems; sickle cell anemia; high blood pressure; and allergies. Operations or Hospitalizations. Reason for care, age at admission, name of surgeon or primary care providers, name of hospital, duration of stay, how child reacted to hospitalization, any complications. (If child reacted poorly, he or she may be afraid now and will need special preparation for the examination that is to follow.) Immunizations. Age when administered, date administered, and any reactions following immunizations (Fig. 4-8). Because of outbreaks of measles across the United States, the American Academy of Pediatrics recommends two doses of the measles-mumps-rubella vaccine, one at 12 to 15 months and one at age 4 to 6 years. Allergies. Any drugs, foods, contact agents, and environmental agents to which the child is allergic and the reaction to the allergens. A true food allergy is an immune response caused by exposure to a food substance. Common pediatric food allergies include cow's milk, eggs, peanuts, soybean, wheat, tree nuts, and fish. A true food allergy can be life threatening but should be differentiated from a food intolerance. Medications. Any prescription and OTC medications (or vitamins) that the child takes, including the dosage, daily schedule, why the medication is given, and any problems. Developmental History Growth. Height and weight at birth and at 1, 2, 5, and 10 years; any periods of rapid gain or loss (Fig. 4-9); process of dentition (age of tooth eruption and pattern of loss). Milestones. Age when child first held head erect, rolled over, sat alone, walked alone, cut his or her first tooth, said his or her first words with meaning, spoke in sentences, was toilet trained, tied shoes, dressed without help. Does the parent believe this development has been normal? How does this child's development compare with that of siblings or peers? Current Development (Children 1 Month Through Preschool). Gross motor skills (rolls over, sits alone, walks alone, skips, climbs), fine motor skills (inspects hands, brings hands to mouth, has pincer grasp, stacks blocks, feeds self, uses crayon to draw, uses scissors), language skills (vocalizes, first words with meaning, sentences, persistence of baby talk, speech problems), and personal-social skills (smiles, tracks movement with eyes to midline, past midline, attends to sound by turning head, recognizes own name). If the child is undergoing toilet training, indicate the method used, age of bladder/bowel control, parents' attitude toward toilet training, and terms used for toileting. School-Age Child. Gross motor skills (runs, jumps, climbs, rides bicycle, general coordination), fine motor skills (ties shoelace, uses scissors, writes name and numbers, draws pictures), and language skills (vocabulary, verbal ability, able to tell time, reading level). Nutritional History For the infant, record whether breastfeeding or bottle-feeding. If the child is breastfed, record nursing frequency and duration, any supplements (vitamin, iron, fluoride, bottles), If the child is bottle-fed, record type of formula used, frequency and amount, any problems with feeding (spitting up, colic, diarrhea), and supplements used; discourage any bottle propping. Record introduction of solid foods (age when the child began eating solids, which foods, whether foods are home or commercially made, amount given, child's reaction to new food, parent's reaction to feeding). For preschool and school-age children and adolescents, record the child's appetite, 24-hour diet recall (meals, snacks, amounts), vitamins taken, how much junk food is eaten, who eats with the child, food likes and dislikes, and parent's perception of child's nutrition. A week-long diary of food intake may be more accurate than a spot 24-hour recall. Also consider cultural practices in assessing child's diet. Family History As with the adult, diagram a family tree for the child, including siblings, parents, and grandparents (see p. 53). Ask specifically for the family history of heart disease, high blood pressure, diabetes, blood disorders, cancer, sickle cell anemia, arthritis, allergies, obesity, cystic fibrosis, mental illness, seizure disorder, kidney disease, mental retardation, learning disabilities, birth defects, and sudden infant death. Review of Systems General. Significant gain or loss of weight, failure to gain weight appropriate for age, frequent colds, ear infections, illnesses, energy level, fatigue, overactivity, and behavioral change (irritability, increased crying, nervousness). Skin. Birthmarks, skin disease, pigment or color change, mottling, change in mole, pruritus, rash, lesion, acne, easy bruising or petechiae, easy bleeding, and changes in hair or nails. Head. Headache, head injury, dizziness. Eyes. Strabismus, diplopia, pain, redness, discharge, cataracts, vision changes, reading problems. Is the child able to see the board at school? Does the child sit too close to the television? Health Promotion. Use of eyeglasses, date of last vision screening. Ears. Earaches, frequency of ear infections, myringotomy tubes in ears, discharge (characteristics), cerumen, ringing or crackling, and whether parent perceives any hearing problems. Health Promotion. How does the child clean his or her ears? Nose and Sinuses. Discharge and its characteristics, frequency of colds, nasal stuffiness, nosebleeds, and allergies. Mouth and Throat. History of cleft lip or palate, frequency of sore throats, toothache, caries, sores in mouth or tongue, tonsils present, mouth breathing, difficulty chewing, difficulty swallowing, and hoarseness or voice change. Health Promotion. Child's pattern of brushing teeth and last dental checkup. Neck. Swollen or tender glands, limitation of movement, or stiffness. Breast. For preadolescent and adolescent girl, when did she notice that her breasts were changing? What is the girl's self-perception of development? Does the female older adolescent perform breast self-examination? (See Chapter 17 for suggested phrasing of questions.) Respiratory System. Croup or asthma, wheezing or noisy breathing, shortness of breath, chronic cough. Cardiovascular System. Congenital heart problems, history of murmur, and cyanosis (what prompts this condition). Is there any limitation of activity, or can the child keep up with peers? Is there any dyspnea on exertion, palpitations, high blood pressure, or coldness in the extremities? Gastrointestinal System. Abdominal pain, nausea and vomiting, history of ulcer, frequency of bowel movements, stool color and characteristics, diarrhea, constipation or stool holding, rectal bleeding, anal itching, history of pinworms, and use of laxatives. Urinary System. Painful urination, polyuria/oliguria, narrowed stream, urine color (cloudy, dark), history of urinary tract infection, whether toilet trained, when toilet training was planned, any problems, bed-wetting (when the child started, frequency, associated with stress, how child feels about it). Male Genital System. Penile or testicular pain, whether told if testes are descended, any sores or lesions, discharge, hernia or hydrocele, or swelling in scrotum during crying. Has the preadolescent or adolescent boy noticed any change in the penis and scrotum? Is the boy familiar with normal growth patterns, nocturnal emissions, and sex education? Female Genital System. Has the girl noted any genital itching, rash, vaginal discharge? For the preadolescent and adolescent girl, when did menstruation start? Was she prepared? Screen for sexual abuse. Sexual Health. What is the child's attitude toward the opposite sex? Who provides sex education? How does the family deal with sex education, masturbation, dating patterns? Is the adolescent in a relationship involving intercourse? Does he or she have information on birth control and sexually transmitted infections? Musculoskeletal System. In bones and joints: arthritis, joint pain, stiffness, swelling, limitation of movement, gait strength and coordination. In muscles: pain, cramps, and weakness. In the back: pain, posture, spinal curvature, and any treatment. Neurologic System. Numbness and tingling. (Behavioral and cognitive issues are covered in the sections on development and interpersonal relationships.) Hematologic Systems. Excessive bruising, lymph node swelling, and exposure to toxic agents or radiation. Endocrine System. History of diabetes or thyroid disease; excessive hunger, thirst, or urinating; abnormal hair distribution; and precocious or delayed puberty.

culture has four basic characteristics:

(1) learned from birth through the processes of language acquisition and socialization; (2) shared by all members of the same cultural group; (3) adapted to specific conditions related to environmental and technical factors and to the availability of natural resources (4) dynamic and ever changing.

objective data

(i.e., what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination).

Abdomen

1. Assess contour of abdomen: Flat, rounded, protuberant. 2. Listen to bowel sounds in all four quadrants. 3. Check any drainage tube placement for color and amount of drainage and insertion site integrity. 4. Inquire whether passing flatus or stool. 5. Knowing diet orders, determine if patient is tolerating ice chips, liquids, solids. Order correct diet as it is advanced. Note if patient is at high risk for nutrition deficit.

Steps to Setting Priorities

1. Assign high priority to first-level priority problems (immediate priorities): Remember the "ABCs plus V": • Airway problems • Breathing problems • Cardiac/circulation problems • Vital sign concerns (e.g., high fever) Exception: With cardiopulmonary resuscitation (CPR) for cardiac arrest, begin chest compressions immediately. Go to www.americanheart.org for the most current CPR guidelines. 2. Next attend to second-level priority problems: • Mental status change (e.g., confusion, decreased alertness) • Untreated medical problems requiring immediate attention (e.g., a person with diabetes who has not had insulin) • Acute pain • Acute urinary elimination problems • Abnormal laboratory values • Risks of infection, safety, or security (for the patient or for others) 3. Address third-level priority problems (later priorities): • Health problems that do not fit into the previous categories (e.g., problems with lack of knowledge, activity, rest, family coping)

Cardiovascular System

1. Auscultate rhythm at apex: Regular, irregular? (Do NOT listen over gown.) 2. Check apical pulse against radial pulse, noting perfusion of all beats. 3. Assess heart sounds in all auscultatory areas: First with diaphragm, repeat with bell. 4. Check capillary refill for prompt return. 5. Check pretibial edema. 6. Palpate posterior tibial pulse, right and left. 7. Palpate dorsalis pedis pulse, right and left. NOTE: Be prepared to assess pulses in the lower extremities by Doppler imaging if you cannot find them by palpation. 8. Verify that the proper IV solution is hanging and flowing at the proper rate according to the physician's orders and your own assessment of the patient's needs.

Health History Sequence

1. Biographic data 2. Reason for seeking care 3. Present health or history of present illness 4. Past history 5. Medication reconciliation 6. Family history 7. Review of systems 8. Functional assessment or activities of daily living (ADLs)

Neurologic System

1. Eyes open spontaneously to name. 2. Motor response is strong and equal bilaterally. 3. Verbal response makes sense; speech is clear and articulate. 4. Pupil size in mm and reaction, R and L. 5. Muscle strength, R and L upper, using hand grips. 6. Muscle strength, R and L lower, pushing feet against your palms. 7. Any ptosis, facial droop. 8. Sensation (omit unless indicated). 9. Communication. 10. Ability to swallow.

General appearance

1. Facial expression: Appropriate to the situation. 2. Body position: Relaxed and comfortable or tense, in pain. 3. Level of consciousness: Alert and oriented, attentive to your questions, responds appropriately. 4. Skin color: Even tone consistent with racial heritage. 5. Nutritional status: Weight appears in healthy range, fat distribution even, hydration appears healthy. 6. Speech: Articulation clear and understandable, pattern fluent and even, content appropriate. 7. Hearing: Responses and facial expression consistent with what you have said. 8. Personal hygiene: Ability to attend to hair, makeup, shaving.

The Interview

1. Gather complete and accurate data about the person's health state, including the description and chronology of any symptoms of illness. 2. Establish trust so the person feels accepted and thus free to share all relevant data. 3. Teach the person about his or her health state. 4. Build rapport for a continuing therapeutic relationship; this rapport facilitates future diagnoses, planning, and treatment. 5. Discuss health promotion and disease prevention.

Genitourinary

1. Inquire whether voiding regularly. NOTE: Needs to void within 4 to 6 hours after surgery. 2. Check urine for color, clarity. 3. If Foley catheter in place, check color, quantity, clarity of urine with every VS check. 4. If urine output is below the expected amount, perform a bladder scan according to agency protocol. Is the problem in the production of urine or its retention?

Activity

1. Know activity orders; if on bed rest, head of bed should be ≥15 degrees. Is patient at high risk for skin breakdown? 2. Sequential compression devices (SCDs), thromboembolic disease (TED) hose, foot pumps need to be hooked up and turned on. Must be on patient 22 out of 24 hours to be effective. 3. If ambulatory, assist patient to sitting up level and move to chair. 4. Note any assistance needed, how tolerates movement, distance walked to chair, ability to turn. 5. Assess need for any ambulatory aid or equipment. 6. Complete any standardized scales used to quantify the patient's risk for falling. 7. Initiate or continue appropriate Plan of Care. Check if any core measures apply, such as heart failure. Implement core measures as appropriate. 8. Complete initial assessment to document into computer when finished. 9. Note examination findings requiring immediate attention: • High or low BP (≤90 or ≥160 mm Hg systolic) • High or low temperature (≤97° or ≥100° F) • High or low heart rate (≤60 or ≥90 bpm) • High or low respirations (≤12 or ≥28/min) • O2 saturations ≤92% • Low or no urine output (≤30 mL/hr or ≤240 mL/8 hr) • Dark amber or bloody urine (except for urology patients) • Postop nausea and/or vomiting • Surgical pain not controlled with medication. Any other unusual pain such as chest pain • Bleeding • Altered level of consciousness (LOC), confusion, or difficult to arouse • Sudden restlessness and/or anxiety

Measurement

1. Measure baseline vital signs (VS) now: Temperature, pulse, respirations, blood pressure (BP). Note which arm to avoid for BP because of surgery, IV access. Collect and document VS more frequently if patient is unstable or if patient condition changes. Know that VS are the ultimate responsibility of the nurse—the nursing assistant is not responsible for interpretation. 2. Pulse oximetry—Maintain ≥92%. Check oxygen use at least first 24 hours after surgery or as ordered. May need to monitor continuously if patient is lethargic or on a PCA or epidural. 3. Rate pain level on a 1-to-10 scale at this and every subsequent visit or VS measure. Note patient's ability to tolerate pain. 4. If pain medication given, note response in 15 minutes for IV administration or 1 hour for oral dosing.

Skin

1. Note skin color, consistent with person's racial or ethnic heritage. 2. Palpate skin temperature; expect warm and dry. 3. Pinch up a fold of skin under the clavicle or on the forearm to note mobility and turgor. 4. Note skin integrity, any lesions, and the condition of any dressings. Note any bleeding or infection, but do not change dressing until after physical examination. 5. Date IV site, and note surrounding skin condition. 6. Complete any standardized scales used to quantify the risk for skin breakdown. 7. Verify that any air loss or pressure loss surfaces being used are properly applied and operating at the correct settings.

Respiratory system

1. Oxygen by mask, nasal prongs, check fitting. 2. Note FIO2. 3. Respiratory effort. 4. Auscultate breath sounds, comparing side to side: Posterior lobes: Left upper, right upper, left lower, right lower. NOTE: If patient is unable to sit up, have another nurse hold patient side to side. Anterior lobes: Right upper, left upper, right middle and lower, left lower. 5. Cough and deep breathe. Any mucus? Check color and amount. 6. Incentive spirometer if ordered—Encourage patient to use every hour for 10 inspirations. If pulse oximetry percentage or respiratory rate drops, encourage use every 15 minutes.

Ten Traps of Interviewing The verbal responses presented in Table 3-3 are productive and enhance the interview. Now we will consider traps, which are nonproductive verbal and nonverbal messages.

1. Providing False Assurance or Reassurance 2. Giving Unwanted Advice 3. Using Authority 4. Using Avoidance Language 5. Distancing (use your and not the) 6. Using Professional Jargon (misunderstandings occur) 7. Using Leading or Biased Questions (you don't smoke do you? You don't have unprotected sex do you?) 8. Talking Too Much 9. Interrupting (do not finish their thoughts) 10. Using "Why" Questions (blames and judgmental)

Religious affiliation and practices can support spiritual harmony and health in the following ways:

1. Religious affiliation and attendance at religious functions may promote health through social networks and social support systems that buffer and affect stress and isolation. 2. Religious affiliation and membership benefit health by promoting healthy behavior and lifestyles. 3. Regular religious fellowship benefits health by offering social support. Faith benefits health by leading to thoughts of hope, optimism, and positive expectation.

Mental disorder

A mental disorder is apparent when a person's response is much greater than the expected reaction to a traumatic life event. It is a clinically significant behavioral, emotional, or cognitive syndrome that is associated with significant distress Mental disorders include organic disorders (caused by brain disease of known specific organic cause [e.g., delirium, dementia, alcohol and drug intoxication, and withdrawal]) and psychiatric mental disorders (in which an organic etiology has not yet been established [e.g., anxiety disorder or schizophrenia]). Mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life. Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual's behaviors: Consciousness: Being aware of one's own existence, feelings, and thoughts and of the environment. This is the most elementary of mental status functions. Language: Using the voice to communicate one's thoughts and feelings. This is a basic tool of humans, and its loss has a heavy social impact on the individual. Mood and affect: Both of these elements deal with the prevailing feelings. Affect is a temporary expression of feelings or state of mind, and mood is more durable, a prolonged display of feelings that color the whole emotional life. Orientation: The awareness of the objective world in relation to the self. Able to name own person, place, and time. Attention: The power of concentration, the ability to focus on one specific thing without being distracted by many environmental stimuli. Memory: The ability to lay down and store experiences and perceptions for later recall. Recent memory evokes day-to-day events; remote memory brings up years' worth of experiences. Abstract reasoning: Pondering a deeper meaning beyond the concrete and literal. Thought process: The way a person thinks; the logical train of thought. Thought content: What the person thinks—specific ideas, beliefs, the use of words. Perceptions: An awareness of objects through the five senses.

health desparities

Among African Americans the 7 largest health care disparities include gonorrhea, congenital syphilis, new cases of acquired immunodeficiency syndrome (AIDS), and deaths from AIDS—these reflect over 1000% difference from the group with the lowest indicators (Asians and/or Non-Hispanic Whites).19 These are followed by nonfatal firearm-related injuries, new cases of tuberculosis, homicides, and drug-induced deaths. For Hispanics the five largest indicators of health disparities were congenital syphilis, new cases of tuberculosis, new cases of AIDS, exposure to environmental contaminants, and cirrhosis deaths. The American Indian or Alaska Native population also had the same largest disparities as the Black non-Hispanic population, including high rates of gonorrhea, new tuberculosis cases, and drug-induced deaths. Non-Hispanic Whites had the highest rates of all racial and ethnic groups in drug-induced deaths and death from cirrhosis, death by poisoning, smoking in pregnant women, physical assault, chronic obstructive pulmonary disease, binge drinking among high school seniors, firearm-related deaths, steroid use among 10th graders, and prostate cancer deaths.

Characteristics of Eating Problems

Anorexia Nervosa • Intense fear of weight gain • Distorted body image • Restricted calories with significantly low body mass index • Subtypes: • Restricting (no consistent bulimic features) • Binge eating/purging type (primarily restriction, some bulimic behaviors) Bulimia Nervosa • Recurrent episodes of uncontrollable binging • Inappropriate compensatory behaviors: vomiting, laxatives, diuretics, or exercise • Self-image largely influenced by body image. Binge eating • Recurrent episodes of uncontrollable binging without compensatory behaviors • Binging episodes induce guilt, depression, embarrassment, or disgust

Childhood Mental Disorders

Attention-Deficit/Hyperactivity Disorder (ADHD) A common behavioral disorder with inappropriate inattention (short attention span, unable to complete tasks or follow directions, easily distracted), impulsiveness, and hyperactivity (restlessness and fidgeting, excess talking). Present in two settings, home and school. Nearly 8% children ages 5-11 years and 12% of adolescents ages 12-17 years have ADHD. Oppositional Defiant Disorder (ODD) A disruptive set of behaviors characterized by negative, aggressive, angry, and irritable mood. Children with ODD lose their temper, argue with adults, refuse to obey adults' requests or rules, deliberately annoy others, and blame their actions on others. They may be spiteful, vindictive, or malicious. Because they violate social norms, presence in school is difficult. It is also hard to make friends or to fit well in the family. Autism Spectrum Disorder A complex neurologic and biologic development disorder characterized by problems in social interactions and verbal and nonverbal communication. Dysfunctions range from mild to severe and include problems making and maintaining friends, strict adherence to rituals or routines, resistance to change, repetitive speech, poor eye contact, motor mannerisms. Autism has a genetic component, appears in early childhood (by 2 or 3 years), is 4 times more common in boys than girls, and is not affected by race, family income, or educational level. Eating Disorder A group of serious and complex psychologic disorders affecting primarily adolescents. (1) Anorexia nervosa presents as a severely low body weight for height (low body mass index) and an intense fear of gaining weight. The person may eat very little food or binge and then purge food by vomiting. (2) Bulimia nervosa is the hallmark of a young person who binge eats, then compensates with self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise. Both disorders leave the person severely underweight and at risk for electrolyte disturbances and other medical comorbidities. (3) People with binge eating disorder use excessive food for comfort or to relieve stress and then feel extreme remorse. This leads to obesity.

Thought Process Abnormalities

Blocking- Sudden interruption in train of thought, unable to complete sentence, seems related to strong emotion. "Forgot what I was going to say." Confabulation Fabricates events to fill in memory gaps. Gives detailed description of his long walk around the hospital although you know Mr. J. remained in his room all afternoon. Neologism- Coining a new word; invented word has no real meaning except for the person; may condense several words.- "I'll have to turn on my thinkilator." Circumlocution- Round-about expression, substituting a phrase when cannot think of name of object.- Says "the thing you open the door with" instead of "key." Circumstantiality - Talks with excessive and unnecessary detail, delays reaching point; sentences have a meaningful connection but are irrelevant (this occurs normally in some people). "When was my surgery? Well I was 28, I was living with my aunt, she's the one with psoriasis, she had it bad that year because of the heat, the heat was worse then than it was the summer of '92. ..." Loosening associations- Shifting from one topic to an unrelated topic; person seems unaware that topics are unconnected. "My boss is angry with me, and it wasn't even my fault. (pause) I saw that movie too, Lassie. I felt really bad about it. But she kept trying to land the airplane and she never knew what was going on." Flight of ideas Abrupt change, rapid skipping from topic to topic, practically continuous flow of accelerated speech; topics usually have recognizable associations or are plays on words.- "Take this pill? The pill is blue. I feel blue. (sings) She wore blue velvet." Word salad- Incoherent mixture of words, phrases, and sentences; illogical, disconnected, includes neologisms. "Beauty, red-based five, pigeon, the street corner, sort of." Perseveration- Persistent repeating of verbal or motor response, even with varied stimuli. "I'm going to lock the door, lock the door. I walk every day, and I lock the door. I usually take the dog, and I lock the door." Echolalia Imitation, repeats others' words or phrases, often with a mumbling, mocking, or mechanical tone Nurse: "I want you to take your pill." Patient (mocking): "Take your pill. Take your pill." Clanging Word choice based on sound, not meaning, includes nonsense rhymes and puns. "My feet are cold. Cold, bold, told. The bell tolled for me."

Collaborative problems

Collaborative problems are those in which the approach to treatment involves multiple disciplines. Collaborative problems are certain physiologic conditions in which nurses have the primary responsibility to diagnose the onset and monitor the changes in status.

Delirium, Dementia, and Depression

Delirium is an acute confusional state, potentially preventable in hospitalized persons. (See Table 5-1.) Characterized by disorientation, disordered thinking and perceptions (illusions and hallucinations), defective memory, agitation, inattention. Dementia is a chronic progressive loss of cognitive and intellectual functions, although perception and consciousness are intact. Characterized by disorientation, impaired judgment, memory loss. (See Table 23-2, 10 Warning Signs of Alzheimer Disease). Depression is a long-term depressed mood (≥previous 2 weeks), with lack of pleasure; disturbed sleep and appetite; feelings of hopelessness, guilt, worthlessness, sadness, loneliness and despair; suicide ideation.

Speech Disorders

Dysphonia- Voice- Difficulty or discomfort in talking, with abnormal pitch or volume, caused by laryngeal disease. Voice sounds hoarse or whispered, but articulation and language are intact. Dysarthria- Articulation- Distorted speech sounds; speech may sound unintelligible; basic language (word choice, grammar, comprehension) intact. Aphasia- Language comprehension and production secondary to brain damage- True language disturbance; defect in word choice and grammar or defect in comprehension; defect is in higher integrative language processing. Types of Aphasia An earlier dichotomy classified aphasias as expressive (difficulty producing language) or receptive (difficulty understanding language). Because all people with aphasia have some difficulty with expression, beginning examiners tend to classify them all as expressive. The following system is more descriptive. Global aphasia- The most common and severe form. Spontaneous speech is absent or reduced to a few stereotyped words or sounds. Comprehension is absent or reduced to only the person's own name and a few select words. Repetition, reading, and writing are severely impaired. Prognosis for language recovery is poor. Caused by a large lesion that damages most of combined anterior and posterior language areas. Broca aphasia - Expressive aphasia. The person can understand language but cannot express himself or herself using language. This is characterized by nonfluent, dysarthric, and effortful speech. The speech is mostly nouns and verbs (high-content words) with few grammatic fillers, termed agrammatic or telegraphic speech. Repetition and reading aloud are severely impaired. Auditory and reading comprehensions are surprisingly intact. Lesion is in anterior language area called the motor speech cortex or Broca area. Wernicke aphasia- Receptive aphasia. The linguistic opposite of Broca aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well articulated but has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often there is a great urge to speak. Repetition, reading, and writing also are impaired. Lesion is in posterior language area called the association auditory cortex or Wernicke area.

Acutely Ill People

Emergent situations require combining the interview with the physical examination. In this case focus the interview on pertinent information only, including history of present illness, medications, allergies, last meal, and basic health state. Subjective information is a crucial component of providing care; therefore it is important that you try to interview as much as possible while performing lifesaving actions. A hospitalized person with a critical or severe illness is usually too weak, too short of breath, or in too much pain to talk. Focus on making him or her comfortable first and then ask priority questions about the history. Explore the first concern the person mentions. You will find that you ask closed, direct questions earlier in the interview to decrease response burden. Finally make sure that you are clear in your statements. When a person is very sick, even the simplest sentence can be misconstrued. The person will react according to preconceived ideas about what a serious illness means; thus anything you say should be direct and precise.

Collecting Four Types of Data

Every examiner needs to establish four different types of databases, depending on the clinical situation: complete, focused or problem-centered, follow-up, and emergency.

Mood and Affect Abnormalities

Flat affect (blunted affect)- Lack of emotional response; no expression of feelings; voice monotonous and face immobile - Topic varies, expression does not. Depression- Sad, gloomy, dejected; symptoms may occur with rainy weather, after a holiday, or with an illness; if the situation is temporary, symptoms fade quickly- "I've got the blues." Depersonalization (lack of ego boundaries) Loss of identity, feels estranged, perplexed about own identity and meaning of existence-"I don't feel real." "I feel like I'm not really here." Elation- Joy and optimism, overconfidence, increased motor activity; not necessarily pathologic - "I'm feeling very happy." Euphoria Excessive well-being; unusually cheerful or elated, which is inappropriate considering physical and mental condition; implies a pathologic mood- "I'm high." "I feel like I'm flying." "I feel on top of the world." Anxiety- Worried, uneasy, apprehensive from the anticipation of a danger whose source is unknown- "I feel nervous and high-strung." "I worry all the time." "I can't seem to make up my mind." Fear Worried, uneasy, apprehensive; external danger is known and identified- Fear of flying in airplanes. Irritability Annoyed, easily provoked, impatient- Person internalizes a feeling of tension, and a seemingly mild stimulus "sets him (or her) off" Rage- Furious, loss of control- Person has expressed violent behavior toward self or others Ambivalence- The existence of opposing emotions toward an idea, object, person- A person feels love and hate toward another at the same time Lability- Rapid shift of emotions- Person expresses euphoric, tearful, angry feelings in rapid succession Inappropriate affect- Affect clearly discordant with content of person's speech Laughs while discussing admission for liver biopsy.

Perception Abnormalities

Hallucination Sensory perceptions for which there are no external stimuli; may strike any sense: visual, auditory, tactile, olfactory, gustatory- Visual: seeing an image (ghost) of a person who is not there; auditory: hearing voices or music Illusion- Misperception of an actual existing stimulus, by any sense- Folds of bedsheets appear to be animated

Interviewing People with Special Needs

Hearing-Impaired People As the population ages, you will encounter more people who are deaf or hard of hearing. They see themselves as a linguistic minority, not as disabled.15 People who are hearing impaired may feel marginalized by professionals and think that their intelligence is questioned because they cannot always understand what is being asked of them. A complete health history of someone who is deaf requires a sign language interpreter. Because most health care professionals are not proficient in signing, try to find an interpreter through a social service agency or the person's own social network. If the person prefers lip reading, be sure to face him or her squarely and have good lighting on your face. Examiners with a beard, mustache, or foreign accents are less effective. Do not exaggerate your lip movements because this distorts your words. Similarly, shouting distorts the reception of a hearing aid. Speak slowly and supplement your voice with appropriate hand gestures or pantomime. Nonverbal cues are important adjuncts because the lip reader understands at best only 50% of your speech when relying solely on vision.

Bedside Assessment and Electronic Health Recording Sequence

Help the person into bed. The patient is in bed with the bed at a comfortable level for the examiner. The Health History General Appearance Measurement Neurologic System Respiratory System Cardiovascular System Skin Abdomen Genitourinary Activity

Functional Assessment (Including Activities of Daily Living) Children

Interpersonal Relationships. Within the family constellation, record the child's position in family; whether the child is adopted; who lives with the child; who is the primary caregiver; who is the caregiver if both parents work outside the home; any support from relatives, neighbors, or friends; and the ethnic or cultural milieu. Indicate family cohesion. Does the family enjoy activities as a unit? Has there been a recent family change or crisis (death, divorce, move)? Activity and Rest. Record the child's play activities. Indicate amount of active and quiet play, outdoor play, time watching television, and special hobbies or activities. Record sleep and rest. Indicate pattern and number of hours at night and during the day and the child's routine at bedtime. Is the child a sound sleeper, or is he or she wakeful? Does the child have nightmares, night terrors, or somnambulation? How does the parent respond? Does the child have naps during the day? Record school attendance. Any experience with daycare or nursery school? In what grade is the child in school? Has the child ever skipped a grade or been held back? Does the child seem to like school? Economic Status. Ask about the mother's and father's occupations. Indicate the number of hours each parent is away from home. Do parents perceive their income to be adequate? What is the effect of illness on financial status? Home Environment. Where does family live (house, apartment)? Is the size of the home adequate? Is there access to an outdoor play area? Does the child share a room, have his or her own bed, and have toys appropriate for his or her age? Environmental Hazards. Inquire about home safety (precautions for poisons, medications, household products, presence of gates for stairways, and safe yard equipment). Inquire about the home structure (adequate heating, ventilation, bathroom facilities), neighborhood (residential or industrial, age of neighbors, safe play areas, playmates available, distance to school, amount of traffic, whether area remote or congested and overcrowded, if crime is a problem, presence of air or water pollution), and automobile (child safety seat, seatbelts). Coping/Stress Management. Is the child able to adapt to new situations? Record recent stressful experiences (death, divorce, move, loss of special friend). How does the child cope with stress? Any recent change in behavior or mood? Has counseling ever been sought? Habits. Has the child ever tried cigarette smoking? How much did he or she smoke? Has the child ever tried alcohol? How much alcohol did he or she drink weekly or daily? Has the child ever tried other drugs (marijuana, cocaine, amphetamines, barbiturates)? Health Promotion. Who is the primary health care provider? When was the child's last checkup? Who is the dental care provider and when was the last dental checkup?

Developmental Competence

Interviewing the Parent or Caregiver When your client is a child, you must build rapport with two people—the child and the accompanying caregiver. Greet both by name, but with a younger child (1 to 6 years old) focus more on the caregiver. Ignoring the child temporarily allows him or her to size you up from a safe distance Begin by interviewing the caregiver and child together. If any sensitive topics arise (e.g., the parents' troubled relationship or the child's problems at school or with peers), explore them later when the caregiver is alone. Provide toys to occupy a young child as you and the caregiver talk. Always refer to the child by name and ensure that he or she is included in the interview as appropriate. Refer to the parent by his or her proper surname instead of "Mom" or "Dad." Make sure that you stoop to meet the child at his or her eye level. Your size can seem overwhelming to young children, and standing at your full height may emphasize his or her smallness. Nonverbal communication is even more important to children than it is to adults. Children are quick to pick up feelings, anxiety, or comfort from nonverbal cues. Keep your physical appearance neat and clean, and avoid formal uniforms that distance you. Keep your gestures slow, deliberate, and close to your body.

Techniques of Communication

Introducing the Interview You may be nervous at the beginning of the interview. Keep in mind that the client likely is nervous as well. Keep the introduction short and formal. "Mrs. Sanchez, I would like to talk about your illness that caused you to come to the hospital." After this brief introduction, ask an open-ended question (see the following section) and then let the person proceed. You do not need much friendly small talk to build rapport. This is not a social visit; the person wants to talk about some concern and wants to get on with it. You build rapport best by letting him or her discuss the concern early. The Working Phase The working phase is the data-gathering phase. Verbal skills for this phase include your ability to form questions appropriately and your responses to the answers given by the client. You will likely use a combination of open-ended and closed questions during the interview. Open-Ended Questions The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. Use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic. "Tell me how I can help you." Verbal Responses—Assisting the Narrative You have asked the first open-ended question, and the client answers. As the person talks, your role is to encourage free expression while keeping the person focused at the same time. Your responses help the teller amplify the story. he first five responses (facilitation, silence, reflection, empathy, clarification) involve your reactions to the facts or feelings that the person has communicated (Fig. 3-4). Your response focuses on the client's frame of reference. Closing the Interview The session should end gracefully. An abrupt or awkward closing can destroy rapport and leave the person with a negative impression of the interaction. To ease into the closing, ask the person: "Is there anything else you would like to mention?"

People Under the Influence of Street Drugs or Alcohol

It is common for people under the influence of alcohol or other mood-altering drugs to be admitted to a hospital; all of these drugs affect the central nervous system (CNS), increasing risk for overdose, accidents, and injuries. Also, chronic alcohol or drug use creates complex medical problems that require more care. The client's behavior depends on which drugs were consumed. Alcohol, benzodiazepines, and the opioids (heroin, methadone, morphine, oxycodone) are CNS depressants that slow brain activity and impair judgment, memory, intellectual performance, and motor coordination. Stimulants of the central nervous system (cocaine, amphetamine) can cause an intense high, agitation, and paranoid behavior. Hallucinogens (LSD, ketamine, PCP) cause bizarre, inappropriate, 42sometimes even violent behavior accompanied by superhuman strength and insensitivity to pain. When interviewing a person currently under the influence of alcohol or illicit drugs, ask simple and direct questions. Take care to make your manner and questions nonthreatening. Avoid confrontation while the person is under the influence and avoid displaying any scolding or disgust since this may make the person belligerent. The top priority is to find out the time of the person's last drink or drug, how much he or she took, and the name and amount of each drug that was taken. This information will help assess any withdrawal patterns. Once a hospitalized substance abuser has been detoxified and is sober, he or she should be assessed for the extent of the problem and its meaning for the person and family. Initially you will encounter denial and increased defensiveness; special interview techniques are needed.

Mental status assessment Defining Mental Status

Mental status is a person's emotional (feeling) and cognitive (knowing) function. Optimal functioning aims toward simultaneous life satisfaction in work, in caring relationships, and within the self.. Mental health is "a state of well-being in which every individual realizes his or her own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.

The Health History

On your way into the room, verify that any necessary markers or flags are in place at the doorway regarding conditions such as isolation precautions, latex allergies, or fall precautions. Once in the room, introduce yourself as the patient's nurse for the next 8 (or 12) hours. Make direct eye contact, and do not allow yourself to be distracted by intravenous (IV) pumps or other equipment as you ask how he or she is feeling and how he or she spent the previous shift. Refer to what you have heard from the previous shift in the process of your own questioning; this alleviates the person's frustration at answering the same questions every time with a new staff member. Assess for pain: "Are you currently having any pain or discomfort?" You should know when the last pain medication was given and what physician orders are written. Determine if further dosing is needed or if you need to contact the physician. Knowing the written orders, confirm settings on the patient-controlled analgesia (PCA) pump or epidural setting if in place. Confirm IV solution hanging matches orders for rate and type. Wash your hands in the patient's presence. Offer water as a courtesy but also note the physical data this gives you: the person's ability to hear, to follow directions, to cross the midline, and especially, to swallow. As you collect this and subsequent history, note data on the General Appearance in the following list. Complete your initial overview by verifying that the correct name band has been applied to the wrist.

PQRSTU

P: Provocative or Palliative. What brings it on? What were you doing when you first noticed it? What makes it better? Worse? Q: Quality or Quantity. How does it look, feel, sound? How intense/severe is it? R: Region or Radiation. Where is it? Does it spread anywhere? S: Severity Scale. How bad is it (on a scale of 1 to 10)? Is it getting better, worse, staying the same? T: Timing. Onset—Exactly when did it first occur? Duration—How long did it last? Frequency—How often does it occur? U: Understand Patient's Perception of the problem. What do you think it means?

Anxiety Disorders

Panic attack- A defined period of intense fear, anxiety, and dread accompanied by signs of dyspnea, choking, chest pain, increased heart rate, palpitations, nausea, and sweating. Also has fear of going crazy or dying or impending doom. Sudden onset, lasts about 10 minutes, then subsides. agoraphobia- An irrational fear of being out in the open or in a place from which escape is difficult (airport or airplane, car or bus, elevator, bridge). Fear of anxiety is so intense that these places are avoided and person is reluctant to leave safe place (home). specific phobia- A pattern of debilitating fear when faced with a particular object or situation (e.g., dogs, spiders, thunder or storms, enclosed spaces, heights, blood). Person knows it is irrational yet studiously avoids the feared object, thus becoming restricted in social or occupational activities. Social anxiety disorder (social phobia) A persistent and irrational fear of speaking or performing in public in which the person anticipates being judged or criticized, feeling or looking foolish, feeling embarrassment, being unable to answer questions, or being unable toremember the lines or notes. Person studiously avoids such situations or endures them with intense anxiety. Generalized anxiety disorder (GAD) A pattern of excessive worrying and morbid fear about anticipated "disasters" in the job, personal relationships, health, or finances. Characterized by restlessness, muscle tension, diarrhea, palpitations, tachypnea, hypervigilance, fatigue, or sleep disturbance. Person devotes much time to preparing for anticipated catastrophe, has difficulty making decisions, and practices avoidance. OCD- A pattern of recurrent obsessions (intrusive, uncontrollable thoughts) and compulsions (repetitive ritualistic actions) done to decrease anxiety and prevent a catastrophe (e.g., contamination [fear of germs], violence, perfectionism, and superstitions). Intrusive thoughts and actions are time consuming, interfere with daily activities, and make the person feel humiliated or ashamed for giving in to them. PTSD- This follows a traumatic event outside the range of usual human experience involving actual or threatened death (e.g., military combat, natural disaster [flood, tornado, earthquake], plane or train accident, violence [mugging, rape, bombing]). The person relives the trauma many times, intrusively and unwillingly. The same feelings of helplessness, fear, or horror recur. Avoidance of any trigger associated with the trauma occurs, and the person has hypervigilance, sleep problems, and difficulty concentrating, leading to feelings of being permanently damaged.

Thought Content Abnormalities

Phobia- Strong, persistent, irrational fear of an object or situation; feels driven to avoid it- Cats, dogs, heights, enclosed spaces Hypochondriasis- Morbid worrying about his or her own health; feels sick with no actual basis for that assumption Preoccupied with the fear of having cancer; any symptom or physical sign means cancer Obsession- Unwanted, persistent thoughts or impulses; logic will not purge them from consciousness; experienced as intrusive and senseless Violence (parent having repeated impulse to kill a loved child); contamination (becoming infected by shaking hands) Compulsion- Unwanted repetitive, purposeful act; driven to do it; behavior thought to neutralize or prevent discomfort or some dreaded event Handwashing, counting, checking and rechecking, touching Delusions- Firm, fixed, false beliefs; irrational; person clings to delusion despite objective evidence to contrary Grandiose—Person believes that he or she is God; famous, historical, or sports figure; or other well-known person Persecution—"They're out to get me."

Nonverbal Skills

Physical Appearance Posture gestures facial expression eye contact voice touch

Documentation and Critical Thinking

Sample Charting Appearance: Person's posture is erect, with no involuntary body movements. Dress and grooming are appropriate for season and setting. Behavior: Person is alert, with appropriate facial expression and fluent, understandable speech. Affect and verbal responses are appropriate. Cognitive functions: Oriented to time, person, place. Able to attend cooperatively with examiner. Recent and remote memory intact. Can recall four unrelated words at 5-, 10-, and 30-minute testing intervals. Future plans include returning home and to local university once individual therapy is established and medication is adjusted. Thought processes: Perceptions and thought processes are logical and coherent. No suicide ideation. Score on Mini-Mental State Examination is 28.

The Process of Communication

Sending Likely you are most aware of verbal communication—the words you speak, vocalizations, the tone of voice, written. Nonverbal communication is as important as verbal communication. This is your body language—posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair. Because nonverbal communication is under less conscious control than verbal communication, it may be more reflective of true feelings. Receiving Being aware of the messages you send is only part of the process. Your words and gestures must be interpreted in a specific context to have meaning. You have a specific context in mind when you send your words, but your context may not be understood by the receiver. The receiver uses his or her own interpretations on your words. These interpretations are based on past experiences, culture, and self-concept. Internal Factors Internal factors are those specific to you, the examiner. As you cultivate your communication skills, you need to focus on the four inner factors of liking others, empathy, the ability to listen, and self-awareness. (empathy, listening ) External factors privacy no interruptions environment Note-Taking Some use of history forms and note-taking may be unavoidable For example, when you sit down later to record the interview, you cannot rely completely on memory to furnish details of previous hospitalizations or the review of body systems. But be aware that excessive note-taking during the interview has disadvantages: • It breaks eye contact too often. • It shifts your attention away from the person, diminishing his or her sense of importance. • Trying to record everything a person says may cause you to ask him or her to slow down, or the person may slow his or her tempo to allow for you to take notes. Either way, the client's natural mode of expression is lost. • It impedes your observation of the client's nonverbal behavior. Electronic Health Record (EHR) Direct computer recording of the health record has moved into many outpatient offices and hospital rooms in the 21st century. This eliminates handwritten clinical data and provides access to online health education materials

Using SBAR for Staff Communication

Situation. What is happening right now? Why are you calling? State your name, your unit, patient's name, room number, patient's problem, when it happened or when it started, how severe it is. Background. Do not recite the patient's full history since admission. Do state the data pertinent to this moment's 805problem: admitting diagnosis, when admitted, and appropriate immediate assessment data (e.g., vital signs, pulse oximetry, change in mental status, allergies, current medications, IV fluids, laboratory results). Assessment. What do YOU think is happening in regard to the current problem? If you do not know, at least state which body system you think is involved. How severe is the problem? Recommendation. What do you want the physician to do to improve the patient's situation? Here you offer probable solutions. Order more pain medication? Come and assess the patient? Review the following examples of SBAR communication.

Heritage Assessment

The Heritage Assessment tool (Fig. 2-8), lists all of the questions that may be asked. It is important to ask the questions slowly over time. If the person appears anxious, it is best to postpone asking the questions or to weave them into other parts of the health history. The responses can be scored, and an image arises as to whether the person identifies with his or her traditional heritage or whether he or she is acculturated and assimilated into the mainstream of modern American culture.

Communicating with Different Ages

The Infant (Birth to 12 months) Infants use coos, gurgles, facial expressions, and cries to identify their needs. Although you will not "interview" an infant, it is important to establish a rapport. Nonverbal communication is the primary method of communicating with infants. When their needs are met, most infants will be calm and relaxed. The Toddler (12 to 36 months) At this stage the child is beginning to develop communication skills. At first they communicate with one- or two-word sentences and a limited vocabulary, which may include grunts and pointing intertwined with words. Language progresses from a vocabulary of about two words at 1 year to a spurt of about 200 words by 2 years. The Preschooler (3 to 6 years) A 3- to 6-year-old is egocentric. He or she sees the world mostly from his or her own point of view. Everything revolves around him or her. Only the child's own experience is relevant; thus telling what someone else is doing will not have any meaning. A 3-year-old uses more complex sentences with more parts of speech. Between 3 and 4 years of age the child uses three- to four-word telegraphic sentences containing only essential words. By 5 to 6 years, the sentences are six to eight words long, and grammar is well developed. The School-Age Child (7 to 12 years) A child 7 to 12 years old can tolerate and understand others' viewpoints. This child is more objective and realistic. He or she wants to know functional aspects—how things work and why things are done. At this age children are beginning to recognize that things they do can affect others. It is very important that you are nonjudgmental. The Adolescent Adolescence begins with puberty. Puberty is a time of dramatic physiologic change. It includes a growth spurt—rapid growth in height, weight, and muscular development; development of primary and secondary sex characteristics; and maturation of the reproductive organs. A changing body affects a teen's self-concept. Adolescents want to be adults, but they do not have the cognitive ability yet to achieve their goal. They are between two stages. The first consideration is your attitude, which must be one of respect. Do not assume that adolescents know anything about a health interview or a physical examination. Explain every step and give the rationale. They need direction. They will cooperate when they know the reason for the questions or actions. Encourage their questions. Adolescents are afraid that they will sound "dumb" if they ask a question to which they assume everybody else knows the answer. The Older Adult The aging adult has the developmental task of finding the purpose of his or her own existence and adjusting to the inevitability of death. Some people have developed comfortable and satisfying answers and greet you with a calm demeanor and self-assurance, but be alert for the person who sounds hopeless and despairing about life and his or her future. Symptoms of illness and worries over finances are even more frightening when they mean physical limitation or threaten independence. Always address the person by his or her proper surname, and avoid using the first name. Some older adults resent being called by their first name by younger people and think that it demonstrates a lack of respect. Above all, avoid "elderspeak,"36 which consists of (1) diminutives (honey, sweetie, dearie); (2) inappropriate plural pronouns ("Are we ready for our interview?"); (3) tag questions ("You would rather sit in this nice, soft chair, wouldn't you?"); and (4) shortened sentences, slow speech rate, and simple vocabulary that sounds like baby talk. Older adults have a longer story to tell; therefore plan accordingly. The interview will likely take longer, and you don't want to appear rushed. Consider physical limitations when planning the interview. Make sure that you face the person with impaired hearing directly so your mouth and face are fully visible. Do not shout; it does not help and actually distorts speech. For a person in a wheelchair, make sure you move the chairs so an appropriate position is available for the client.

Evidence based practice

The conviction that all patients deserve to be treated with the most current and best-practice techniques led to the development of evidence-based practice (EBP). EBP is more than the use of best-practice techniques to treat patients. "EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinician's experience, as well as the patient preferences and values, to make decisions about care and treatment"

Components of the Mental Status Examination

The full mental status examination is a systematic check of emotional and cognitive functioning. However, the steps described here rarely need to be taken in their entirety. Usually you can assess mental status through the context of the health history interview. During that time keep in mind the four main headings of mental status assessment: Appearance, Behavior, Cognition, and Thought processes, or A, B, C, T Integrating the mental status examination into the health history interview is sufficient for most people. You will collect ample data to be able to assess mental health strengths and coping skills and to screen for any dysfunction. It is necessary to perform a full mental status examination when you discover any abnormality in affect or behavior and in the following situations: • Patients whose initial brief screening suggests an anxiety disorder or depression. • Family members concerned about a person's behavioral changes such as memory loss or inappropriate social interaction. • Brain lesions (trauma, tumor, stroke). A mental status assessment documents any emotional or cognitive change associated with the lesion. Not recognizing these changes hinders care planning and creates problems with social readjustment. • Aphasia (the impairment of language ability secondary to brain damage). A mental status examination assesses language dysfunction and any emotional problems associated with it such as depression or agitation. • Symptoms of psychiatric mental illness, especially with acute onset. In every mental status examination, note these factors from the health history that could affect your interpretation of the findings: • Any known illnesses or health problems such as alcohol use disorders or chronic renal disease • Current medications with side effects that may cause confusion or depression • The usual educational and behavioral level—note that factor as the normal baseline and do not expect performance on the mental status examination to exceed it • Responses to personal history questions indicating current stress, social interaction patterns, sleep habits, drug and alcohol use.

Cultural Formulation Model

The model has five categories: cultural identity of the individual, cultural explanation of the individual's illness, cultural factors related to psychosocial environment and levels of functioning, cultural elements of the relationship between the individual and the clinician. This assessment tool provides an overall cultural assessment to promote culturally competent diagnosis and care.

Follow-Up Database

The status of any identified problems should be evaluated at regular and appropriate intervals. What change has occurred? Is the problem getting better or worse? Which coping strategies are used? This type of database is used in all settings to follow up both short-term and chronic health problems.

Electronic Health Recording

The use of technology at the bedside extends far beyond the standard equipment. Most hospitals or clinics use a basic or a comprehensive electronic health record (EHR) system. EHRs replace the paper medical record, placing all relevant patient information in an easily accessible electronic system. EHRs do not include billing and scheduling systems, but focus instead on patient information. Patient Safety The meaningful use of EHRs, which include physician order entry and clinical decision support, may increase patient safety and quality care. EHRs allow all providers, regardless of geographic location, to access the health information, place orders, and receive timely patient status updates. No longer does a provider have to be on the clinical unit to retrieve test results, vital signs, or the most recent nurse's or physician's note. The use of computer physician order entry (CPOE) has decreased transcription and prescribing errors.1 Well-designed EHR systems can notify providers of potential medication interactions, dosage adjustments for renal patients or advanced age, and additional required testing

Complete (Total Health) Database

This includes a complete health history and a full physical examination. It describes the current and past health state and forms a baseline against which all future changes can be measured. It yields the first diagnoses. For well and ill people, the complete database must screen for pathology and determine the ways people respond to that pathology or to any health problem. You must screen for pathology because you are the first, and often the only, health professional to see the patient.

Emergency Database

This is an urgent, rapid collection of crucial information and often is compiled concurrently with lifesaving measures. Diagnosis must be swift and sure. The person is questioned simultaneously while his or her airway, breathing, circulation, level of consciousness, and disability are being assessed. Clearly the emergency database requires more rapid collection of data than the episodic database. Once the person has been stabilized, a complete database can be compiled.

Focused or Problem-Centered Database

This is for a limited or short-term problem. Here you collect a "mini" database, smaller in scope and more targeted than the complete database. It concerns mainly one problem, one cue complex, or one body system. It is used in all settings—hospital, primary care, or long-term care.

The Adolescent

This section presents a psychosocial review of symptoms intended to maximize communication with youth. The HEEADSSS method of interviewing focuses on assessment of the Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, and Safety from injury and violence The tool minimizes adolescent stress because it moves from expected and less-threatening questions to those that are more personal. It presents the questions in three colors: green are considered essential to explore with every adolescent; blue are important for you to ask if time permits; red questions delve more deeply if the situation demands it.10 Interview the youth alone while the parent waits outside and fills out past health questionnaires.

database

Together with the patient's record and laboratory studies, these elements form the database. From the database you make a clinical judgment or diagnosis about the individual's health state, response to actual or potential health problems, and life processes. Thus the purpose of assessment is to make a judgment or diagnosis.

First-level priority problems

are those that are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing. Airway Breathing Circulation

Third-level priority problems

are those that are important to the patient's health but can be addressed after more urgent health problems are addressed. Interventions to treat these problems are more long term, and the response to treatment is expected to take more time.

Second-level priority problems

are those that are next in urgency—those requiring your prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security).

naturalistic or holistic perspective

found most frequently among American Indians, Asians, and others who believe that human life is only one aspect of nature and a part of the general order of the cosmos. These people believe that the forces of nature must be kept in natural balance or harmony.

magicoreligious perspective

he basic premise is that the world is an arena in which supernatural forces dominate.14 The fate of the world and those in it depends on the action of supernatural forces for good or evil. Examples of magical causes of illness include belief in voodoo or witchcraft among some Blacks and others from circum-Caribbean countries.

Spirituality

is borne out of each person's unique life experience and his or her personal effort to find purpose and meaning in life.

Assessment

is the collection of data about the individual's health state. Throughout this text you will be studying the techniques of collecting and analyzing subjective data (i.e., what the person says about himself or herself during history taking)

Diagnostic

is the process of analyzing health data and drawing conclusions to identify diagnoses. Novice examiners most often use a diagnostic process involving hypothesis forming and deductive reasoning. This hypothetico-deductive process has four major components: (1) attending to initially available cues; (2) formulating diagnostic hypotheses; (3) gathering data relative to the tentative hypotheses; and (4) evaluating each hypothesis with the new data collected, thus arriving at a final diagnosis. A cue is a piece of information, a sign or symptom, or a piece of laboratory data. A hypothesis is a tentative explanation for a cue or a set of cues that can be used as a basis for further investigation.

Acculturation

is the process of social and psychological exchanges that take place when there are ongoing encounters between individuals of different cultures, with subsequent 15changes in either or both groups

Ethnicity

refers to a social group that may possess shared traits such as a common geographic origin, migratory status, religion, language, values, traditions or symbols, and food preferences. The ethnic group may have a loose group identity with few or no cultural traditions in common or a coherent subculture with a shared language and body of tradition

religion

refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in a divine or superhuman power to be obeyed and worshipped as the creator(s) and ruler(s) of the universe (called by names such as Allah, God, Yahweh, and Jehovah).

Biomedical

theory of illness causation, assumes that all events in life have a cause and effect, that the human body functions more or less mechanically (i.e., the functioning of the human body is analogous to the functioning of an automobile), that all life can be reduced or divided into smaller parts (e.g., the reduction of the human person into body, mind, and spirit), and that all of reality can be observed and measured (e.g., intelligence tests and psychometric measures of behavior).

Cultural competency

• Culturally sensitive- implies that caregivers possess some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting in which they are practicing. • Culturally appropriate- implies that the caregivers apply the underlying background knowledge that must be possessed to provide a given person with the best possible health care. • Culturally competent- implies that the caregivers understand and attend to the total context of the individual's situation, including awareness of immigration status, stress factors, other social factors, and cultural similarities and differences.39

Consider the interview a contract between you and your client. The contract concerns what the client needs and expects from health care and what you as a clinician have to offer. Your mutual goal is optimal health for the client. The terms of the contract include:

• Time and place of the interview and succeeding physical examination. • Introduction of yourself and a brief explanation of your role. • The purpose of the interview. • How long it will take. • Expectation of participation for each person. • Presence of any other people (e.g., family, other health professionals, students). • Confidentiality and to what extent it may be limited. • Any costs to the client.