Fundamentals Modules 1-10 Study Guides

Foundations of Nursing
VN 214 Fundamentals
Module 1 Study Guide
1
1 1 Module 1 – Introduction to the Role of a Student Nurse and Introduction to Wellness

and Self Care
Study Guide 1.1
The Four Learning Styles
The Visual /Verbal Learning Style

The Visual/Non-Verbal Learning Style
The Tactile/Kinesthetic Learning Style
The Auditory/Verbal Learning Style
The Visual/Verbal Learning Style
You learn best when information is presented visually and in a written language format. In a
classroom setting, you benefit from instructors who use the blackboard (or overhead projector) to
list the essential points of a lecture, or who provide you with an outline to follow along with
during lecture. You benefit from information obtained from textbooks and class notes. You tend
to like to study by yourself in a quiet room. You often see information “in your mind’s eye”
when you are trying to remember something.
Learning Strategies for the Visual/Verbal Learning Style

• To aid recall, make use of “color coding” when studying new information in your textbook or
notes. Using highlighter pens highlight different kinds of information in contrasting colors.
• Write out sentences and phrases that summarize key information obtained from your
textbook and lecture.
• Make flashcards of vocabulary words and concepts that need to be memorized. Use
highlighter pens to emphasize key points on the cards. Limit the amount of information per
card so your mind can take a mental “picture” of the information.
• When learning information presented in diagrams or illustrations, write out explanations for
the information.
• When learning mathematical or technical information, write out in sentences and key phrases
your understanding of the material. When a problem involves a sequence of steps, write out
in detail how to do each step.
• Make use of computer word processing by copying key information from your notes and
textbook onto a computer. Use the print-outs for visual review.
• Before an exam, make yourself visual reminders of information that must be memorized.
Make “stick it” notes containing key words and concepts and place them in highly visible
places – on your mirror, notebook, car dashboard, etc.
2
The Visual/Non-Verbal Learning Style
You learn best when information is presented visually and in a picture or design format. In a
classroom setting, you benefit from instructors who use visual aids such as film, video, maps and
charts. You benefit from information obtained from the pictures and diagram in textbooks. You
tend to like to work in a quiet room and may not like to work in study groups. When trying to
remember something, you can often visualize a picture of it in your mind. You may have an
artistic side that enjoys activities having to do with visual art and design.
Learning Strategies of the Visual/Non-Verbal Learner

• Make flashcards of key information that needs to be memorized. Draw symbols and pictures
on the cards to facilitate recall. Use highlighter pens to highlight key words and pictures on
the flashcards. Limit the amount of information per card, so your mind can take a mental
“picture” of the information.
• Mark up the margins of your textbook with key words, symbols, and diagrams that help you
remember the text. Use highlighter pens of contrasting colors to “color code” the
information.
• When learning mathematical or technical information, make charts to organize the

information. When a mathematical problem involves a sequence of steps, draw a series of
boxes, each containing the appropriate bit of information in sequence.
• Use large square graph paper to assist in creating charts and diagrams that illustrate key
concepts.
• Use the computer to assist in organizing material that needs to be memorized. Using word
processing, create tables and charts with graphics that help you to understand and retain
course material. Use spreadsheet and database software to further organize material that
needs to be learned.
• As much as possible, translate words and ideas into symbols, pictures, and diagrams.
The Tactile/Kinesthetic Learning Style
You learn best when physically engaged in a “hands on” activity. In the classroom, you benefit
from a lab setting where you can manipulate materials to learn new information. You learn best
when you can be physically active in the learning environment. You benefit from instructors
who encourage in-class demonstrations, “hands on” student learning experiences, and field work
outside the classroom.
Strategies for the Tactile/Kinesthetic Learner
• To help you stay focused on class lecture, sit near the front of the room and take notes
throughout the class period. Don’t worry about correct spelling or writing in complete
3
sentences. Jot down key words and draw pictures or make charts to help you remember the
information you are hearing.
• When studying, walk back and forth with textbook, notes, or flashcards in hand and read the
information out loud.
• Think of ways to make your learning tangible, i.e. something you can put your hands on. For
example, make a model that illustrates a key concept. Spend extra time in a lab setting to
learn an important procedure. Spend time in the field (e.g. a museum, historical site, or job
site) to gain first-hand experience of your subject matter.
• To learn a sequence of steps, make 3x5 flashcards for each step. Arrange the cards on a table
top to represent the correct sequence. Put words, symbols, or pictures on your flashcards –
anything that helps you remember the information. Use highlighter pens in contrasting
colors to emphasize important points. Limit the amount of information per card to aid recall.
Practice putting the cards in order until the sequence becomes automatic.
• When reviewing new information, copy key points onto a chalkboard, easel board or other
large writing surface.
• Make use of the computer to reinforce learning through the sense of touch. Using word
processing software, copy essential information from your notes and textbook. Use graphics,
tables, and spreadsheets to further organize material that must be learned.
• Listen to audio tapes on a Walkman tape player while exercising. Make your own tapes
containing important course information.
The Auditory/Verbal Learning Style
You learn best when information is presented auditory in an oral language format. In a
classroom setting, you benefit from listening to lecture and participating in group discussions.
You also benefit from obtaining information from audio tape. When trying to remember
something, you can often “hear” the way someone told you the information, or the way you
previously repeated it out loud. You learn best when interacting with others in a
listening/speaking exchange.
Strategies for the Auditory/Verbal Learner

• Join a study group to assist you in learning course material. Or, work with a “study buddy”
on an ongoing basis to review key information and prepare for exams.
• When studying by yourself, talk out loud to aid recall. Get yourself in a room where you
won’t be bothering anyone and read your notes and textbook out loud.
• Tape record your lectures. Use the ‘pause’ button to avoid taping irrelevant information.
Use a tape recorder equipped with a 3-digit counter. At the beginning of each lecture, set
your counter to ‘000’. If a concept discussed during lectures seems particularly confusing,
4
glance at the counter number and jot it down in your notes. Later, you can fast forward to
that number to review the material that confused you during lecture. Make use of a counter
and pause button while tape recording allows you to avoid the tedious task of having to listen
to hours and hours of lecture tape.
• Use audio tapes such as commercial books on tape to aid recall. Or, create your own audio
tapes by reading notes and textbook information into a tape recorder. When preparing for an
exam, review the tapes on your car tape player or on a “Walkman” player whenever you can.
• When learning mathematical or technical information, “talk your way” through the new
information. State the problem in your own words. Reason through solutions to problems by
talking out loud to yourself or with a study partner. To learn a sequence of steps, write them
out in sequence form and read them out loud.
5
Module 1 – Introduction to the Role of a Student Nurse and Introduction to Wellness and
Self Care
Study Guide 1.2
Description of How to Use a Module
A module as used in the Nursing Program as a self-contained unit of instruction. Each contains
specific sections. The following will describe these sections, their purposes and how they are to
be used. This is intended to be a general information sheet. Multiple modules make up courses.
Introduction
This section acquaints you with the overall purpose of the module by describing broadly what
the module contains.
Expected Outcomes
These are the competencies or the activities you must master in order to successfully complete
the module. The objectives are divided into three specific groups; the cognitive or knowledge
domain, the affective or attitudes domain, and the psychomotor or skills domain. Column I and
III are the expected outcomes from the module.
Study Guides
This section provides information that may not be found in the listed textbook and multimedia
assignments.
Column I
Content Outline and theory objectives.
Column II
Suggested learning activities gives the student/instructor resources and assignments that the
student will need to meet the objectives in Column I. Learning Activities may contain:
• Required reading
• Recommended reading
• Internet Resources
• Audiovisual (AV) resources
• Handouts – these are Study Guides attached to the module
• Assignments – samples of these and required forms will be in attachments
• Practice Test Questions – will be found in most modules in the attachments
Column II will have activities for the entire module, for all objectives in that module.
Column III
6
Has a clinical objective. This column is how the student takes knowledge from Column I and
applies it in a clinical lab/assignment to situations and real patient assignments.
Column IV
These are the activities, skills, competencies that the student must demonstrate in the lab or the
hospital, or community setting to meet Column III objectives.
Self Care
Study Guide 1.3
Critical Elements
Overriding Areas of Care: Critical Elements

The advisory committee and the curriculum writers identified the following critical elements to
ensure safe nursing.
It is accepted that each patient, or client, for whom a nursing student provides care has the right
to receive safe nursing care.. It is, therefore, understood that it is essential to avoid physical
jeopardy, emotional jeopardy, and a break in asepsis. It is also understood the nursing student
will provide caring nurse-patient interactions. These areas of nursing function apply to every
nursing situation at all times.
1. Asepsis:
Is defined as the prevention of the introduction and/or transfer of microorganisms.
Special consideration should be given to hand-washing before and after the
administration of each area of health care as required by principles of assessment.
Critical Elements: The instructor should be realistic in evaluating violations of asepsis.

The perspective of the client’s well-being and safety are paramount, but 100 percent
perfection and a germ-free state are idealistic rather than realistic goals. It is necessary to
keep in mind the principles of asepsis.
Examples of clear violation:

 A student does not wash hands before implementing patient care
 A student does not protects self from contamination
 A student does not protect client from contamination
 A student does not dispose of contaminated material in designated containers
 A student does not confine contaminated material to contaminated area
 A student does not establish and/or maintain a sterile field when required
2. Emotional Jeopardy:
Is defined as any action or inaction on the part of the student which threatens the
emotional well-being of the client or significant others.
Critical Elements: The student’s behavior must not create emotional stress or create a
non-therapeutic situation for the client.
7

 A student’s use of words or body language that constitute disapproval or
disgust.
 A student’s use of overt or covert threats to elicit client’s response and/or
cooperation.
 A student’s use of probing, attacking-type questions when interacting with the
client.
 Any violation of client’s legal protection, such as maintenance of
confidentiality, which are protected under the client rights guarantees.
3. Physical Jeopardy:
Is defined as any action or inaction on the part of the student which threaten the client’s
physical well-being.
Critical Elements: Because of the vast number of possibilities, the critical elements
depend on the situation as judged by the instructor. There are no predetermined critical
elements for physical jeopardy. The student is accountable for the assigned patient’s
safety. Any time the patient’s safety is threatened through omission, such as not
reporting a deterioration in the patient’s clinical condition, or by the students incorrect
action, the instructor will document and report describing the behavior of the student in
clear terms.

 The student medicates a client with a Central Nursing System depressant and
leaves the side rails down.
 A student leaves a client, adult or child in a bed or crib with the side rails down
or unattended in other precarious situations.
 A student disconnects or interrupts a treatment, i.e., IV, croupette, etc., and does
not reestablish the connection as required.
 A student elevates urine collection bag in a close drainage system above the
level of the client’s bladder.
 A student administers medication incorrectly.
4. Caring: Is defined as a pattern of behavior that pervades the nurse-client interaction as

characterized by attentiveness to others’ experiences, the establishment of a trusting
relationship with the client and/or significant other, and respect for the values, dignity
and culture of others.
Critical Elements: Establishes communication with the client by introducing self;

explaining purpose of the interaction; and using touch with a client who is a child or adult
who is unable to verbally communicate.

 The student does not encourage the patient’s expression of needs
8
 The student does not respond to the client’s verbal expressions

 The student does not respond to the client’s nonverbal expressions
 The student does not facilitate goal-directed interactions by:
o Explaining the nursing actions to be taken
o Asking questions to determine the client’s response to nursing care.
o Asking questions to determine the client’s comfort level
o Focusing communication toward client-oriented interest
o Using language consistent with the client’s level of understanding.
o Eliciting the client’s choices/desires in the organization of care.
 The student does not use verbal expressions that are not overly familiar,
patronizing, demeaning, abusive or otherwise unacceptable.
 The student does not use physical expressions that are not overly familiar,
patronizing, demeaning, abusive or otherwise unacceptable.
 The student does not relate in a manner that respects the values, dignity and
culture of others.
9
Self Care
Study Guide 1.4
The Metaparadigm for Nursing
In the late 20th Century, much of the theoretical work in nursing focused on articulating
relationships among four major concepts: person, environment, health, and nursing. Because
these four concepts can be superimposed on almost any work in nursing, they are sometimes
collectively referred as a metaparadigm for nursing. The term originates from two Greek words:
meta, meaning “with,” and paradigm, meaning “pattern.”
Many consider the following four concepts to be central to nursing.
• Person or client, the recipient of nursing care (includes individuals, families, groups, and
communities).
• Environment, the internal and external surroundings that affect the client. This includes
people in the physical environment, such as families, friends, and significant others.
• Health, the degree of wellness or well-being that the client experiences.
• Nursing, the attributes, characteristics, and actions of the nurse providing care on behalf of,
or in conjunction with, the client.
The work of American nurse theorists reflects a wide range of ideas about people, health, values,
and the world. Each nurse theorist’s definitions of these four major concepts vary in accordance
with scientific and philosophical orientation, experience in nursing, and the effects of that
experience on the theorist’s view of nursing. A single metaparadigm may be impossible given
the divergence in world views expressed in nursing models.
10
Self Care
Study Guide 1.5
Conceptual Frameworks of Models
Concepts are often called the building blocks of theories. Concepts are hard to define because
the definition has to include everything from the speed of light to the unconscious.
A Conceptual Framework is a group of related ideas, statements, or concepts. Freud’s structure

of the mind (id, ego, superego) could be considered a conceptual framework or model. The term
conceptual model is often used interchangeably with conceptual framework, and sometimes with
grand theories, those that articulate a broad range of the significant relationships among the
concepts of a discipline.
11
Self Care
Study Guide 1.6
Organizing Framework
The curriculum for this course was developed by a statewide committee of faculty representing
all the community college Vocational Nursing Programs.
Definition of Nursing
There are many definitions of nursing in references written for and about the nursing profession.
The following are two definitions that the curriculum writers of this project support.
1. Nursing is the diagnosis and treatment of human responses to actual or potential

health care problems. American Nursing Association (ANA).
2. Nursing is a health care profession that focuses on human life processes and patterns,
and emphasizes promotion of health for individuals, families, groups and society as a
whole.
The study of nursing is a very complex one that requires mental and physical abilities to
complete the tasks necessary to become a registered nurse. Two of the most essential tools are
the Nursing Process and the Organizing Framework around which the curriculum is framed.
The nursing process is a problem solving process that guides the method of thought and action.
It is the thinking process used by registered nurses to care for the clients’ response to their health
care issues as well as to guide prevention and wellness activities.
Mission
The mission of the California Statewide Vocational Nursing (VN) Curriculum Model is to
prepare entry-level Licensed Vocational Nurses as providers of care across the health/illness
continuum and as members within the profession. The curriculum model respects the
individuality of students and recognizes that each student has different educational, experiential,
cultural, spiritual, economic and social backgrounds and a unique support system. The aim of
the curriculum is to provide a positive, innovative learning model that fosters the development of
critical thinking and problem solving skills so that the graduate nurse is equipped to deliver care
to a culturally diverse population in a variety of healthcare settings. Graduate nurses will
collaborate with members of the health care team, be effective communicators, be politically
aware, and demonstrate a commitment to life long learning.
Philosophy/Organizing Framework
The organizing/conceptual framework for this curriculum is a theoretical model developed
jointly by the advisory committee and the curriculum writers of this project. It is based on the
nursing process and nursing competencies. Educational outcomes facilitate the integration of
information relevant to nursing and patient care. Curriculum and course sequence progress from
simple to complex knowledge and skills with emphasis on caring, problem solving and critical
thinking. We believe that there are philosophical values critical to and inherent in nursing and
nursing education that should be the foundation on which educational experiences are structured.
12
Included in the organizing framework are the definitions of the basic concept of person,
environment, health, nursing, education and teaching/learning.
Persons refer to individual open systems with physiological, psychological, social,

cultural, developmental and spiritual dimensions that are in constant interaction with the
environment.
Environment consists of internal and external factors that impact the individual.
Health is a dynamic state of equilibrium maintained by lines of defense and exists on a

continuum between optimal functioning or wellness and alterations in functioning or
illness. Health is affected by lifestyle behaviors and noxious stressors.
Nursing as defined in Nursing’s Social Policy Statement is “the prevention of illness,

alleviation of suffering, and the protection, promotion and restoration and restoration of
health in the care of individuals, families…’ (American Nursing Association, 2003). It is
an art and applied science based on principles from the biological, physical and
behavioral sciences which focuses on the diagnosis and treatment of human responses to
actual or potential health problems. Nurses collaborate with health team members and
respond to the care of clients across the life cycle based on physiological, psychological,
social, cultural and spiritual needs.
Education is a dynamic and synergistic process of sharing information between

individuals resulting in a modification of behavior. Education respects the individuality
of students and recognizes that each student has different educational, experience,
cultural, spiritual, economic and social backgrounds and a unique support system. The
aim of education is to develop critical thinking and problem solving skills in a positive,
innovative environment moving from beginning (simple) to advanced competencies
(complex).
Teaching/Learning is defined as the right and responsibility of nurse educators to utilize

sound educational practices and theoretical concepts to present relevant knowledge and
skills reflecting current healthcare practices, to facilitate students’ achievement of their
highest potential. Recognition of differences in individual needs, learning styles,
ethnicity and cultural backgrounds are essential components in effective teacher-learner
interactions.
Learning occurs via a dynamic and synergistic process that prepares the learner to
function effectively as an entry-level LVN, provider of care across the health/illness
continuum and as a member within the profession.
In addition, the organizing framework focuses on the individual needs of learners and
clients/patients, within the context of families, communities and environments. Learners and
clients/patients exist on a health-illness continuum.
13
Self Care
Study Guide 1.7
Curriculum Threads
Threads
The nursing curriculum is sequential and builds on previously acquired knowledge and skills.
Overriding all student experiences, the ability to think critically will be emphasized. Critical
thinking is exercised in all aspects of client care: nursing care decision, priority setting,
appropriate interventions to individualize client care, and evaluating outcomes.
Patient teaching, one of nursing’s unique functions is another focus of nursing. The student will
have opportunities to explore factors that affect learning and identify some of the principles of
the teaching-learning process.
There are “threads” of learning in the nursing education curriculum, that is, topics in nursing that
are taught in every semester beginning with the simple and moving to complex. Nursing process
is an example of a curriculum thread, as is leadership. The advisory committee and the
curriculum writers identified the following threads to be included in each course:
• Communication
• Critical Thinking
• Nursing Process
• Teaching/Learning Principles
• Safety
• Ethics
• Caring
• Legalities
• Leadership
• Lifespan/Age-Appropriate Care
• Professionalism
• Fiscal Responsibility/Health Care Financing
• Diversity
• Collaboration
• Research/Evidence Based Practice
• Patient Advocacy
• Self Care
• Pain
• Informatics
• Nutrition
As the student continues through the nursing program, each student is responsible for retaining
the knowledge and skills acquired in all of the prerequisite courses including anatomy and
physiology and microbiology, and other courses required as prerequisites in any VN Program.
14
Self Care
Study Guide 1.8

Outcomes, Standards of Competency, Terminal Objectives
Outcomes
The following outcomes have been identified as a requirement for students completing the
California Statewide Vocational Nursing (VN) Curriculum Model.
1. Communication Skills
a. Utilizes appropriate communication styles and basic leadership skills in patient
care management.
b. Use of select therapeutic communication techniques to establish a therapeutic
environment.
2. Thinking and Reasoning
a. Utilizes nursing process to plan, implement, and evaluate care for patients.
b. Develops an individualized nursing care plan for assigned patients.
3. Information Competency
a. Employs appropriate scientific resources and technology to plan and deliver
patient care.
b. Documents patient care as per facility policy.
4. Diversity
a. Prioritize nursing actions to coincide with changing patient conditions, cultural
variants, and multiple patient assignments.
5. Civic Responsibility
a. Anticipates ethical-legal dilemmas and intervenes as a patient advocate
6. Life Skills
a. Applies principles of time management, organization, delegation and priority
setting in providing nursing care.
7. Careers
a. Begins the process of lifelong learning
b. Correlates theoretical concepts and clinical practice to identify the complex needs
of patients in multiple settings.
8. Critical Elements
a. Has met identified overriding critical elements while providing patient care.
9. Has maintained professional behavior at all times.
Standards of Competency
The student who completes a VN program will meet the standards of competency, delineated by
the Board of Registered Nursing for the State of California. The successful VN graduate will:
1. Demonstrate knowledge to function as a patient advocate.

2. Demonstrate knowledge to safely perform as a clinician in the delivery of patient
care.
15
3. Demonstrate knowledge to implement critical thinking utilizing the nursing process in

the care of patients.
4. Demonstrate knowledge to provide leadership, manage resources, delegate and
supervise based on legal scope of practice.
5. Demonstrate knowledge to teach individuals, families, communities and members of
the health care team.
Terminal Objectives
The graduate nurse will demonstrate the following:
1. Assist individuals to achieve optimal health utilizing the knowledge gained from
biological, social, and nursing sciences.
2. Formulate a comprehensive plan of care using all components of the nursing process.
3. Safely perform basic psychomotor skills in the delivery of care as a technically
competent clinician.
4. Integrate the role of professional nurse into clinical practice.
5. Research and communicate to identify problems, initiate actions and evaluate
outcomes for health promotion and maintenance.
6. Apply psychological, social, and cultural knowledge to the nursing role.
7. Support physiological well-being of individuals and families in the health care
environment.
8. Assume the role of advocate to improve health care delivery by communicating and
acting according to the expressed needs of the individual.
9. Manage the clinical environment through assessment, planning, intervention, and
evaluation.
10. Apply critical thinking skills to make judgments based on evidence (fact) rather than
conjecture.
11. Organize individuals or groups toward goal setting and goal achievement.
12. Implement a comprehensive teaching plan to help individuals and families achieve
optimal health.
13. Take and pass the NCLEX-PN Examination.
14. Understand that the culmination of the Vocational Nursing program prepares for
entry into practice and that continuing education and lifelong learning is imperative.
16
Self Care
Study Guide 1.9
Wellness Worksheet – Personal Health Profile - Exercise
Complete the following personal health profile and keep it with your Personal Infectious Disease
and Allergy Record so that you have a complete record of your health status. Keep your profile
up-to-date.
NAME:_______________________________________________ DATE:
___________________
AGE: ________ yrs. HEIGHT: __________ inches
WEIGHT: _________ lbs.
Current Conditions or Diseases Treatments and Medications

_____________________________________ ________________________________________
_____________________________________ ________________________________________
_____________________________________ ________________________________________
_____________________________________ ________________________________________
_____________________________________ ________________________________________
Current Conditions or Diseases Common in Your
Family Ethnic Group

_____________________________________ ________________________________________
_____________________________________ ________________________________________
_____________________________________ ________________________________________
_____________________________________ ________________________________________
Prescription Medication Information
Drug Prescription No. No. of Refills Pharmacy Tele. No.
____________________ ______________ _____ _______________________
____________________ ______________ _____ _______________________
____________________ ______________ _____ _______________________
____________________ ______________ _____ _______________________
17
Health care provider: _________________________________________

_______________________
Pharmacy: _________________________________________________
18
Record of Medical Tests and Exams

Enter the date of your most recent test, exam, or vaccination.
Date Test/Exam/Vaccination Recommended Frequency

__________ Blood Pressure Check Every 1-2 years
__________ Cholesterol Measurement Every 5 yrs. For men 35-65 and women 45-85
__________ Screening for HIV infection Routinely for pregnant women and
and other STD’s others at risk
__________ Tuberculosis Test Members of high-risk groups only
__________ Vision Test Every 2-3 years
__________ Fecal Occult Blood Test Every year for people over 50
__________ Sigmoidoscopy Every 3-5 years for people over 50
__________ Tetanus/Diphtheria Vaccination Every 10 years
__________ Influenza Vaccination Yearly for people over 65 or at special risk
For Men
__________ Testicular self-exam Monthly
For Women
__________ Blood test for iron deficiency anemia Pregnant women and high-risk infants
__________ Pap Test Every 3 years
__________ Breast self-exam Monthly
__________ Mammography Every 1-2 years for women 50-69 years
Note: The guidelines presented above represent the minimum tests recommended for people
without symptoms. If you have symptoms or are at increased risk for certain conditions because
of your medical or family history, additional tests may be advised. You should discuss your
particular needs with your physician.
19
What’s your Medicine Cabinet IQ?
Take this quiz to evaluate your knowledge of common medications; decide whether each
statement is true or false.
TRUEFALSE
___ ___ 1. Acetaminophen (Tylenol) is safer for children than aspirin.
___ ___ 2. It’s a good idea to keep some prescription antibiotics on hand in case you
start to come down with a cold.
___ ___ 3. Hydrogen peroxide is a safe, effective antiseptic for cleaning cuts and
scrapes.
___ ___ 4. Vitamin pills containing iron can be very toxic to children
___ ___ 5. Taking vitamin C can help prevent you from catching a cold.
___ ___ 6. It’s OK to share prescription medications with other people you know
with the same physical complaints.
___ ___ 7. Calamine lotion is a good product for relieving minor itching.
___ ___ 8. Everyone should take vitamin supplements to boost his or her health.
Answers:
1. True. Aspirin can cause a dangerous condition known as Reye’s syndrome in children.
2. False. It is very dangerous to keep old antibiotics on hand. If you get a prescription for
antibiotics, you should finish taking them even if you start to feel better.
3. True. Hydrogen peroxide is just as effective and less expensive than other OTC
antiseptics.
4. True. Consuming iron-containing vitamins is the leading cause of poisoning in children
under age 6. Be sure they are stored where children can’t get them.
5. False. But some studies indicate that taking vitamin C may slightly diminish the severity
of symptoms once a cold develops.
6. False. Taking someone else’s prescription medicine can be very dangerous.
7. True. Calamine lotion can relieve itching from poison ivy or oak, insect bites, sunburn,
and minor forms of dermatitis (skin irritations).
8. False. Most people who eat a healthy diet don’t need vitamin supplements. There are
some exceptions; ask your physician.
Scoring: Add up the number of questions you answered correctly.

7.8 Congratulations! You are very knowledgeable about self-care. Continue to
educate yourself about home health issues.
4.6 You have some knowledge about self-care issues, but you need to be careful
to read and follow all medication instructions.
0.3 Your lack of knowledge about self-care could put your health at risk. Read
____________ carefully, and look for other ways to educate yourself about home
health care issues.
20
Medicine Cabinet Check-up
Your home pharmacy should contain essential medical supplies. You can evaluate your
pharmacy by completing the checklist below; consider purchasing any supplies that you do not
check off.
Equipment Over-the-Counter Medications

____ Adhesive bandages ____ Antacids or acid reducers
____ Adhesive tape ____ Antibacterial ointment or cream
____ Cotton balls ____ Antifungal preparations
____ Elastic bandages ____ Antihistamines
____ Eye cup ____ Aspirin, acetaminophen, ibuprofen,
____ Gauze and/or naproxen sodium
____ Heating pad or hot water bottle ____ Burrow’s solution
____ Ice pack ____ Cough suppressant and expectorant
____ Needle-nosed tweezers ____ Decongestant tables or nose sprays
____ Sterile bandages ____ Eye drops and artificial tears
____ Thermometer ____ Hemorrhoid preparation
____ Hydrocortisone cream
____ Kaolin/pectate or loperamide
____ Milk of magnesia or a bulk laxative
____ Povidone iodine
____ Sodium bicarbonate
____ Sunscreen (SPF 15+)
____ Syrup of ipecac
____ Throat lozenges, spray or gargle
Getting the Most Out of Your Medical Care
To manage your own health successfully, you need to learn how to identify and manage medical
problems and how to make the health care system work effectively for you. Review your
knowledge of these areas by answering the questions below. Refer to your textbook, if
necessary.
• List five things you should observe about symptoms.

o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
21
• What four general categories of symptoms require professional assistance?

o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
• List ten symptoms that indicate an urgent condition requiring a trip to the emergency
room.
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
• List ten quidelines for using OTC medications safely and effectively.
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
22
23
• What can you do before an appointment with your physician that will help ensure good
communication?
o _________________________________________________________________
_
List seven things you can do during an appointment that will help ensure good
communication.
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
List three things you can do at the end of an appointment with your physician that will
help ensure good communication.
o ______________________________________________
o ______________________________________________
o ______________________________________________
• List five questions you should ask about a medical test recommended by your physician.
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
• What key questions should you ask when considering treatment options?
o ______________________________________________
o ______________________________________________
24
• List seven important questions you should ask about a prescription medication.
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
• List four questions you should ask if your physician recommends surgery.
o ______________________________________________
o ______________________________________________
o ______________________________________________
o ______________________________________________
Selecting and Evaluating a Physician

Use the checklist below to evaluate your current physician or to choose a new one.
YES NO
___ ___ The office appears to be run efficiently.
___ ___ The office atmosphere is friendly and reassuring.
___ ___ The receptionist is helpful when I call to make an appointment or arrive for a
visit.
___ ___ Phone messages are passed on and phone calls returned in a timely manner.
___ ___ I am informed ahead of time if there will be any delays.
___ ___ The waiting area is rarely crowded.
___ ___ Privacy is provided when I am asked personal questions.
___ ___ The office accepts insurance, and requirements for payment are clearly
explained.
___ ___ The physician seems thorough when taking my medical history.
___ ___ The physician gives me sufficient time and encouragement to completely
describe my problem.
___ ___ The physician is receptive to my questions and concerns.
___ ___ The physician answers all of my questions.
___ ___ The physician explains things clearly; he or she does not use so much medical
jargon that I have difficulty understanding him or her.
___ ___ The physician explains the purpose and procedure for all medical tests.
25
___ ___ The physician explains the reasons a particular drug is prescribed. He or she
provides complete instructions for using the drug safely and effectively.
___ ___ Follow-up instructions are clearly given. I understand what my next step should
be.
___ ___ The physician supports my decision to seek a second opinion when I feel it’s
necessary.
___ ___ The physician refers me to a specialist, when indicated.
___ ___ The physician is willing to consult with me on the telephone, when needed.
___ ___ Overall, the physician makes me feel comfortable with and confident of the
services he or she is providing.
“NO” answers indicate areas where your relationship with your physician or the running of the
office may be less than ideal. Discuss any areas of concern with your physician. If things do not
improve, consider changing physicians. Remember, your physician works for you.
Internet Activity
You can find information about many U.S. physicians from the online AMA Physician Select
service, sponsored by the American Medical Association (http://www.ama-assn.org). This
service lists the physician’s address, area of specialty, training, and whether he or she is board
certified; you can search for a physician by name or by location and area of specialty. Look up
your current physician or one who is practicing at a clinic or a hospital near you. Or search for a
particular type of specialist practicing in your area.
Physician’s Name: __________________________________________________
Information obtained:
26
Evaluating Health Insurance
The following questions are designed to help you evaluate different health insurance policies and
choose the most appropriate one for you.
Costs
What is the yearly premium for the policy? _____________________________________

What is the deductible? _____________________________________
Is there a coinsurance system? If so, describe it: _____________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Does the plan require a co-payment for services? _____________________________________
If so, what is the system of co-payments? _____________________________________
_____________________________________________________________________________
_
Does the policy pay only the “usual” or “customary” fee for particular services? _____________
Is there a maximum limit of coverage, either on a yearly basis or over the life of the policy? Are
there limits on the coverage of any particular conditions? _______________________________
_____________________________________________________________________________
_
(For point-of-service plans) If you visit a physician outside the plan, what percentage of the cost
is covered? ____________________________________________________________________
Coverage
What services does the policy cover? Check those that are covered; circle those you are most
likely to need.
___ Physician visits ___ Preventive care
___ Allergy testing and treatment ___ Dental care
___ Hospitalization ___ Prenatal care and routine deliveries
___ Prescription drugs ___ Surgical costs, including anesthesia
___ Second opinions ___ X-rays and lab services
___ Ambulance service ___ Emergency room care
___ Mental health counseling/psychiatric care ___ Substance abuse treatment
___ Vision care ___ Physical therapy
___ Transfusions ___ Out-of-town care
___ Contraceptives ___ Skilled nursing home care
27
List other services or supplies you may require and check whether or not these are covered under
the policy.
Services/Supplies Covered?
______________________________________________________________ _______
______________________________________________________________ _______
______________________________________________________________ _______
______________________________________________________________ _______
Restrictions/Exclusions
Are there exclusions for any pre-existing conditions? If so, list any exclusions that would affect
you.
__________________________________________________________________________
_____________________________________________________________________________
_
_____________________________________________________________________________
_
How long must you be free of symptoms before these conditions would be covered? __________
Is preauthorization required for any services? ______________ Which services? ____________

_____________________________________________________________________________
_
28
Does the policy exclude particular conditions? If so, list any exclusions that may affect you.
_____________________________________________________________________________
_
_____________________________________________________________________________
_
Choice of Physician/Facilities
Are restrictions placed on your choice of physician? ___________________________________

_____________________________________________________________________________
_
Would your current physician be covered by the plan? __________________________________
Are there any restrictions on choice of clinic, hospital, or emergency room? _________________
_____________________________________________________________________________
_
Waiting Period/Cancellation
Is the policy effective immediately? _________ If not, how long is the waiting period? _______
Is there a grace period for non-payment of premiums or other fees? _______________________
Under what circumstances can the policy be cancelled? _________________________________

_____________________________________________________________________________
_
If you leave your job, can you maintain the policy by paying the premiums yourself? _________
Do you have any other options, such as temporarily extending the policy or changing to an
individual policy? _______________________________________________________________
_____________________________________________________________________________
_
29
Self Care
Study Guide 1.11

The Stress of Adjusting to Change - Activity
Self Evaluation
Circle the points for any event in your life in the last years.
Scale of
Event Impact
Death of spouse……………………………………………………………………………….. 100
Divorce………………………………………………………………………………………... 73
Marital Separation ……………………………………………………………………………. 65
Jail Term………………………………………………………………………………………. 63
Death of Close Family Member………………………………………………………………. 63
Personal Injury or Illness……………………………………………………………………… 53
Marriage………………………………………………………………………………………. 50
Fired at Work…………………………………………………………………………………. 47
Marital Reconciliation………………………………………………………………………… 45
Retirement…………………………………………………………………………………….. 45
Change in Health of Family Member…………………………………………………………. 44
Pregnancy ..…………………………………………………………………………………… 40
Sex Difficulties……………………………………………………………………………….. 39
Gain of New Family Member………………………………………………………………… 39
Business Readjustment……………………………………………………………………….. 39
Change in Financial State…………………………………………………………………….. 38
Death of Close Friend………………………………………………………………………… 37
Change to Different Line of Work…………………………………………………………… 36
Change in Number of Arguments with Spouse……………………………………………… 35
Mortgage over $10,000………………………………………………………………………. 31
Foreclosure of Mortgage or Loan……………………………………………………………. 30
Change in Responsibilities at Work…………………………………………………………. 29
Son or Daughter Leaving Home…………………………………………………………….. 29
Trouble With In-Laws……………………………………………………………………….. 29
Outstanding Personal Achievement…………………………………………………………. 28
Wife Begins or Stops Work…………………………………………………………………. 26
Beginning or Ending School………………………………………………………………… 26
Change in Living Conditions………………………………………………………………… 25
Revision of Personal habits………………………………………………………………….. 24
Trouble With Boss…………………………………………………………………………… 23
Change in Work Hours or Conditions……………………………………………………….. 20
Change in Residence………………………………………………………………………… 20
Change in Schools…………………………………………………………………………… 20
Change in Church Activities………………………………………………………………… 19
Change in Social Activities………………………………………………………………….. 18
30
Mortgage or Loan Less Than $10,000………………………………………………………. 17

Change in Sleeping Habits…………………………………………………………………… 16
Change in Number of Family Get-Togethers………………………………………………… 15
Change in Eating Habits……………………………………………………………………… 15
Vacation………………………………………………………………………………………. 13
Christmas……………………………………………………………………………………… 12
Minor Violations of the Law………………………………………………………………….. 11
_______
Total all circled points Total Score: _______
31
Self Care
Study Guide 1.12
Health/Illness-Positive/Negative Adaptation
The nurse’s role is to promote health for the client. In order to do this, we need to be able to
assess an individual’s present state of health and to evaluate for forces acting on the person that
cause the stress and, therefore, may lead to illness.
• The nature of a person is described as a biopsychosocial being in constant

interaction with a changing environment.
o This means that each person consists of a physical, a psychological, and a social
part; each of these parts is closely related and influences other parts. I f a person
has a cold, which affects his physical well-being, it may also make the person feel
depressed and withdraw from contact with other people. This statement also
means that we are constantly reacting to change within and around us. If you
walk into a very cold house, you will try to find a way to get warm. Being
physically cold may make you irritable and impatient with others who are in the
house. The people in the house will have to adapt to the cold and to the change in
your health. Such changes occur very frequently every day of our lives.
• People have innate and acquired mechanisms to cope with this changing
environment.
o These mechanisms are physical, psychological, and social. All people have some
of these mechanisms, such as when running, the ability to breath more rapidly in
order to supply the increased demand of oxygen the body needs. Since this
occurs instinctively, these mechanisms, such as apply pressure to stop bleeding.
We use mechanisms such as denial to relieve feelings of anxiety and may seek out
a friend in order to discuss a problem which is causing anxiety. Whatever the
change in our internal or external environment, we all have mechanisms to cope
with and/or adapt to a changing world.
• A positive response to a changing environment is commonly known as the process of

adaptation.
o A person’s ability to adapt to change depends on the degree or extent of the
change which is taking place and the state or condition of the person who much
cope with the change. It is much harder to adapt to “bigger” changes in our
environment. When a woman returns to work after 10 years of being a stay at
home mom, she will experience many large and small changes which require
adaptation. A flexible person is more adaptable and has a greater chance of
survival and to be able to experience life fully.
• Human responses may be effective or ineffective.

o An effective or positive response is behavior which promotes the integrity of a
person and enables that person to cope with internal and external changes which
32
occur. In other words, it is a response which is considered within the normal

range of the person’s culture and mode of living. An ineffective response is
behavior which disrupts or does not preserve the integrity of a person.
Interestingly enough, many behaviors by themselves may be either effective or
ineffective responses, depending on the situation. For example, the respiratory
rate will increase with strenuous exercise. This would be considered an effective
response. If, on the other hand one begins to hyperventilate resulting from pain or
anxiety, the person will feel weak and dizzy and manifest other uncomfortable
effects or symptoms.
CHARACTERISTICS OF ADAPTATION
• Adaptation involves the biological, psychological and social aspects of a person, all
of which are very closely interrelated.
o Here is an example: If a person has an accident and breaks their arm, this person
is not only painfully injured physically but also experiences psychological anxiety
and a change in their social role due to the inability to perform activities they used
to perform. This person may have to be temporarily quiet dependent on others,
requiring an adaptive response.
• A person is able to adapt to a greater degree of stress over a period of time than
when that person is forced to adapt quickly to a sudden onset of stress.
o Here is an example: A woman knows that when the Spring season begins she
wants to start working on a healthy looking tan for the Summer season. She
knows that an initial long and intense exposure to the sun will most likely result in
a sever sunburn, the sun being the stressor. However, she also knows that a
gradual exposure for short periods of time will result in a tan without severe
damage to the skin.
• The person who has a great capacity for flexibility has a greater capacity for
adaptation and survival. The quality of that survival or life is greatly enhanced.
o Here is an example: If a man with rigid personality characteristics works in an
institution where many changes are being made, he may become ill or even resign
because of the inability to be flexible and to accept the changes . This
inflexibility limits exposure to new limits exposure to new experiences and new
learning and limits to ability to function productively and effectively. The quality
of life is affected.
• Whatever adaptation is made is usually the best possible adaptation the person is
capable of making at any given time.
Here is an example: A person develops ways of coping or adapting to
environmental stimuli and can only react within the patterns of behavior he/she
usually uses. The degree or extent of stress a person is under and the ability to
understand oneself affect one’s ability to adapt
33
Self Care
Study Guide 1.13
The Relationship of Change and Illness
Some interesting studies have been done on the relationship of change and illness. These studies
point to physical and/or psychological symptoms that often occur when a person must adapt to
many changes over a relatively short period of time.
One of these studies, which were done by Rahe and Holmes, resulted in a life-change scale in
which numerical values were given to various events. People in diverse cultures and countries
were requested to rate the severity of common changes which occurred, and when the results
were made known, there was agreement. The death of a spouse – 100 points, was rated as the
most traumatic event demanding readjustment. Other events which were rated included divorce
– 73 points, marriage – 50 points, change in residence – 20 points, and a vacation -- 13 points.
When a person experiences these and other such events which have been rated and the total is
between 0-150 points, the probability of getting sick within the next two years is 37 percent. If
the points add up to 150-299, the chances of an illness rise to 51 percent.
The changes or events which will require an adjustment may be very continuous and cover a
short period of time. If they exceed 300 points, you have an 80 percent chance of a serious
illness within the next two years. The higher the number of life changes, then the more serious
the predicted or probable illness.
Holmes concluded that all illnesses are preceded by a significant number of changes in a
person’s life. This infers that all illnesses are psychosomatic or caused by factors which are
social and psychological in nature.
These acquired facts concerning the effects of change are important in working with clients.
Adaptation to change is essential and establishes a role for the helping person in promoting and
maintaining positive behavior responses by clients. It may even be necessary to encourage
clients to plan and control the number of changes in their lives in any given span of time,
keeping mind that some people adapt to change more readily than others – probably because of
differences in training or temperament, or a combination of both of these.
34
Self Care
Study Guide 1.14
Psychological Disorders Most Frequently Seen in Acute Care Hospitals
Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is the development of characteristic symptoms after a
psychologically stressful event that is considered outside the range of normal human experience
(eg, rape, combat, motor vehicle crash, natural catastrophe, terrorist attack). Symptoms of this
disorder include intrusive thoughts and dreams, phobic avoidance reaction (avoidance of
activities that arouse recollection of the traumatic event), heightened vigilance, exaggerated
startle reaction, generalized anxiety, and societal withdrawal. PTSD may be acute, chronic or
delayed.
Depressed Patients
Clinical manifestations may include sadness, apathy, feelings of worthlessness, self-blame,
suicidal thoughts, desire to escape, avoidance of simple problems, anorexia and weight loss,
decreased interest in sex, sleeplessness, and ceaseless activity or reduction in activity. The
agitated depressed individual may exhibit motor restlessness and severe anxiety.
Suicidal Patients
Attempted suicide is an act that stems from depression (eg. Loss of a loved one, loss of body
integrity or status, poor self-image) and can be viewed as a cry for help and intervention. Males
are at greater risk than females. Others at risk are elderly people; young adults; people who are
enduring unusual loss or stress; those who are unemployed, divorced, widowed, or living alone;
those showing signs of significant depression (eg, weight loss, sleep disturbances, somatic
complaints, sucidal preoccupation); and those with a history of a previous suicide attempt,
suicide in the family, or psychiatric illness.
Being aware of people at risk and assessing for specific factors that predispose a person to
suicide are key management strategies. Specific signs and symptoms of potential suicide include
the following:
• Communication of suicidal intent, such as preoccupation with death or talking of someone
else’s suicide (eg, “I’m tired of living, I’ve put my affairs in order. I’m better off dead. I’m
a burden to my family.”).
• History of a previous suicide attempt (the risk is much greater in these cases)
• Family history of suicide
• Loss of a parent at an early age
• Specific plan for suicide
• A means to carry out the plan
Substance Abuse
Substance abuse is the misuse of specific substances to alter mood or behavior; drug and alcohol
abuse are two examples of substance abuse. Drug abuse is the use of drugs for other than
legitimate medical purposes. People who use drugs often take a variety of drugs simultaneously
35
(such as alcohol, barbiturates, opioids, and tranquilizers), and the combination may have additive
and addictive effects. IV/injecting drug users are at increased risk for HIV infection, acquired
immunodeficiency syndrome (AIDS), and hepatitis B and are the most frequent victims of
tetanus in the United States.
Acute Alcohol Intoxication

Alcohol is a psychotropic drug that affects mood, judgment, behavior, concentration, and
consciousness. Many heavy drinkers are young adults or people older than 60 years of age.
Alcohol Withdrawal Syndrome/Delirium Tremens

Alcohol withdrawal syndrome (AWS) is an acute toxic state that occurs as a result of sudden
cessation of alcohol intake after a bout of heavy drinking or, more usually, after prolonged intake
of alcohol. Severity of symptoms depends on how much alcohol was ingested and for how long.
Delirium tremens may be precipitated by acute injury or infection (pneumonia, pancreatitis,
hepatitis) and is the most severe form of AWS.
Patients with AWS show signs of anxiety, uncontrollable fear, tremor, irritability, agitation,
insomnia, and incontinence. They are talkative and preoccupied and experience visual, tactile,
olfactory, and auditory hallucinations that often are terrifying.
36
Self Care
Study Guide 1.15

Environmental Health
Overview:
Environmental health is defined as freedom from illness or injury due to exposure to factors in
the physical environment that are potentially detrimental to human health. The physical
environment includes a set of factors beyond the individual’s choice or control that can have
either positive or negative effects on health. There are few major chronic diseases to which
environmental factors do not contribute. Environmental health is not a new specialty. Florence
Nightingale’s major focus was on the environment and the five essential indicators of health,
including pure air, light, cleanliness, pure water, and efficient drainage. Miss Nightingale felt
that the public needed to believe and practice these procedures in order to have healthy homes.
There is a growing awareness today of the direct relationship between health conditions and the
particular environment in which we live and work. For example, researchers have evidence that
tertogens in the environment cause cancer more than genetic defects do. Other related factors
include behavioral patterns, such as tobacco use, low-fiber diet, and excessive intake of
aspartame. It is also evident that the major causes of death in the U.S. (cardiovascular disease,
cancer, and stroke) are primarily the result of unhealthy lifestyle choices as related to the
environment in which we live. Through the community assessment, the nurse can detect
environmental exposures and potential environmental hazards in the home, workplace, and local
community.
Environmental Hazards Leading to Adverse Health Outcomes
• Naturally occurring: may be radon or ultraviolet light from the sun.

• Man-made hazards: include the particulates and gases released into the environment
from automotive exhaust, industrial sources, tobacco smoke, and chemical and biological
agents related to bio-terrorism).
o It is estimated that there are 72,000 chemicals currently used in commerce
(excluding food additives, drugs, cosmetics, and pesticides) and the majority of
these have had limited testing for effects on human health and the environment.
o A Superfund site is a hazardous waste site that poses a threat to public health and
the environment. These sites are determined by the U.S. Environmental
Protection Agency (EPA). More than 70 million people live within 4 miles of a
Superfund site, and approximately 4 million reside within 1 mile of a site.
• Exposure pathways: include contaminated air, water, soil, and food.
• Routes of exposure: include inhalation (dust or fumes), ingestion (pesticide residues on
fruits and vegetables), and dermal absorption (ultraviolet-B radiation from the sun or
direct skin contact with caustic household cleaners).
37
Classifying Hazards
• Chemical (e.g., lead, carbon monoxide, benzene, and vinyl chloride)

• Physical (e.g., noise, ionizing radiation, electromagnetic fields, and temperature
extremes)
• Biological (e.g., bacteria, parasites, viruses, and vectors)
• Mechanical (e.g., vibration, repetitive motion, and lifting)
• Psychological (e.g., violence, stress, and high-demand/low-control occupations)
Environmental Hazards in the Home
• Home safety can prevent the many deaths each year that result from accidents in the
home. The leading causes of accidental death in the home are falls, with the majority
involving persons older than 65 years, as well as the very young (under 4 years). Other
causes of accidental deaths include poisoning from drugs, alcohol, and household
chemicals (e.g., cleaning agents, gardening products); fires and burns; suffocation;
drowning, and firearm accidents.
• Death rates from poisoning are highest in the 25-44 age group, primarily from use of
drugs, such as cocaine, alcohol, and medications. Findings indicate that men and women
over 60 years are at greater risk of accidental poisoning from medications than are
younger persons. Children and toddlers are particularly susceptible to exposure to
poisons in household cleaning products and pesticides, lead-based products, and
poisonous houseplants due to crawling and hand-to-mouth activities.
• Burns are the third highest cause of home deaths. Deaths are highest among those
considered to be the most dependent: the very young and the very old.
• Drowning and near drowning that occurs in home swimming pools is most common for
children under 5 years of age.
• Firearm deaths can occur while people are playing with and cleaning firearms or from
domestic violence situations in the home. Death rates from accidental firearm deaths are
highest for the 15-24 age group.
• Household cleaning products, including cleaning agents, personal care products,
pesticides, paints, hobby products, and solvents, are sources of potentially harmful
chemicals. Contamination from household products can result from continued exposure
to the chemical or from the multiplying effect of using different products. Pesticides,
however, can produce toxic results with single use. Another pesticide product is
Naphthalene found in mothballs and some air fresheners (used in toilets and diaper pails),
which can cause damage to red blood cells. Many pesticides are now banned from home
use. Reducing pesticide exposure is one of the selected national objectives for Healthy
People 2010.
• Radon, a radioactive gas created by the breakdown of radium occurring naturally in the
soil and in many building materials, is one source of exposure to ionizing radiation.
Radon can be found in some well water and may be expelled into household air through
seepage from cracks in foundations, basement walls, or during showers and baths. After
inhalation, the radioactive particles can damage lung tissue and may result in lung cancer.
38
• Carbon monoxide exposure can cause anoxic injury and death. The nurse can educate
people about various ways to reduce accidental inhalation of this indoor pollutant,
including:
o Purchase a carbon monoxide detector for home use.
o Never use a combustion heater overnight while sleeping.
o Have appliances professionally installed and appropriately vented.
o Do not vent gas clothes dryer into the home for heating purposes.
o Never ignore the smell of gas in the home.
o Use a hooded fan if using a gas cooking range.
o Is using an unvented gas space heater in the home, be sure to open a window
and/or open the doors to the rest of the house.
o Do not allow a motor vehicle of any kind to run in a closed area, such as a garage.
• Asbestos consists of fibers of tiny, easily inhaled fibers and was used in building
materials and insulation prior to 1973 for its fire-resistant and indestructible qualities. If
inhaled or swallowed, asbestos fibers can cause asbestosis, leading to lung scarring,
breathing problems, and heart failure, which may not appear until 15-40 years later. The
spraying of asbestos-containing materials has been banned since the 1970’s, but homes
and buildings built before 1973 may contain asbestos laden products.
• Lead paint chips and pipes may be present in homes built before 1978 prior to lead-based
paint being prohibited for use. Lead may also be present in soil, water, and in the air.
Lead is a heavy metal that interferes with red blood cell production and may cause
damage to the brain, liver, and other vital organs. Typical symptoms of lead poisoning
include headache, irritability, weakness, abdominal pain, vomiting, and constipation.
Low-level exposure with blood levels of 10-25 mcg/dL can cause mental retardation.
Children absorb 50% of the lead they eat, drink, or breathe, whereas adults absorb only
10%. Children are more likely to come in contact with lead by eating paint chips and
playing in contaminated dirt. The most common sources of lead ingestion by children are
dust and soil contaminated with lead from paint that flaked or chalked with age. Other
sources are “take home” exposures related to parental occupations and hobbies.
Substandard nutrition also increases the absorption of lead. Lead in automobile exhaust
and industrial emissions is inhaled and contaminates the ground near busy freeways and
factories. Lead also remains in the soil for thousands of years. Mercury is another heavy
metal in which poisoning can occur from ingestion of paint chips used prior to 1991.
Arsenic is used in both pesticides and herbicides and contained in ant poisoning.
• Indoor air pollution can occur in new homes, as well. Formaldehyde, organic dust, and
fibrous glass particles can be released from new carpets or components of buildings and
furnishings. Cigarette smoke is the largest source of indoor air pollution and the major
cause of lung cancer and other respiratory illness. Second-hand tobacco smoke also
contains carcinogenic and toxic agents and has been shown to cause respiratory tract
infections, such as pneumonia, bronchitis, and new cases of asthma in preschool-age
children. Carbon monoxide poisoning from improperly ventilated furnaces, wood stoves,
and kerosene heaters results in more that 1500 deaths each year. There has been an
increase in indoor air contaminants since the 1970’s due to weathering of buildings and
decrease in air exchange. This also leads to mold, mildew, and fungal growth, which can
trigger respiratory illnesses and asthma, especially in younger children.
39
• Substandard housing (sick building syndrome) may lead to many health concerns. Poorly
ventilated and maintained homes lead to greater risk for accidents, lead paint exposure,
contamination from improper waste disposal, and episodes of asthma and allergies due to
exposure to insects, rodents, and pesticides. Four of the Healthy People 2010 objectives
for environmental health involve reduction of substandard homes and increase in testing
for radon, lead-based paint, and sanitation.
Environmental Hazards in the Community
There are literally thousands of potential hazards in our environment.
Chemical Hazards:
• Chemicals come in a wide variety of forms (dusts, mists, vapors, and gases) and affect
almost every system in the body.
• The toxic effects are often subtle and persons suffering from exposures are often
misdiagnosed.
• Toxicology is the science that studies the harmful effects of chemicals on humans in the
ecosystem in which we live.
• The extent of biological damage produced by a chemical depends on two things: the
amount of the exposure (its’ “dose”) and the “response” of the person exposed. This is
called the dose-response of the person exposed. The higher the dose, the greater the
response. However, some people have hypersensitivities to certain chemicals and will
have responses at a much lower than the expected dosage response.
Chemical Poisons:
• Exposure to chemical poisons, such as formaldehyde in insulation, can cause increased
respiratory allergies. Other chemical poisons include insecticides, herbicides, fungicides,
and rodenticides, as well as, industrial chemicals.
• Lead can lead to behavior disorders, cognitive impairment, and neurological symptoms.
Lead contamination may occur from lead-based paint or plumbing installed prior to 1930,
which used pipes that contained lead. In newer plumbing, some of the faucets and
fittings still contain lead, and therefore, may be sources of potential lead exposure. EPA
recommendations to reduce lead in drinking water include:
o Allowing cold water to run for a brief time prior to drinking as a way to flush the
lead out of the pipes.
o Testing the water periodically for presence of lead and other metal contaminants.
o Purchasing bottled water if plumbing is known to contain lead fittings, faucets, or
pipes.
o Installing filtering devices for cooking, cleaning, and other general purposes.
o Using only cold water for consumption because hot water is more likely to
contain higher levels of lead.
• Pesticides are the insecticides, termicides, rodenticides, and fungicides, used for pest
control. Exposure to pesticides is a primary factor in the increased agricultural
production in the U.S. Poisoning can occur with a single exposure or with cumulative
exposures over time. Indirect pesticide exposure occurs through contamination of food
40
and water ingested by humans and animal sources of food. For example, even though
DDT has been banned since 1972 in the U.S., it can still be found in some imported foods
or from old supplies found in homes. DDT is absorbed in body fat and is found in
animals that consume treated vegetation. The DDT is thus concentrated in the body fat of
the animal that eventually serves as a food source for humans. It is estimated that eating
one fish taken from contaminated waters provides enough toxic exposure equivalent to
drinking 1,000 gallons of water from the same source. The results of pesticide exposure
can include liver disease, headaches, cancer, and birth defects. Pesticides are designed to
have a neurotoxic effect and damage the reproductive system of insects. These products
have not been fully tested on animals or humans. Some pesticides are prohibited for sale
to the general public although many people may still use old products in their homes.
Air Pollution:
• Chemicals and gaseous materials contribute to air pollution, occurring in both indoor and
outdoor or “ambient” air with many hazards to human health. Pollution of ambient air is
measured in terms of the Pollutant Standards Index (PSI). PSI ratings between 100 and
200 are considered “unhealthful,” ratings from 200-300 are “very unhealthful,” and levels
over 300 are “hazardous” to health.
• The two essential types of air pollution are the oxidizing atmosphere caused by
photochemical smog and the by-products of burning fossil fuels. The effect is ozone
depletion, which is linked to increases in skin cancer, cataracts, and dysfunction of the
immune system.
• Over 62% of the U.S. population lives in areas where the outdoor air did not meet EPA
standards for contaminants (nitrogen dioxide, ozone, carbon monoxide, sulfur dioxide,
particulates, and lead) during the previous 12 months.
• Even though vehicles produced today emit fewer hazardous and polluting substances than
in the past, the number of autos on U.S. roads has doubled from that of 20 years ago and
each vehicle spends more idle time in traffic. The fumes emitted from automobile
tailpipes are catalyzed by ultraviolet light to produce irritating oxidant compounds. The
burning of fossil fuels, such as coal and fuel oil, produces pollution from oxides of sulfur.
• Even though levels of emissions permissible by large industries are controlled under
Clean Air Act, contributions to air pollution are made by numerous small business (e.g.,
dry cleaning) and the use of nail polish remover, paints, aerosols, and other household
products that are not controlled.
• Pollutant emissions have a cumulative effect that can be compounded by geographic
features. In some parts of the country, barriers to air movement compound the pollutants
(e.g., nearby mountains). When pollutants interact with sunlight, they produce
photochemical smog. The air pollutants contribute to erosion and decay of organic and
inorganic structures. They harm crops and other vegetation. Additionally, heavy air
pollution can cause changes in climate through the “greenhouse effect.”
• Acid rain is produced by air pollution that contributes to both ground water and surface
water supplies. Acid rain enhances leaching of a variety of compounds from the soil and
solid waste disposal sites and from lead and copper pipes.
• Indoor air pollution is particularly serious since most people spend 90% of their time
indoors and pollution tends to be most severe in newer buildings that were designed, for
reasons of conservation, to reduce air exchange with the outdoors. Buildings tend to have
41
more closed windows; decreased natural light; decreased air exchange, and increased
chance of mold, mildew, and fungal growth.
• Health effects of air pollution include allergy and asthma symptoms; nose, throat, and eye
irritation; fatigue; headache; heart disease; central nervous system damage, and a variety
of cancers. Mortality related to air pollution generally occurs in the elderly and those
with chronic respiratory diseases.
• Air pollution can also result in increased nonfatal respiratory illness, particularly in
vulnerable populations, such as children and the elderly. Incidence of childhood asthma
has risen 300% for some age groups and is likely related in part to chemical pollutants in
the air.
Water Pollution
• Only 2.5% of the earth’s water is fresh water and two thirds of that amount comprises
glaciers and polar ice caps, leaving less than 1% of the earth’s water for human
consumption. With increased world population, water consumption increases each year.
Healthy People 2010 objectives involve safe drinking water and the prevention of
waterborne diseases.
• Despite the advances made in the purification of public water in the last century, water
contamination remains a threat to some rural and suburban communities. With
increasing populations, there is a greater likelihood that major water supplies may be
threatened in the future.
• Three main sources of water contamination are industrial waste, sewage, and agricultural
chemicals. Examples of industrial waste include oil and chemical spills into waterways
from manufacturing industries, mining industries, and underground chemical storage
facilities. Sewage contaminants include human waste, sewage sludge, and faulty septic
tanks. Agricultural contaminants can include pesticide and herbicide runoff into local
waterways and aquifers. Local communities may contribute to chemical contamination
by use of salt and de-icing chemicals on streets and highways. It is estimated that 50% of
all large public water systems in the U.S. are not evaluated to assure that pesticide or
sewage runoff does not enter drinking water.
• Four of the Healthy People 2010 National Objectives for environmental health relate to
safe water quality.
• Toxic contamination of fish and seafood is a concern, as 25% of all rivers, lakes, and
streams in the U.S. cannot support beneficial uses, including fishing and swimming, due
to widespread pollution. Disadvantaged populations who consume larger quantities of
contaminated fish caught in local waters experience greater burdens of exposure than
members of other socioeconomic groups did.
• Soil serves as a receptacle for many of the pollutants that are deposited from the air or
water. Radioactive matter that disperses into the environment eventually falls to the
ground and settles in the soil. Hazardous waste dumps that contaminate soil have been an
ongoing and increasing problem.
• Health effects of water pollution include bladder and colorectal cancers, central nervous
system effects, skin irritation, alopecia, seizures, hepatitis, infertility, congenital
anomalies, developmental disabilities, anemia, renal failure, gastritis, stomach cancers,
and heart disease.
42
Hazardous Wastes:
• Hazardous waste is any material that is of no further use and cannot be disposed of
safely, but is allowed to enter the environment in its original form in an uncontrolled
manner.
• These wastes include infectious wastes, agricultural and industrial by-products,
radioactive substances, flammable products, and chemical agents.
• Hospitals are now considered a “smokestack industry” and there is concern about the
volume of hazardous medical waste that they produce. Hospitals, medical offices, and
laboratories must dispose of hazardous wastes separately from regular solid waste. Many
of the waste products are made of polyvinyl chloride or PVC. Dioxin is one chemical
emitted when PVC plastics are incinerated. Burning PVC releases dioxin, which has
been shown to be carcinogenic. Two thirds of the medical waste incinerators in the U.S.
have no pollution control devices.
Physical Hazards
• Physical hazards in the community include accidents as the leading cause of death among
persons aged 1-37 years. Motor vehicles are by far the single most common cause of
these deaths. Falls, drowning, and burns are responsible for the majority of non-motor
vehicle deaths. Most of these deaths are preventable with seat belt use, adherence to
speed limits, and avoidance of drinking and driving.
• Two types of radiation can be health hazards: ionizing radiation and non-ionizing
radiation. Ionizing radiation is the transfer of energy through electromagnetic fields
produced when atoms disintegrate. Sources of ionizing radiation include x-ray machines,
cosmic rays, uranium and other minerals, radon, nuclear power plants, and atomic fallout.
Non-ionizing radiation is a lower energy form of radiation and transfers energy into heat.
Examples include microwaves, television and radio waves, electromagnetic fields;
infrared sources, ultraviolet radiation in sunlamps or sunlight, video display terminals,
and lasers. Excessive and prolonged exposure to radiation can cause mutagenic and
tertogenic effects. Of particular concern is the high incidence of skin cancers, malignant
melanoma, and burns resulting from overexposure to ultraviolet radiation.
• Noise is a physical hazard that has received increased attention in recent years since the
long-term effects from exposure can be devastating. Some consider noise to be a noxious
and pervasive pollutant in our environment. Health effects include increased anxiety,
emotional stress, insomnia, skin problems, heart trouble, hypertension, drug use,
depression, and diminished work productivity. Hearing loss due to noise exposure is a
serious problem in industry. OSHA standards require sound levels in the workplace not
to exceed 90 dB. Some communities are passing ordinances that set limits or decibel
levels in certain neighborhoods.
43
Biological Hazards
• Infectious disease is spread through the environment from common sources such as
water, direct contact, air, food, and animal sources.
• Water is a primary means for environmental transmission of infectious agents. Most
waterborne outbreaks are caused by infectious agents, such as Cryptosporidium or
Giardia Iamblia, Salmonella, and Campylobacter. These agents attack the lower
intestinal tract with persistent diarrhea. Many rural communities not connected to safe
central water systems or municipal water supplies may be threatened. Chlorination, the
most widely used mode of water treatment in the U.S., is not effective against newer
pathogens such as Giardia Iamblia.
• Contamination of drinking water supplies can occur from improper sewage treatment and
improper solid waste disposal. Communities not connected to safe central water systems
or municipal water supplies may be threatened. Approximately 30% of the population
uses septic tanks to dispose of wastes and 3-5 billion gallons of human waste are
introduced into the soil and groundwater each day. Disposable diapers (used by 80% of
households using diapers) are a major concern for human waste disposal.
• Biological contamination can occur when solid waste is improperly handled. Rainwater
is contaminated with bacteria, viruses, and other disease-producing microorganisms.
• Pathogens can also be found in food. Death and millions of cases of illness may be
attributed to contaminated food each year. The most common contributor to food-borne
disease is Salmonella (found in undercooked eggs and chicken) and is most often found
in the elderly, young children, and persons with immunosuppression.
• Vector-borne diseases can be spread by flies, mosquitoes (West Nile Disease introduced
in the U.S.), cockroaches, ticks, and rodents. Improper solid waste disposal can provide a
breeding ground for insect and animal vectors. One example of vector-borne disease is
Lyme disease, which is caused by a spirochete and transmitted by an infected tick.
• Animals also can present health hazards when additives to animal feed (e.g., antibiotics,
hormones, and steroids) are still contained in the meat consumed by humans. Wild
animals, such as skunks, foxes, bats, coyotes, bobcats, and raccoons, can increase the
potential for transmission of rabies to humans. Large numbers of un-immunized
domestic animals (e.g., cats and dogs) also present a health hazard. Animals and fish
may contain contaminants, such as dioxin, that appear in our meats and baby food.
• Plants can pose biological health hazards. Pollen, mold, and fungi may trigger allergic
responses and poison ivy and poison oak may produce severe dermatologic symptoms.
Some household plants, such as poinsettias, can be toxic if children or pets chew the
leaves.
• Human feces can be a source of infectious organisms: The most common parasite is the
roundworm (ascaris). It is prevalent in warm areas with poor sanitation. This can lead to
intestinal obstruction caused by a bolus of worms. Daycare settings are areas of high risk
for respiratory and enteric diseases due to the number of children in diapers, along with
children’s natural tendency to put objects in their mouths. Nurses can emphasize the
importance of hand washing, safe drinking water supply, and adequate treatment of
infected individuals to prevent the spread of disease.
44
Psychological Hazards
• Psychological factors and stress have a profound effect on the health and well being of
our communities, but it is much more difficult to measure and identify the relationship
between illness and psychological factors. Societal stresses that can affect the well being
of the population include crime, poor economic conditions, rising unemployment,
multiple role demands, and keeping up with the rapidly changing technological
developments.
• Environmentally induced stress is a natural by-product of our fast-paced society and is
also the result of natural and man-made disasters, such as earthquakes, hurricanes, floods,
droughts, and volcanoes, forest fires, and human threats to national safety.
• If coping mechanisms are in place, stress can have positive outcomes. However, if
stressors are overwhelming, the health of the individual or the community can be severely
affected. Depression, ulcers, hypertension, and heart disease have all been linked to
increased stress levels. Clients may be referred to local mental health centers to assist in
managing their stress and preparing for man-made and natural disasters.
• Violence-related environmental health problems can arise from conditions such as
extreme poverty, widespread unemployment, proliferation of handguns, pervasive media
images of violence, high rates of homicide, and increasing incidence of hate crimes.
Communities face concerns about how to curtail violence in their environments. Nurses
can provide prevention programs that focus on anger management and copy strategies
with children and adolescents.
Occupational Health Hazards
• Working conditions and exposures pose many health hazards and risks for potential
injury and illness. More than 20 million work-related injuries and 400,000 new work-
related diseases occur each year. The three industries with the highest rates of trauma to
workers are mining, construction, and agriculture.
• Environmental health problems at work sites include occupational toxic poisoning,
machine-operating hazards, repetitive motion injuries, and sexual harassment. Pollutants
in work sites include carcinogenic particulate inhalants (e.g., asbestos), dust pollutants
(e.g., dust), and heavy metal poisoning. The most frequent work-related illnesses and
injuries are lung disease, musculoskeletal and repetitive motion injuries, cancer, and
traumatic injury.
• Prevention efforts by nurses include risk reduction, elimination of hazardous exposures,
and occupational safety and health programs.
45
Environmental Hazards and Global and Ecological Issues
• Deforestation:
o Deforestation refers to loss of the earth’s crown cover of trees to less than 10%.
This involves cutting or burning trees and may eliminate natural habitats for
plants and animals and contribute to soil erosion and climatic changes.
o Deforestation contributes to global warming through the release of greenhouse
gases that trap heat close to the earth. So far, one-third to one half of the earth’s
forests have already transformed by human activity.
• Global Warming:
o Global warming is an overall increase in temperature throughout the world. One
contributing factor is the greenhouse effect in which gases from the use of fossil
fuels collect in the atmosphere and reflect heat back to the earth, rather than
letting it dissipate. This has increased the atmospheric concentration of carbon
dioxide and increased the earth’s energy absorption.
o Increasing warmth leads to increased growth rates of insects and parasites, crop
destruction, and infectious disease. It also results in the melting of the polar ice
caps and rising sea levels, escalating dangers of flood for some island areas.
Increasing temperature and humidity can also lead to heat-related mortality.
• Ozone Depletion:
o Air pollution and chlorofluorocarbons (CFC’s) interact with and destroy the
filtering function of the layer of ozone.
o Without the ozone layer, skin cancers will increase, as well as, global warming.
• Planetary Toxification:
o Planetary toxification refers to the accumulation and environmental effects of a
variety of wastes on the planet. An average of 217 tons of solid waste is
generated annually in the U.S., amounting to 4.4 pounds per person per day.
o Solid waste consists of paper, glass, metal, and plastic products; rubber and
leather; textiles, and food and yard wastes.
o Liquid wastes present hazards primarily through sewage. Only two-thirds of U.S.
households are connected to municipal sewage treatment systems. The remaining
third of residences use septic systems, which may lead to contamination of ground
water sources of fresh water sources if the septic system is malfunctioning. Other
liquid wastes from agricultural runoff and industrial waste pose potential health
hazards.
o Hazardous and toxic wastes are generated by chemical and metal-related
industries and those producing and using petroleum and coal products. Industries
release over 2 billion pounds of toxic chemicals each year.
o Solid, liquid, and toxic wastes lead to health problems such as cancers, heavy
metal poisoning, and infectious disease.
46
• Overpopulation:
o The world’s population continues to increase rapidly in spite of efforts for zero
population growth.
o Population growth is expected to result in water shortages in many parts of the
world.
o Social effects of urban crowding include growing unemployment, insufficient
housing, poverty, and political unrest.
o Ecological effects of population growth include continued overgrazing, soil
erosion, and deforestation.
• Vulnerable Populations:
o Individuals vary widely in their susceptibility to adverse health effects following
exposure to toxic substances.
o Personal characteristics such as age, gender, weight, skin tone, genetic
composition, nutritional status, physiologic status (including pregnancy and
behavior and lifestyle factors), may affect human responses to environmental
conditions.
o Elderly populations are at risk for environmental health hazards due to decreasing
function or cardiac, renal, pulmonary, and immune system processes. They may
have impaired host defenses, impaired immune system function, and changes in
their ability to detoxify chemicals. There is a decline in the elderly of metabolic
clearance of certain drugs and deceased ability to detoxify and eliminate toxic
substances from the body.
o Children are especially susceptible to environmental hazards. They have a higher
basal metabolic rate for absorption and metabolism of toxicants. Children have a
lower breathing zone, which is closer to the floor, where dust, dirt, and toxic
chemicals, such as lead, are deposited. They are more susceptible to genetic
alterations associated with chemical exposures. The normal hand-to-mouth
activity of toddlers increases the likelihood of exposure through ingestion of toxic
substances. Nurses caring for children in any setting, including inpatient pediatric
unites, well-child clinics, home health agencies, and prenatal health centers, need
to be able to detect and prevent adverse environmental exposures in children.
o Pregnant women are at increased risk for health hazards of environmental
exposures. During the first trimester, the unborn child is extremely vulnerable to
teratogenic and developmental defects.
o Those with immuno-compromised systems and lowered immunity, as well as
those with chronic disease, are more susceptible to adverse environmental
exposures.
Environmental Health Assessment
Assessment is the first step in addressing environmental health problems and the factors that may
increase the risk or severity of the health effects of environmental conditions.
• Assess the existing genetic and physiologic conditions that may increase the potential of
health effects of environmental factors.
47
• Community health nurses assess individual clients, as well as population groups, for
evidence of environmentally caused disease.
• Occupational health nurses should assess the potential for occupational exposure to
hazardous environmental conditions posed by local occupations and industries.
• Assess the population’s personal lifestyle behaviors what may interact with the physical
environment, such as smoking, potential lead exposure in the home, and recreational
activities that pose hazards.
Key Questions for Environmental Health History

• Housing: What are the location, age, and physical condition of residence, school,
daycare, or work site? Are lighting, ventilation, and heating/cooling systems adequate?
• What are the occupations of household members: current and past, longest held job?
• Is tobacco smoke present?
• Are there any recent home remodeling activities? Have you recently installed new
carpet, furniture, or re-finished furniture?
• List all hobbies done in the home.
• Is there any other recent exposure to chemicals or radiation?
• Are pets present in the home and are they healthy?
• Has there been any lead exposure to old paint, crafts, leaded pottery, or dishes?
• What is the source and quality of their drinking water?
• How is sewage and waste disposed of in the home?
• Do you use pesticides around your home or garden? Is there any evidence of mold or
fungi?
• Where do children play? Are there any hazardous play equipment or toys?
• Does the surrounding neighborhood present any hazards with closeness to highways,
small businesses such as dry cleaning, photo processing, and industry and auto repair?
Environmental Health Priorities

• Birth Defects
• Cancer
• Immune Function Disorders
• Kidney and Liver Dysfunction
• Lung and Respiratory Diseases
• Neurotoxic Disorders
Types of Prevention
• Primary prevention:
o Is the most common intervention for environmental health.
o Involves health promotion and illness prevention in the home, at work, school,
and in the community.
o Uses nursing strategies that focus on modifying origins of the problem.
o Focuses on teaching individuals and populations to use protective and safety
devices.
o Focuses on teaching individuals and populations to reduce environmental hazards.
48
o Examples of primary prevention for environmental health:

 Teach home safety related to falls, fire prevention, poisonings, burns, and
firearms safety.
 Advocate safety devices, such as seat belts, car seats, and bicycle helmets.
 Encourage opening doors and windows to permit air exchange.
 Implement health and a safety programs at work sites and schools.
 Educate school children and adolescents to use healthy coping strategies
and anger management techniques for violence prevention.
 Counsel women of childbearing age regarding exposure to environmental
hazards.
 Advocate for safe air and water.
 Teach avoidance of ultraviolet exposure and use of sunscreen.
 Support programs for waste reduction and recycling.
 Advocate for waste reduction and effective waste management.
• Secondary prevention:
o Focuses on signs and symptoms of environmental exposures.
o Assesses all clients for environmental risk.
o Involves surveillance for health conditions that may be related to environmental
and occupational exposures.
o Involves screening, reporting of disease, follow-up and interventions in the
community.
o Includes data collection, analysis, interpretation, and dissemination of findings.
o Examples of secondary prevention:
 Assess homes, schools, work sites, and the community for environmental
hazards.
 Obtain environmental health histories for individuals.
 Screen children 6 months to 5 years old for blood lead levels.
 Monitor workers for levels of chemical exposures at job sites.
 Screen at-risk workers for hearing loss, lung disease, and cancer.
 Participate in data collection regarding incidence and prevalence of injury
and disability in homes, schools, and work sites.
• Tertiary prevention:
o Occurs after the disease has been diagnosed.
o Aims at minimizing disability and maximizing functional capacity.
o Assists individuals or community to adapt to changes resulting from the illness.
o Involves becoming active in consumer and health-related organizations and
legislation related to environmental health issues.
o Includes networking with others who share the same interests.
o Examples of tertiary prevention:
 Support cleanup of toxic waste sites and removal of other hazards.
 Refer homeowners to lead abatement resources.
 Become involved with such organizations as The American Heart
Association, The American Cancer Association and participate in local
and community action groups.
49
50
Self Care
Study Guide 1.16

Critical Thinking Activity – Environmental Health
Situation:
A female infant born weighing 8 pounds appeared healthy during her first month at home.
However, she became ill at 3 weeks of age and developed diarrhea and vomiting after feeding.
She was hospitalized at 6 weeks of age for treatment of vomiting, failure to thrive, and
dehydration. She weighed 6 pounds, 10 ounces with no other signs of infection. The family
began to use bottled water to dilute the formula and the symptoms did not recur. The family’s
home sits on a riverbank near 100 acres of corn and alfalfa. Water was supplied by a shallow,
28-foot well. Water samples from the well were analyzed and found to contain excess amounts
of nitrates, and samples from the kitchen faucet were found to contain excess levels of copper.
• What environmental hazards are present in this situation? What health effects, if any, are
these hazards causing?
• What levels of prevention can be applied to this situation?
Situation:
A 6-year-old girl who lives in an economically depressed neighborhood in a large urban city
comes into the community health clinic complaining of weakness, emaciation, loss of hair,
constant nosebleeds, and falls down frequently. Her lead level was found to be 7 times as high
as that needed to cause impairment of intelligence. She was given painful and risky intravenous
treatment with chelating agents over a period of one year and most of her symptoms have
cleared. The concentration of lead in the soil was found to be above the 500-1000 parts per
million sufficient to cause dangerous high blood levels of lead in children. Her mother is
concerned that the area is not being cleaned up and that as people move in and out, the poison
still remains.
• What environmental hazards are present and what health effects are these hazards
causing?
• What levels of prevention can be applied in this situation?
51
Critical Thinking Exercise - Environmental Health – Answer Key
Situation:
A female infant born weighing 8 pounds appeared healthy during her first month at home.
However, she became ill at 3 weeks of age and developed diarrhea and vomiting after feeding.
She was hospitalized at 6 weeks of age for treatment of vomiting, failure to thrive, and
dehydration. She weighed 6 pounds, 10 ounces with no other signs of infection. The family
began to use bottled water to dilute the formula and the symptoms did not recur. The family’s
home sits on a riverbank near 100 acres of corn and alfalfa. Water was supplied by a shallow,
28-foot well. Water samples from the well were analyzed and found to contain excess amounts
of nitrates, and samples from the kitchen faucet were found to contain excess levels of copper.
• What environmental hazards are present in this situation? What health effects, if any, are
these hazards causing?
o Chemical poisons (copper from the kitchen pipes and nitrite in the drinking water)
and possible biological organisms. Health effects are diarrhea, vomiting, weight
loss, failure to thrive, and dehydration.
• What levels of prevention can be applied to this situation?

o Primary Prevention: At birth, nurses in the inpatient setting could provide
teaching and discharge planning to include a health history of any known
environmental risks. This teaching could also be provided in an outpatient setting
for well-child and acute illness care. At this point, primary prevention strategies
could eliminate environmental health risks by teaching appropriate procedures for
handling food and water to prevent gastrointestinal problems. This could include
information on the possible sources and routes of contamination of food and water
and how to recognize signs and symptoms of illness that require early medical
attention.
o Secondary Prevention: When symptoms developed at three weeks of age, an
environmental health history should be completed. The exposure history may
have identified the environmental health risks. Secondary prevention strategies
could focus on protection of the infant and other family members from possible
continued exposure and parent education. Knowing that private wells, especially
in rural areas, may be contaminated with a variety of chemicals such as pesticides,
nitrites, and bacteria, a referral to the local health department could be made for
further investigation of the home situation. The public health nurse could
schedule a home visit to investigate the possible sources of water pollution. Since
the home sits on a riverbank near 100 acres of corn and alfalfa, the nurse knew
that fertilizers are one of the most common causes of nitrite contamination of
drinking water.
52
o Tertiary Prevention: During the home visit, the nurse could advise the family of
the hazards and ways to avoid further illness. The family should refrain from
ingesting the water and use bottled water for drinking and food preparation since
nitrates were the contaminant. Private wells should be tested annually for nitrate
contamination. The nurse could also assist the family in seeking long-term
solutions such as digging a deeper well or gaining access to a community water
supply. The nurse can also be sure that the EPA is aware of the situation to
control a problem that could threaten the safety of the surrounding community.
Additionally, the nurse could get information to the community of health risks
and ways to protect themselves.
Situation:
A 6-year-old girl who lives in an economically depressed neighborhood in a large urban city
comes into the community health clinic complaining of weakness, emaciation, loss of hair,
constant nosebleeds, and falls down frequently. Her lead level was found to be 7 times as high
as that needed to cause impairment of intelligence. She was given painful and risky intravenous
treatment with chelating agents over a period of one year and most of her symptoms have
cleared. The concentration of lead in the soil was found to be above the 500-1000 parts per
million sufficient to cause dangerous high blood levels of lead in children. Her mother is
concerned that the area is not being cleaned up and that as people move in and out, the poison
still remains.
• What environmental hazards are present and what health effects are these hazards
causing?
o High lead levels and substandard housing conditions could cause the changes in
cognition, growth and development, irritability, nosebleeds, and probably learning
levels. These problems, along with malnutrition, may have existed for many
months if she resided in similar substandard home conditions. Continued
exposure to high lead levels can lead to hearing loss, learning disabilities, and
central nervous system and renal disturbances.
• What levels of prevention can be applied in this situation?

o Primary Prevention: When the child was seen for well child visits in outpatient
settings, education could have been done to make parents aware of possible
sources and routes of lead contamination to include soil; particles from steel
structures, gasoline fumes, and dusts; water from lead pipes, and food from lead
containers and pottery. Parents could also be informed about how to recognize
the signs and symptoms of illness that require medical attention. This education
could also have been given to the parents if they used daycare or pre-school
facilities. The school nurse at the elementary school could present information on
lead poisoning as well as any home visitors she may have had during her first 12
months such as with Healthy Start program.
53
o Secondary Prevention: The CDC recommends lead screening for all children at
9-12 months of age and then annually. This could have been done at the
outpatient setting she may have visited. Routine lead screening may not be
enforced in her community. If detected at an earlier age, she may not have the
debilitating condition and symptoms. All family members should also be
screened and treated, if indicated. Referrals to the local health department can be
made for further investigation. An environmental health history could have been
completed to determine the level of risk from environmental hazards. Many
inner-city neighborhoods are situated near numerous freeways, railways, and
industrial yards. Economically depressed neighborhoods often consist of older
homes with crumbling lead paint, old lead pipes, and unsafe play areas consisting
of contaminated dirt. Heads of households may work in nearby industries or
small businesses such as automobile repair shops, scrap metal yards, or battery
manufacturing plants. Lead dust may be carried home on clothing or shoes. The
nurse could schedule a home visit to complete the environmental health screening
and investigate possible sources of lead contamination from home, neighborhood,
and family occupations. Considerations need to be made regarding cultural and
language barriers and use of interpreters, if necessary.
o Tertiary Prevention: During the home visit, the nurse could advise the family of
the hazards and ways to avoid further illness since children can be re-poisoned
after treatment. Routine annual screening should be advised. Long term solutions
of this serious community health problem (such as removing the contaminated top
soil and replacing with good soil) can be brought to the attention of and addressed
by neighborhood leaders, government officials, church leaders, local parent-
Teacher Association, and State child health programs. Nurses can generate
involvement, participate in meetings, and report on potential actions.
54
Fundamentals
55
2 2 Module 2 – Health Promotion

Study Guide 2.1
Health Promotion – Healthy People 2010
Health promotion is an important component of nursing practice. It is a way of thinking that

revolves around a philosophy of wholeness, wellness, and well-being. In the past two decades,
the public has become increasingly aware of and interested in health promotion. Many people
are aware of the relationship between lifestyle and illness and are developing health-promoting
habits, such as getting adequate exercise, rest, and relaxation; maintaining good nutrition; and
controlling the use of tobacco, alcohol, and other drugs.
The vision of health promotion was expressed in 1979 with the surgeon general’s report Healthy
People, which emphasized health promotion and disease prevention. Healthy People 2000
followed in 1990 and provided a framework for national health promotion, health protection, and
preventive service strategy (U.S. Department of Health and Human Services (USDHHS), 1990).
Healthy People 2010: Understanding and Improving Health (USDHHS, 2000) presents a
comprehensive 10-year strategy for promoting health and preventing illness, disability, and
premature death. The two major goals of Healthy People 2010 reflect the nation’s changing
demographics:
• “Increase quality and years of healthy life” indicates the aging or “graying” of the
population.
• “Eliminate health disparities” reflects the diversity of the population.
The 28 focus areas in Healthy People 2020:

• Access to quality health services
• Arthritis, osteoporosis, and chronic back conditions
• Cancer
• Chronic kidney disease
• Diabetes
• Disability and secondary conditions
• Educational and community-based programs
• Environmental health
• Family planning
• Food safety
• Health communication
• Heart disease and stroke
• HIV
• Immunization and infectious diseases
• Injury and violence prevention
• Maternal, infant, and child health
• Medical product safety
• Mental health and mental disorders
• Nutrition and overweight
• Occupational safety and health
56
• Oral health
• Physical activity and fitness
• Public health infrastructure
• Respiratory disease
• Sexually transmitted diseases
• Substance abuse
• Tobacco use
• Vision and hearing
Note: From Healthy People 2010: Understanding and Improving Health, 2nd ed., by U.S.
Department of Health and Human Services, 2000, Washington, DC: U.S. Government Printing
Office.
57
Module 2 – Health Promotion

Study Guide 2.2
Health Promotion and Disease Prevention
Overview: Health promotion and disease prevention are vital to containing health care costs.
With the first Healthy People document (1980-1990), the U.S. public health care goals changed
to health promotion and disease prevention from a focus on treatment and cure. Healthy People
2000 and now, Healthy People 2010 continue to focus on health promotion and disease
prevention. These activities utilize a cooperative effort of the individual, community (e.g.,
schools, employers, religious organizations), government, and health care professionals to
educate and motivate the public to adopt health-promoting behaviors and maintain or attain their
highest level of wellness. Primary prevention consists of health promotion and disease
prevention. Secondary prevention involves restoration of health, early diagnosis, and treatment.
Rehabilitation includes limiting further disability and maximizing the client’s potential, which is
considered tertiary prevention.
• Primary Prevention: is prevention of the initial occurrence of a disease or injury (e.g.,

immunizations, family planning environmental protection, fitness classes).
• Secondary Prevention: includes early detection of disease or disability, prevention or
limitation of disability, and diagnosis and treatment (e.g., blood pressure screenings,
hearing and vision screening, pregnancy testing).
• Tertiary Prevention: is care after disease or disability has occurred to prevent further
disease progression and assist an individual to their maximum potential in spite of the
illness or injury (e.g., long term care, rehabilitation).
Terms
• Health habits are the activities and behaviors of an individual that could affect one’s
health, positively or negatively. The health care professional should include an
assessment of health habits in the full health assessment (e.g., history of dietary intake,
seatbelt use, immunization record, alcohol use, tobacco use, exercise).
• Health risks are activities, behaviors, exposures, or lack of activities that put an individual
at risk for an illness, injury, or premature death (e.g., unprotected sex; not using seat
belts; lack of immunizations; lack of prenatal care, and use of alcohol, tobacco, or drugs).
• Screening programs are an integral part of primary and secondary preventative measures
to detect individuals with risk for disease and to identify those in the early stages. The
goal of screening is early identification, which decreases or eliminates the level of
disability and the costs of health care. There are two basic types of screening programs:
o Single screening test where only one condition is being targeted (e.g., TB skin
tests, blood pressure screening).
o Multi-phasic screening tests where several tests are done at once to detect more
than one problem (e.g., health fairs where each individual is offered height,
weight, blood glucose, vision, and blood pressure screenings at one time).
58
Screening
Screening programs are designed based on the following principles:

• Screening for a condition that is an important health problem affecting a large percentage
of the population.
• The natural history of the condition should be understood.
• The condition should have an early or latent detection period.
• The condition should have an accepted treatment to improve the health and quality of life
for the client with the recognized disease.
• The screening test should be acceptable to the clients.
• The screening test should be effective in detecting the disease earlier than without
screening.
• Health care, as well as, treatment of the condition, should be available to those diagnosed.
• The cost of diagnosing and treating the condition should be considered relative to
medical care costs as a whole.
• The screening should be an ongoing process.
Some Types of Health Promotion Interventions

• Education/information: increases knowledge level
• Services: increases access to needed health care services.
• Technological: use of scientific methods to protect and promote health.
• Legislative/regulatory: laws that mandate behaviors and conditions that enhance
behaviors or conditions.
• Economic: use of financial incentives and penalties to motivate healthy behaviors.
Primary Prevention
Primary prevention is the prevention of the initial occurrence of disease or injury. Primary
prevention is directed toward well people. It may include education for healthy living and
promotion of activities and favorable conditions for wellness. Examples include:
Activity Goal
Immunization Clinics Prevention of communicable diseases

Smoking Cessation Prevention of lung and heart disease and cancer
Tobacco Chewing Prevention Prevention of cancer of the mouth, tongue and throat
Sex Education, use of condoms Prevention of AIDS and other STD’s
Use of infant seats and seat belts Prevention of serious injury and death in car accidents
Primary prevention may include the following activities for each group:
• Individual
o Sexual education
o Family planning education
o Dietary teaching and exercise
o Programs for weight loss
59
o Substance-abuse prevention activities

• Family
o Infection control measures or education
• Group
o Prenatal classes
o Sexuality education about AIDS, STD’s
• Community
o Fluoride in water
o Environmental clean-up
Primary prevention in ambulatory health care occurs when a nurse provides information to
families on matters such as the proper use of infant seats, child restraints, and use of helmets
when bicycling, skating, or skateboarding. Primary prevention occurs when the school nurse
communicates with families regarding exposure to, and decreasing the risk of acquiring
communicable diseases. Teaching in these settings may be to an individual or group. Other
topics may include weight management, stress reduction, exercise awareness, family planning, or
prenatal teaching. The occupational setting provides primary prevention for injury prevention
education, hearing conservation programs, and use of personal protective equipment. The home
health nurse generally provides secondary or tertiary prevention, but has the opportunity to offer
primary prevention by asking about immunizations of the family members and their access to
affordable health care.
Secondary Prevention
Secondary prevention is the early detection and treatment of disease or injury and to limit
disability. This level includes identifying health needs, health problems, and individuals at
increased risk of disease or injury. Secondary prevention may include:
Activity Goal
Testicular Self-exam Early identification and treatment of testicular cancer

Blood Pressure Screening Early identification and treatment of hypertension to
prevent stokes and heart disease
Breast Self-exam Early identification and treatment of breast cancer
Annual Pap Smears Early identification and treatment of cervical cancer
Lipid Levels Early identification and treatment of hypercholesterolemia
Secondary prevention may include the following activities for each group:
• Individual:
o Counseling and HIV Test
o Early prenatal care
o Screening for early detection of diabetes
• Family:
o TB screening for families at risk
• Group:
60
o Vision screening for first-graders

o Hearing screening at senior centers
• Community:
o Health fairs
o Lead screening of seniors
Secondary prevention involves informing clients about the availability of various community
health screening programs (e.g., lipid screening, glaucoma screening, blood pressure screening,
Pap tests). The community nurse can identify individuals at risk for disease and provide
information regarding community resources. The home health nurse can involve family
members to assist in management of treatment for individuals with illness or injury. The home
health nurse can also identify risks within the home and educate the client about ways to reduce
or eliminate the risk for further disease or injury.
Tertiary Prevention
Tertiary prevention maximizes recovery after an injury or illness. Rehabilitation is the major
care component of tertiary prevention. Tertiary prevention may include:
Activity Goal
Counseling, low-sodium diet, exercise Minimize the effects of hypertension (HTN)

for management of HTN
Exercise and speech therapy after a Restore function and limit disability
cerebral vascular accident
Direct nursing care for a chronic Minimize sequelae and decrease disability
health condition
Tertiary prevention may include the following activities for each group:
• Individual
o Nutrition teaching for HIV/AIDS clients to maximize health
o Foot care teaching for diabetic
• Family:
o Teaching family caregiver how to follow sterile procedure for a dressing change
o Support groups for parents with LBW infants
• Group:
o Support groups for children with asthma
o Swim therapy for disabled
• Community:
o Shelter or relocation for victims of natural disasters
o Programs to assist children with developmental delays from lead exposure
In the ambulatory care setting, the nurse often provides information about community resources
for those with chronic disease or disability. The clinic may also provide direct care (e.g.,
dressing changes, splinting, intravenous infusions). Both of these activities are examples of
61
tertiary care. In schools, families learn about community services for children with chronic
illnesses, such as diabetes, asthma, and cystic fibrosis. Some schools provide caregivers,
laboratory testing, and direct nursing care (e.g., urinary catheterization, assistance with
mechanical ventilation, use of insulin pump) to children with chronic illnesses. In the
occupational setting, the nurse may facilitate the return to work programs for those with recent or
chronic illness or injury to maximize their potential in the workplace. Much of home health care
is provided to those with chronic conditions and includes a majority of tertiary prevention
regarding that condition. Teaching in home health care settings will include rehabilitative and
restorative care for conditions, such as stroke, head injury, hip fracture, and surgery.
62
Fundamentals
63
3 3 Module 3 – Introduction to Nursing and Basic Nursing Skills

Study Guide 3.1
Caring
The concept of caring is not new to nursing. Since 1875, the obligation to care has defined the
distinctive art of the American nurse. Nurses care for and about people. Caring may be
interpreted as “liking” or having an attraction for another person. The task of caring for a total
sick “stranger” may seem a bit difficult for some nursing students to comprehend, yet caring for
and about a client is a process that begins in the first semester and continues to evolve
throughout the nursing profession. Caring involves developing a relationship of mutual respect,
knowledge, trust, and courage.
Jean Watson, a nursing theorist, defines nursing as a human science and an art. Her theory and
philosophy of caring is based on the values of kindness, concern, love of self and others, and
respect for the spiritual dimensions of the person. Contrary to the medical model of “curing,”
Jean Watson states that the future of nursing belongs to “caring” more than “curing.”
M. Mayerhoff, another nurse theorist on caring, states:
“Though we sometimes speak as if caring did not require knowledge, as if caring for
someone, for example, were simply a matter of good intentions or warm regard….to care
for someone, I must know many things. I must know, for example, who the other is,
what his powers and limitations are, what his needs are, and what is conducive to his
growth; I must know how to respond to his needs and what my own powers and
limitations are.”
There are three distinctive methods of caring:
• Tangible Caring: When a nurse attends to the physical and environmental needs of the
client (i.e., administering a bed bath, medications, moves the slippers from the floor,
providing a safe environment, etc.).
• Emotional Caring: When the nurse attends to the psychological, social, and spiritual
needs of the client (i.e., touch, presence, verbal and nonverbal communication
techniques, empathy, limit-setting, and humor). The assessment, planning, interventions,
and evaluation of the client’s multiple emotional needs are all components of emotional
carrying.
• Informational Caring: When a nurse employs teaching, information-giving, health
promotion, resource allocation and communication, these are methods of information
caring.
64
It is the “emotional caring” that the psychosocial aspects are focused on. The nursing faculty
value caring. We see caring as a concept that can be learned, but not taught. We can teach you
how to pour medications adhering to the five rights and how to miter the corner of a bed sheet,
but we can’t teach you how to care about and for another human being. We also believe that we
need to love, respect, and care for ourselves with dignity before we can respect, love and care for
others and treat them with dignity.
Some behaviors indicative of caring may be described (but not limited to) as follows:
• Looking at and talking to clients of all ages. Showing patience and understanding to
clients of all ages and cultures.
• Beginning to identify and demonstrate advocacy role in the clinical facility.
• Avoiding unnecessary exposure of the body.
• Recognizing the need for privacy.
• Keeping client safe.
• Respecting client’s values and beliefs, incorporating spiritual needs in care.
• Caring for self with adequate diet, rest, play, and exercise.
• Beginning to utilize skills of assertion.
• Empathy to client’s and family’s suffering
• Respect and courtesy to staff, peers, faculty, and self.
Adapted with permission from Golden West College Associate Degree Nursing Program.
65
Module 3 – Introduction to Nursing and Basic Nursing Skills

Study Guide 3.2
Principles of Caring In Nursing
Communication
• One cannot NOT communicate.

• All behaviors are meaningful and purposeful and can be understood.
• All communication must be viewed within the context in which the context in which it
occurs.
• The need to communicate is universal.
• The satisfaction of many of our human needs comes though interacting with other
people.
• Both verbal and nonverbal communication modes are significant in maintaining
interaction with others.
• One must grow in self-awareness before one can learn to better understand others.
• Words that have different connotative meanings can be easily misinterpreted by the
person receiving the message.
Self-Concept
• Self-concept is the composite of beliefs and feelings that one holds about oneself at a
given time, formed by internal perceptions and the perceptions of others’ reactions.
• If a person has a low value of self, he/she tends to perceive the environment as negative
and threatening.
• Ineffective behavior in any area (physiological or psychosocial), affect the person as a
whole.
• Adaptation problems in this area may interfere with the person’s ability to heal, to do
what is necessary to maintain health, and to be a healthy person.
• Adaptation problems associated with the personal self-concept mode, are experienced as
problems in body image disturbance, sexual dysfunction, and loss.
Role Function
• Health and illness experiences affect one’s performance in various roles.

• If a person is experiencing problems concerning the role he or she occupies, the effects
may be manifested in the ability to heal and maintain health.
• Role conflict for clients occurs when they receive conflicting messages about behavior
from others in their environment.
• Adaptation problems associated with the role function mode are experienced as problems
in role transition, role distance, and role conflict.
Interdependence
• The interdependence mode is one in which affectional needs are met.
66
• In the interdependence mode a sense of adequacy is experienced through satisfying

relationships with other people.
• Adaptation problems associated with the interdependence mode; separation anxiety and
loneliness.
Older Adult
• A nurse’s attitudes toward older adults affects the quality and level of care.
• The older adult must adjust to various losses, having significant impact, self-concept, role
function, and interdependence.
• Multiple physical changes occur in aging that may affect role function, self-concept, and
interdependence.
• Loss of control and independence seems to be the greatest threat to the older adult and
their self concept, role function, and interdependence.
Transcultural Nursing
• Culture is a patterned behavioral response that develops over time learned through
socialization.
• Each person has individual responses to cultural influences.
• Transcultural assessment provides a method for the nurse to identify the client’s unique
health care needs.
Sexuality
• Sexuality is an integral part of life and person, and may have an impact on or be affected
by health status.
• Cultural, religious, and ethical beliefs significantly influence the nurse’s and client’s
sexual values and practices.
• A client’s sexuality is not left at the door when he/she enters the healthcare system.
• Asking questions regarding a client’s sexual concerns is never asked as probing or a
matter of curiosity. A nurse must understand the reasoning for the questions on sexuality
and be able to provide the rationale to the client on request.
• The degree to which any nursing intervention involving sex is successful depends on the
attitudes and beliefs of the nurse and client and their understanding of the effects of the
illness and its treatment on sexual functioning.
• In its broad sense, sexuality involves physical, emotional, social, and ethical aspects of
being and behaving.
Spiritual
• At times of hospitalization or illness, the need for spiritual care may be heightened.
67
• Nurses should be aware (through assessment) of the client’s general spiritual needs and
facilitate the client’s chosen practices.
• The spiritual dimension of care is not limited to the practices and dogma of organized
religion.
• The nurse should utilize resources such as family members, spiritual advisors, and other
members of the healthcare team to help the client maintain or regain a state of spiritual
health.
68
Module 3 – Introduction to Nursing and Basic Skills

Study Guide 3.3
Hygiene – Activity
Identify three (3) common methods of bathing.
1. ______________________________________________
2. ______________________________________________
3. ______________________________________________
Identify five (5) purposes of a bath:
1. _______________________________________________
2. _______________________________________________
3. _______________________________________________
4. _______________________________________________
5. _______________________________________________
Identify three (3) purposes of the back massage:
1. _______________________________________________
2. _______________________________________________
3. ________________________________________________
You are assigned to care for an 80 – year old female client who was admitted
approximately 2 hours ago after a fall in her home yesterday. Following the fall, she was
unable to get up and was found this morning on the floor by a neighbor. She has severe
arthritis of the hands and knees and has experienced increasing deficiencies in mobility
and self-care. She is now confused and incontinent of urine. She has a bruised sore left
hip with but the x-rays are negative for a hip fracture. Thigh high antiembolic stockings
(TED hose) were applied in the emergency room Her vital signs are stable.
From the case scenario above discuss the purpose for assessing the hands, feet and nails.
69
Identify the type of bath this client should be given:
Discuss specific areas that should be assessed during the bath:
Identify three (3) purposes for oral hygiene:
1. ________________________________________________
2. ________________________________________________
3. ________________________________________________
Describe the nurse’s role in the provision of oral hygiene:
_______________________________________________________________________
_
What is the purpose of and nursing responsibilities related to the antiembolic stockings?
Purpose:
________________________________________________________________
Nursing Responsibilities: __________________________________________________
Describe the proper method for performing perineal care for a:
Female: ________________________________________________________________
Male: __________________________________________________________________
Describe the skin care for this client:
70
What are the nursing responsibilities related to the care of the hands, feet, hair?
Hands: _________________________________________________________________
Feet: ___________________________________________________________________
Hair: ___________________________________________________________________
Select a partner from your assigned clinical group. Using the scenarios below, identify
the type of bath that would be most appropriate for each client:
(CBB) – Complete bed bath (PBB) – Partial Bed bath (TB) – Tub bath
(S) - Shower
An eighteen (18) year old diabetic
client who has recovered from a diabetic CBB PBB TB/S
ketoacidotic episode who is preparing
for discharge
A first day postoperative client who

received general anesthesia CBB PBB TB/S
An 80 year old client with a fractured CBB PBB TB/S

left hip which was pinned 4 days ago
71
Study Guide 3.4

Body Mechanics – Activity
Identify two (2) purposes of using body mechanics to move clients.
1. _________________________________________________________________
_
2. _________________________________________________________________
_
List five (5) factors that affect a client’s/patient’s mobility and maintenance of body
alignment:
1. _________________________________________________________________
_
2. _________________________________________________________________
_
3. _________________________________________________________________
_
4. _________________________________________________________________
_
5. _________________________________________________________________
_
List four (4) principles of body mechanics:
1. _________________________________________________________________
_
2. _________________________________________________________________
_
3. _________________________________________________________________
_
4. _________________________________________________________________
_
72
Provide definitions for the following terms:
Range of motion(ROM)____________________________________________________
Active Range of Motion (ROM) _______________________________________
Passive Range of Motions (ROM) ______________________________________
Exercise ________________________________________________________________
Aerobic exercise ____________________________________________________
Definitions (continued)
Anaerobic exercise __________________________________________________
Isotonic exercise ___________________________________________________
Isometric exercise __________________________________________________
Contracture _____________________________________________________________
Ataxic gait ______________________________________________________________
Muscle atrophy ___________________________________________________________
A 47 year-old female is admitted with a diagnosis of bilateral pneumonia in the lower

lobes. She is severely overweight. Her temperature is elevated and she is sweating
profusely. The doctor has ordered that she be placed on strict bedrest. She has been
treated for this diagnosis for two weeks on an outpatient basis with no response to the
prescribed antibiotics.
• Describe the assessment methods that are immediately necessary to care

for this client.
• Identify body areas that are going to require special nursing care.
• Select the most appropriate supportive device from the list and the body
area in which it will be used that will help in maintaining proper body alignment
for the client.
Body Area Supportive Device

Hand Roll
Trochanter
Pillow
Trapeze Bar
Sand bag
Footboard
73
Identify five (5) complications of immobility:

1. _________________________________________________________________
_
2. _________________________________________________________________
_
3. _________________________________________________________________
_
4. _________________________________________________________________
_
5. _________________________________________________________________
_
Interactive Activities- Select a partner:
Number the following interventions in the order necessary to assist the client to transfer
from a bed to a wheelchair and back to bed. Number from 1 (highest priority) to 7.
________ Place wheelchair at t 45o degree angle to the bed
________ Assist the client to a sitting position
________ Lock the wheelchair brakes
________ Assist the client to a sitting position on the side of the bed
________ Provide instructions to the client
________ Assist the client to a standing position with weight bearing on the strong
lower extremity
________ Assist the client into the wheelchair
Demonstrate moving a client to a standing position from the bed using a “gait belt.”
Document the client’s progress and tolerance for activities in the appropriate area(s) of
the record/chart.
74

Study Guide 3.5
Vital Signs
Vital signs are obtained to monitor the functions of the body. The temperature, pulse, respiratory
rate, blood pressure, and oxygen concentration measurements indicate how the body is
functioning or responding to medications or treatments. Many people consider pain to be one of
the vital signs.
Temperature
Temperature is a measurement of the balance between heat produced by the body and heat lost
from the body. A fever results from inadequate heat loss; a low temperature, from excessive heat
loss. When measured orally, adult temperature is 36.7C to 37C. The many varieties of
thermometers include glass, electronic, and chemical. Leave the thermometer in place for the
length of time recommended for the type of thermometer and location of measurement.
Temperatures can be taken via the following methods:
• Oral – If the client is too young or too confused to cooperate, use another means of
measuring temperature.
• Rectal – Use water-soluble lubricant to insert the thermometer. Do not use the rectal
method if client has rectal disease or convulsions. Be sure to hold a child firmly.
• Axillary – Wipe the axillary area of dampness. After placing the thermometer, hold the
arm against the chest.
Pulse
The pulse is a wave of blood created by contraction of the heart’s left ventricle. The nine sites
where pulses are commonly taken are:
• Temporal
• Carotid
• Apical
• Brachial
• Radial (most common)
• Femoral
• Popliteal
• Posterior Tibial
• Pedal
75
To take a client’s pulse, proceed with the following steps:
• Before taking the pulse, ensure that the client is at rest. If the client has been active, wait
10 to 15 minutes.
• Use your index and middle fingers to palpate all pulse sites, except for the apex of the
heart, where a stethoscope is required.
• Note rate, rhythm, volume, arterial wall elasticity, presence of bilateral equality, and
intensity.
• Count irregular pulses a full 60 seconds.
Respirations
When assessing respirations, note the rate (breaths per minute), depth (normal, deep, or shallow),
rhythm (regularity), and quality (effort required to breathe, and the sound of the respirations).
When possible, use the following methods to assess respirations, when the client is unaware that
you are doing so.
• While standing at the bedside, ask the client to place the arm farthest away from you
across the chest, if possible. The arm will rise and fall as the client breathes, making it
easier to count respirations.
• After assessing the pulse, continue holding the wrist. Count the respiratory rate and
observe the depth, rhythm, and quality of respirations.
Blood Pressure
Blood pressure is a measure of the pressure the blood exerts as it flows through the arteries. The
systolic pressure (the top number) measures the amount of pressure during contraction of the
ventricles, and diastolic pressure (the bottom number) is the measure of the pressure in the
arteries when the ventricles are at rest. Blood pressures can be taken on the arm or on the thigh.
Points to remember include the following:
• Be sure the cuff is of adequate size. For the obese client, use a large or thigh cuff. The
cuff should be wide enough to cover two-thirds of the upper arm.
• Make sure the client is calm and has not smoked or exercised within 30 minutes of the
measurement.
• Inspect the arm or thigh before placing the cuff. Do not use an extremity that has an IV
line or is injured.
76

Study Guide 3.6
Vital Signs – Activity
• Vital signs
• Core body temperature
• Pulse
• Respiration
• Blood pressure
List the five (5) sites for taking a temperature:
• ___________________________________________________
• ___________________________________________________
• ___________________________________________________
• ___________________________________________________
• ___________________________________________________
List the nine (9) sites for taking a pulse (Pulse points):
• ____________________________________________________
• ____________________________________________________
• ____________________________________________________
• ____________________________________________________
• ____________________________________________________
• ____________________________________________________
• ____________________________________________________
77
• _____________________________________________________
• _____________________________________________________
If the blood pressure is taken in an upper extremity, it is auscultated or palpated at the

__________artery in the ____________ space.
If the blood pressure is taken in a lower extremity, it is auscultated or palpated at the at the
______________ artery in the ______________ fossa.
Interactive Activity: Using the graph below, enter the following vital signs. Record the B/P
in linear areas at the bottom of the graph.
1200 – T: 102.6oF P: 100 R: 28 B/P: 152/78
o
1600 - T: 100.2 F P: 90 R: 30 B/P: 148/68
2000 - T: 99.8oF P: 88 R: 24 B/P: 144/82
08 09 10 11 12 13 14 15 16 17 18 19 20
102
101
100
99
Select a partner and identify the normal ranges for vital signs in adult clients:
• Body temperature (oral) __________________________________________
• Pulse (radial) _________________________________________________
• Respirations _________________________________________________
• Blood Pressure _________________________________________________
78
79

Study Guide 3.7
Temperature – Activity
• Basal metabolism rate
• Conduction
• Convection
• Hyperthermia
• Hypothermia
• Radiation
• Thermoregulation
Regulation of body temperature is very important. In order for core temperature to remain
normal, ___________ production must equal _____________ loss.
The body’s built in thermostat is the ______________________ located in the

___________gland in the brain..
Factors that influence heat production:
• ___________________________________________________
• ___________________________________________________
• ___________________________________________________
Factors that influence heat loss:

• ___________________________________________________
• ___________________________________________________
• ___________________________________________________
80
Factors that affect body temperature:
• ____________________________________________________
• ____________________________________________________
• ____________________________________________________
• ____________________________________________________
• ____________________________________________________
• ____________________________________________________
With a partner, select the appropriate equipment and demonstrate the correct procedure for each
site for assessing temperature. Insert the findings and the normal ranges for each.
• Oral __________________________________________________________
• Rectal _______________________________________________________
• Temporal artery(forehead)_________________________________________
• Axillary _________________________________________________
81

Study Guide 3.8
Pulse – Activity
• Auscultation
• Bradycardia
• Dysrhythmia
• Palpation
• Pulse deficit
• Pulse quality
• Pulse rate
• Pulse rhythm
• Sinoatrial node
• Stroke volume
• Tachycardia
Assessing the pulse is an important component of vital signs. The principle for selecting a site
for the pulse is that a pulse may be assessed wherever an _____________ lies close to the
surface of the skin and can be compressed against a firm structure such as ____________ or
_______________.
When assessing the pulse in addition to the rate, other characteristics that are important are:
• ____________________________________
• ____________________________________
• ____________________________________
82
Factors that influence the quality of the pulse are:
• ___________________________________________________
• ___________________________________________________
• ___________________________________________________
Factors that affect the pulse rate are:

• ___________________________________________________
• ___________________________________________________
• ___________________________________________________
With a partner, select the appropriate equipment and demonstrate the correct procedure for each
site for assessing the pulse. In writing, describe the area of the body and the a rationale for
assessing the pulse at these sites.
• Apical_________________________________________________________
_________________________________________________________
• Brachial________________________________________________________
________________________________________________________
• Radial _________________________________________________________
________________________________________________________
• Femoral ________________________________________________________
_________________________________________________________
• Popliteal ________________________________________________________
_________________________________________________________
• Pedal ___________________________________________________________
_________________________________________________________
83
• Posterior Tibial ___________________________________________________
_________________________________________________________
_
You admit a 70 year old client who has a history of atherosclerotic heart disease with a
diagnosis of congestive heart failure. He is taking digoxin 0.125 mg daily. Which site
would you use for assessing the pulse? ________________________________________
The client’s admission pulse is 110. The term for this type of pulse is
__________________________________________________
84

Study Guide 3.9
Respiration - Activity
Provide definitions for the following terms

• Apnea
• Bradypnea
• Cheyne-Stokes
• Cyanosis
• Dyspnea
• Expiration
• Hemoptysis
• Inspiration
• Kussmaul’s respirations
• Orthopnea
• Phlegm
• Pulse oximetry
• Respiration
• Tachypnea
• Tidal volume
The normal respiration rate range for an adult is _________________.
There are several factors that affect respiratory rate, rhythm and depth. List (8) of the factors
that affect respirations:
1. _____________________________________
2. _____________________________________
3. _____________________________________
85
4. _____________________________________
5. _____________________________________
6. _____________________________________
7. _____________________________________
8. _____________________________________
When assessing respirations, consider the normal ________________, disease

_________________, any ___________________________.
Discuss the method most commonly used for assessing respirations:
The respiratory center in the brain stem is the __________________________.
Match the following from the list with the most appropriate definition or explanation:
_______ Amount of air inhaled and exhaled during normal breathing
_______ Crackling sound which may be fine or coarse, heard frequently on inspiration
_______ Area/structures in the lungs where gas exchange takes place.
_______ Exchange of gases at the cellular level.
_______ Coarse sound usually heard on expiration
_______ Amount of air remaining in lungs following maximum inhalation.
A. Internal respiration
B. Vital Capacity
C. Wheeze
D. Internal respiration
E. Crackle
F. Tidal volume
86
87

Study Guide 3.10
Blood Pressure – Activity
• Auscultatory Gap
• Blood pressure
• Cardiac output
• Diastolic blood pressure
• Hypertension
• Hypotension
• Korsakoff’s Sounds
• Pulse pressure
• Systolic pressure
The average blood pressure for an adult is _______________________________..
Factors affecting blood pressure are:
• __________________________________________________________
• __________________________________________________________
• __________________________________________________________
• __________________________________________________________
• __________________________________________________________
• ________________________________________________________
• ________________________________________________________
• ________________________________________________________
88
With a partner, select the appropriate equipment and demonstrate the correct procedure for
assessing the blood pressure. In writing, describe the procedure for assessing the blood
pressure in the upper extremity.
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Identify factors which would determine why you would not select a certain upper extremity
(limb) for assessing the blood pressure.
• ______________________________________________________
• ______________________________________________________
• ______________________________________________________
• ______________________________________________________
89

Study Guide 3.11
Pain Management
Accurate pain assessment is essential for effective pain management. Many health facilities are
making pain assessment the fifth vital sign. The strategy of linking pain assessment to routine
vital sign assessment and documentation ensures pain assessment for all clients. Because pain is
subjective and experienced uniquely by each individual, nurses need to assess all factors
affecting the pain experience—physiologic, psychologic, behavioral, emotional, and
sociocultural.
The extent and frequency of the pain assessment varies according to the situation. For clients
experiencing acute or severe pain, the nurse may focus only on location, quality, severity, and
early intervention. Clients with less severe or chronic pain can usually provide a more detailed
description of the experience. Frequency of pain assessment usually depends on the pain control
measures being used and the clinical circumstances. For example, in the initial postoperative
period, pain is often assessed whenever vital signs are taken, which may be as often as every 15
minutes and then extended to every 2 to 4 hours. Following pain management interventions,
pain intensity should be reassessed at an interval appropriate for the intervention. For example,
following the intravenous administration of morphine, the severity of pain should be reassessed
in 20 to 30 minutes.
Because it has been found that many people will not voice their pain unless asked about it, pain
assessments must be initiated by the nurse. It is also essential that nurses listen to and rely on the
client’s perceptions of pain. Believing the person experiences and conveying the perceptions is
crucial in establishing a sense of trust.
Pain assessments consist of two major components: (a) a pain history to obtain facts from the
client and (b) direct observation of behavioral and physiologic responses of the client. The goal
of assessment is to gain an objective understanding of a subjective experience. Often a 10-point
Scale is used to make a complete pain assessment.
0 1 2 3 4 5 6 7 8 9 10
No Mild Moderate Severe Very Worst

pain pain pain pain severe possible
pain pain
90

Study Guide 3.12
Standard Precautions and Infection Control Strategies
CDC Isolation Precautions
Tier 1: Standard Precautions
These precautions are used in the care of all hospitalized persons regardless of their diagnosis or
possible infection status. They combine the major features of Universal Precautions (UP) and
Body Substance Isolation (BSI).
Tier 2: Transmission-Based precautions
These precautions are used in addition to Standard Precautions for clients with known or
suspected infection that is spread in one of three ways: by airborne or droplet transmission, or by
contact. The three types of transmission-based precautions may be used alone or in combination,
but always in addition to Standard Precautions. They encompass all the conditions or diseases
previously listed in the category-specific or disease-specific classifications developed by the
CDC.
Recommended Isolation Precautions in Hospitals
Standard Precautions (Tier 1)
• Designed for all clients in hospital.

• These precautions apply to (1) blood; (2) all body fluids, excretions, and secretions
except sweat; (3) non-intact (broken) skin; and (4) mucous membranes.
• Designed to reduce risk of transmission of microorganisms from recognized and
unrecognized sources.
o Wash hands after contact with blood, body fluids, secretions, excretions, and
contaminated objects regardless if gloves are worn.
 Wash hands immediately after removing gloves.
 Use a non-anti-microbial soap for routine hand washing.
 Use an anti-microbial agent or antiseptic agent for the control of specific
outbreaks of infection.
o Wear clean gloves when touching blood, body fluids, secretions, excretions, and
contaminated items (e.g., soiled gowns).
 Clean gloves can be unsterile unless they are intended to prevent the
entrance of microorganisms into the body.
 Remove gloves before touching non-contaminated items and surfaces.
 Wash hands immediately after removing gloves.
o Wear a mask, eye protection, or a face shield if splashes or sprays of blood, body
fluids, secretions, or excretions can be expected.
91
o Wear a clean, non-sterile gown if client care is likely to result in splashes or

sprays of blood, body fluids, secretions, or excretions. The gown is intended to
protect clothing.
 Remove a soiled gown carefully to avoid the transfer of microorganisms
to others (e.g., clients or other health care workers).
 Wash hands after removing gown.
o Handle client care equipment that is soiled with blood, body fluids, secretions, or
excretions carefully to prevent the transfer of microorganisms to others and to the
environment.
 Make sure reusable equipment is cleaned and reprocessed correctly.
 Dispose of single-use equipment correctly.
o Handle, transport, and process linen that is soiled with blood, body fluids,
secretions, or excretions in a manner to prevent contamination of clothing and the
transfer of microorganisms to others and to the environment.
o Prevent injuries from used equipment such as scalpels or needles, and place them
in puncture-resistant containers.
Transmission-Based Precautions (Tier 2)
Airborne Precautions
Use the Tier 1 Precautions, as well as, the following:
• Place client in a private room that has negative air pressure, 6 to 12 air changes per hour,
and discharge of air to the outside or a filtration system for the room air.
• If a private room is not available, place client with another client who is infected with the
same microorganism.
• Wear a respiratory device (N95 respirator) when entering the room of a client who is
known or suspected of having primary tuberculosis.
• Susceptible people should not enter the room of a client who has rubella (measles) or
varicella (chickenpox). If they must enter, they should wear a respirator.
• Limit movement of client outside the room to essential purposes. Place a surgical mask
on the client, if possible.
Droplet Precautions
• Place client in a private room.

same microorganism.
• Wear a mask if working within 3 feet of the client.
• Transport client outside of the room only when necessary and place a surgical mask on
the client, if possible.
92
Contact Precautions
• Place client in a private room.

same microorganism.
• Wear gloves as described in Standard Precautions.
o Change gloves after contact with infectious material.
o Remove gloves before leaving client’s room.
o Wash hands immediately after removing gloves. Use an anti-microbial agent.
o After hand washing, do not touch possibly contaminated surfaces or items in the
room.
• Wear a gown (see Standard Precautions) when entering a room if there is a possibility of
contact with infected surfaces or items, or if the client is incontinent, has diarrhea, a
colostomy, or would drainage not contained by a dressing.
o Remove gown in the client’s room.
o Make sure uniform does not contact possible contaminated surfaces.
• Limit movement of client outside the room.
• Dedicate the use of non-critical client care equipment to a single client or to clients with
the same infecting microorganisms.
Note: Adapted from “Guidelines for Isolation Precautions in Hospitals,” by J. S. Garner and the
Hospital Infection Control Practices Advisory Committee (HICPAC), 1996, Infection Control
Hospital Epidemiology, 17, pp. 53-80; and 1996, American Journal of Infection Control, 24, pp.
24-52.
Blood-borne Pathogens
Sometimes, despite the best practices, the nurse may be exposed to body substances likely to
transmit blood-borne pathogens – those microorganisms carried in blood and body fluids that are
capable of infecting other persons with serious and difficult to treat viral infections, namely
Hepatitis B Virus, Hepatitis C Virus, and HIV. Currently, all health care workers should be
vaccinated against Hepatitis B, but no vaccines are available for prevention of Hepatitis C or
HIV. The three major modes of transmission of infectious materials in the clinical setting are:
• Puncture wounds from contaminated needles or other sharps.

• Skin contact, which allows infectious fluids to enter through wounds and broken or
damaged skin.
• Mucous membrane contact, which allows infectious fluids to enter through mucous
membranes of the eyes, mouth, and nose.
93
It is critical that the nurse follow the next steps to ensure prompt evaluation and treatment, if
indicated.
Steps to Follow after Exposure to Blood-borne Pathogens
• Report the incident immediately to appropriate personnel within the agency.

• Complete an injury report.
• See appropriate evaluation and follow-up. This includes:
o Identification and documentation of the source individual when feasible and legal.
o Testing of the source for Hepatitis B, Hepatitis C, and HIV when feasible and
when consent if given.
o Making results of the test available to the source individual’s health care provider.
o Testing of blood of exposed nurse (with consent) for Hepatitis B, Hepatitis C, and
HIV antibodies.
o Post-exposure prophylaxis, if medically indicated.
o Medical and psychological counseling regarding personal risk of infection or risk
of infecting others.
• For a puncture/laceration:
o Wash/clean the area with soap and water.
o Initiate first aid and seek treatment, if indicated.
• For a mucous membrane exposure (eyes, nose, mouth), perform saline or water flush for
5 to 10 minutes.
Post-Exposure Prophylaxis (PEP)
HIV
• For high-risk exposure (high blood volume and source with a high HIV titer): three-drug
treatment is recommended. Must be started within 1 hour.
• For increased-risk exposure (high blood volume or source with a high HIV titer): three-
drug treatment is recommended. Must be started within 1 hour.
• For low-risk exposure (neither high blood volume nor source with high HIV titer): two-
drug treatment is considered. Must be started within 1 hour.
• Drug prophylaxis is for 4 weeks.
• Drug regimens vary. Drugs commonly used are zidovudine, lamivudine, didanosine, and
indinavir.
• HIV antibody tests done shortly after exposure (baseline), and 6 weeks, 3 months, and 6
months afterward.
Hepatitis B
• Anti-HB’s testing 1 to 2 months after last vaccine does.
Hepatitis C
94
• Anti-HCV and ALT at baseline and 4 to 6 months after exposure.
Infection Control Strategies
• Use strict aseptic technique when performing any invasive procedure (e.g., inserting an
intravenous needle or catheter, suctioning an airway, and inserting a urinary catheter) and
when changing surgical dressings.
• Handle needles and syringes carefully to avoid needle stick injuries.
• Change intravenous tubing and solution containers according to hospital policy (e.g.,
every 48 to 72 hours).
• Check all sterile supplies for expiration date and intact packaging.
• Prevent urinary infections by maintaining a closed urinary drainage system with a
downhill flow of urine; do not irrigate a catheter unless ordered to do so; provide regular
catheter care; and keep the drainage bag and spout off the floor.
• Implement measures to prevent impaired skin integrity and to prevent accumulation of
secretions in the lungs (e.g., encourage the client to move, cough and breath deeply at
least every 2 hours).
95

Study Guide 3.13
Infection Control/Transmission of Organisms – Activity
• Antiseptic
• Asepsis
• Bactericidal
• Bacteriostatic
• Disinfectant
• Iatrogenic
• Isolation
• Nosocomial
• Pathogens
• Sepsis
• Standard precautions
List the agents that cause infections:

• _______________________________
• _______________________________
• _______________________________
• _______________________________
Identify the six components of the chain of infection and provide an example of each:
• __________________________________________________________
• __________________________________________________________
96
• __________________________________________________________
• __________________________________________________________
• __________________________________________________________
• __________________________________________________________
Scenario: A 43 year old fireman is admitted for observation following smoke inhalation suffered
during his team’s attempt to extinguish a house fire. He had recently returned to duty following
recovery from the flu. Within 24 hours, he is exhibiting the following symptoms, T - 102.2oF; R
– 28; P – 92; B/P 132/80; WBC – 12,000 and is diagnosed with bacterial pneumonia. He is
placed on respiratory isolation precautions.
Identify factors that made this client a susceptible host:
• ____________________________________________________________
____________________________________________________________
Do you believe that this is a noscomial infection?  Yes  No. Explain why you chose the
response that you did.
With a partner, select the appropriate equipment and demonstrate the correct procedure for
caring for this client with the respiratory precautions and explain the rationale for each item of
equipment.
_________________________________________________________
_________________________________________________________
• _________________________________________________________
_________________________________________________________
_________________________________________________________
Differentiate between medical and surgical asepsis by definition and procedures used with
examples of the equipment/types of solutions
_________________________________________________________
_________________________________________________________
97
• _________________________________________________________
98

Study Guide 3.14
Nursing History Interview (Intake Assessment)
Date: _________________
Student’s Name: ____________________________________
Facility: ___________________________________________
Client’s Initials: ________ Client’s Age: _______
Likes to be called: ______________ Primary Language: ______________
Home Environment
• Describe: ________________________________________________________
• Occupation:_______________________________________________________
• Present: __________________________________________________________
• Past: ____________________________________________________________
• Hobbies: _________________________________________________________
• Daily Schedule: ___________________________________________________
• Usual Sleep Pattern: _______________________________________________
• Lives with (ages): __________________________________________________
Identified Concerns
• Psychosocial Stressors: _____________________________________________

• Physiological Stressors: _____________________________________________
• Behavior Responses to Stressors: ______________________________________
Coping Strategies
• Describe: ________________________________________________________
• Guidance Needed: _________________________________________________
• Cultural Beliefs Concerning Health/Illness:______________________________
99
o Medicine/Wellness: __________________________________________
Medical History:
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________
Limitations – Describe Plus Treatment:______________________________________
Nutrition
• Height: ____________ Weight: ____________

• Cultural Preference: _________________________________________
• Intolerance – Allergies – How Manifested: _______________________
• Understanding of Basic Food Pyramid: __________________________
• Favorite Foods, Drink – How much H2O/Daily: __________________
• Use/Restrictions of Fats, Caffeine, Sugars, Salt: __________________
Medications – Dosage and Frequency
• Heart: ________________________
• Blood Pressure: ________________
• Anticoagulant (Blood Thinner): _________________________
• Diuretic (Water Pill): ________________________________
• Respiratory Aids: ____________________________________
• Hypoglycemics (Oral & Insulin): ______________________
• Hormones - _ - Female: ______________________________
• Hormones - _ - Male: ________________________________
• Vitamins: _________________________________________
• Antacids: _________________________________________
• Other:
_______________________________________________________________________
100
_______________________________________________________________________
_______________________________________________________________________
___
_______________________________________________________________________
_
101

Study Guide 3.15
Aspects of Delegation
In nursing, delegation refers to indirect care-the intended outcome is achieved through the work
of someone supervised by the nurse-and involves defining the task, determining who can
perform the task, describing the expectation, seeking agreement, monitoring performance, and
providing feedback to the delegate regarding performance. The National Council of State
Boards of Nursing (NCSBN) published five “rights” of delegation: the nurse delegates the right
task, under the right circumstances, to the right person, with the right direction and
communication, and the right supervision and evaluation (1995). Once the decision has been
made to delegate, the nurse must communicate clearly and verify that the person understands:
• The specific tasks to be done for each client.

• When each task is to be done.
• The expected outcomes for each task including parameters outside of which an
unlicensed person must immediately report to the nurse (and any action that must
urgently be taken).
• Who is available to serve as a resource, if needed.
• When and in what format (written or verbal) a report on the tasks is expected.
Examples of Tasks that May and May Not Be Delegated to Unlicensed Assistive Personnel
Tasks that May Be Delegated to Unlicensed Assistive Personnel:
• Vital signs
• Intake and output
• Patient transfers and ambulation
• Postmortem care
• Bathing
• Feeding
• Clean catheterization
• Gastrostomy feedings in established systems
• Safety
• Weighing
• Simple dressing changes
• Suction of chronic tracheostomies
• Basic life support (CPR)
102
Tasks that May Not Be Delegated to Unlicensed Assistive Personnel:
• Assessment
• Interpretation of data
• Nursing diagnosis
• Creation of a nursing care plan
• Evaluation of care effectiveness
• Care of invasive lines
• Parenteral medications
• Venipuncture
• Insertion of nasogastric tubes
• Client education
• Triage
• Telephone advice
• Sterile procedures
Principles Used by the Nurse to Determine Delegation to Unlicensed Assistive Personnel
• The nurse must assess the individual client prior to delegating tasks.
• The client must be medically stable or in a chronic condition and not fragile.
• The task must be considered routine for this client.
• The task must not require a substantial amount of scientific knowledge or technical skill.
103

Study Guide 3.16
Vital Signs – Practice Quiz
Vital Signs are _______________________ measures
______________________ is the study of structure

______________________ is the study of function
______________________ is the study of what’s malfunctioning
Vital signs become critical measures of what is happening with your client!
Vital signs are __________________ what they were an hour ago may be irrelevant if your
client’s status has changed.
When vital signs are outside of “normal” ranges do the following…

• Recheck
• Think about technique
• Think is this truly a problem or unmet need for this client.
• Look at the client’s “normal” – is this something to consider?
Vital Sign Technique/Pointers Normal Range Age Considerations Other Notes
Temperature
Pulse
Respirations
Blood
Pressure
104
Fundamentals
105
4 Module 4 – Introduction to the Professional Role

Study Guide 4.1
Title 16 – Standards of Competent Performance –
Excerpt from California Code of Regulations
1443.5 STANDARDS OF COMPETENT PERFORMANCE
A licensed vocational nurse shall be considered to be competent when he/she consistently

demonstrates the ability to transfer scientific knowledge from social, biological and physical
sciences in applying the nursing process, as follows:
• Formulates a nursing diagnosis through observation of the client’s physical condition and
behavior, and through interpretation of information obtained from the client and others,
including the health team.
• Formulates a care plan, in collaboration with the client, which ensures that direct and
indirect nursing care services provide for the client’s safety, comfort, hygiene, and
protection, and for disease prevention and restorative measures.
• Performs skills essential to the kind of nursing action to be taken, explains the health
treatment to the client and family and teaches the client and family how to care for the
client’s health needs.
• Delegates tasks to subordinates based on the legal scopes of practice of the subordinates
and on the preparation and capability needed in the tasks to be delegated, and effectively
supervises nursing care being given by subordinates.
• Evaluates the effectiveness of the care plan through observation of the client physical
condition and behavior, signs and symptoms of illness, and reactions to treatment and
through communication with the client and the health team members, and modifies the
plan as needed.
• Acts as the client’s advocate, as circumstances require by initiating action to improve
health care or to change decisions or activities which are against the interests or wishes of
the client, by giving the client the opportunity to make informed decisions about health
care before it is provided.
Authority Cited: Business and Professions Code, Section 2715. Reference:

Business and Professional Code, Section 2725 and 2761.
106
Module 4 – Introduction to the Professional Role

Study Guide 4.2
Government Agencies, Legislation, and Public Health Policy
Key Points:
• The Department of Health and Human Services (DHHS) is the federal agency responsible
for protecting the health of Americans and providing essential human services, especially
to those unable to help themselves.
• The U.S. Office of Public Health and Science (OPHS) is responsible for administering
most of the federal health agencies and services by providing leadership and coordination
to other departments.
• Public health policy involves promoting and protecting health, preventing disease, and
preserving life through policies that ensure health for all segments of the U.S. population.
• Three core functions in ensuring public health determined by the Institute of Medicine
are: assessment, policy development, and assurance.
• The Healthy People Initiative was developed to establish national health objectives and
policy. It changed the focus of health care from illness, treatment, and cure to health
promotion and prevention of disease and injury.
Overview:
Although there is no federally-funded health program in the U.S., the government is involved in
focusing and regulating health care for the general public. There are many agencies, initiatives,
and laws that effect health care delivery in the U.S. One of the most important initiatives in
public health in the U.S. has been the Healthy People Initiative, which is updated each decade to
reflect new goals and objectives. The community health nurse must be aware of agencies,
legislation, and initiatives that involve the population of the community they serve. “Healthy
People 2010” is designed to provide support to the community health nurse’s programs and
initiatives for wellness.
Terms:
• Health care policy: a set of principles used to guide activities to safeguard and promote
the health of the public.
• Public health policy: the way in which a society or its elected representatives allocate
and distribute political and economic resources to meet the health needs of the
population.
107
Government Agencies:
• U.S. Department of Health and Human Services (USDHHS or DHHS) advises

government leaders regarding national health and welfare issues. Some of the DHHS’s
more than 300 activities include:
o Assuring food and drug safety.
o Improving maternal and infant health.
o Medical and social science research.
o Preventing outbreak of infectious disease, including immunization services.
o Medicare and Medicaid.
o Financial assistance and services for low-income families.
o Head Start (pre-school education and services).
o Preventing child abuse and domestic violence.
o Substance abuse treatment and prevention.
• U.S. Office of Public Health and Science (OPHS) is the oldest service of the USDHHS
and is under the supervision of the Assistant Secretary for Health. The OPHS is
responsible for protecting and advancing the nation’s physical and mental health. It is the
nation’s premier public health agency. Management of health care services is provided
through the following OPHS offices:
o Office of Disease Prevention and Health Promotion (ODPHP)
o Office of Minority Health (OMH)
o Office on Women’s Health (OWH)
o Office for Human Research Protections (OHRP)
o Office of Emergency Preparedness
o Office of Population Affairs
• Centers for Disease Control and prevention (CDC): a primary source for educating the
public health care communities about disease transmission, immunization, and treatment.
Information about hazardous biological contamination is also available through this
agency.
• Food and Drug Administration (FDA): ensures that food, drugs, and biologic products
are safe; medical services are safe and effective, and electronic products that emit
radiation are safe. Major divisions include:
o Center for Drug Evaluation and Research
o Center for Food Safety and Applied Nutrition
o Center for Veterinary Medicine
o Center for Devices and Radiological Health
o National Center for Toxicological Research
• Agency for Toxic Substances and Disease Registry (ATSDR): prevents exposure to toxic
and hazardous substances and reduce sources of environmental pollution.
108
• Indian Health Services (HIS): raises the physical, mental, social, and spiritual health of
Native American and Alaska Natives to the highest level.
• National Institutes of Health (NIH): the world’s premier medical research organization
that funds and oversees research endeavors nationwide.
• Health Resources and Services Administration (HRSA): provides access to essential

health services for those who cannot afford it. HRSA works with state and community
organizations ensure mothers and children are healthy, increase the number and diversity
of health care professionals in underserved communities, and provide supportive services
for those with AIDS under the Ryan White Care Act.
• Substance Abuse and Mental Health Services Administration (SAMHSA): provides

national leadership in the prevention and treatment of addictive and mental disorders.
The SAMHSA houses:
o Center for Substance Abuse Prevention
o Center for Substance Abuse Treatment
o Center for Mental Health Services
• Administration on Aging (AoA) is the principal agency designated to carry out provisions
of the Older Americans Act of 1965. Programs under this Act help elderly persons to
remain in their homes through supportive services, including nutrition programs (Meals
on Wheels).
• Administration for Children and Families (ACF) is responsible for programs that promote
the economic and social well-being of children, individuals, families, and communities.
It provides a variety of programs that include state and federal welfare programs,
Temporary Assistance to Needy Families, national child support enforcement system,
Head Start program, funding for child care and foster care, and programs to prevent child
abuse and domestic violence.
• Centers for Medicare and Medicaid Services (CMS) was created in 2001. It was
formerly the Health Care Financing Administration (HCFA) and administers the
Medicare and Medicaid programs that provide health care to one of four Americans. It
also administers the Children’s Health Insurance Program (CHIP), Health Insurance
Portability and Accountability Act (HIPAA), and the Clinical Laboratory Improvement
Amendment (CLIA).
• Social Security Administration (SSA) is an independent agency of the federal

government that oversees the Old Age, Survivors, and Disability Insurance (OASDI) and
Social Security Insurance (SSI) programs. It is responsible for studying poverty and
health care needs in the U.S., assigning Social Security numbers, and maintaining Social
Security earnings records.
109
The Public Health System Functions
• Define the health problem.

• Identify risk factors associated with the problem.
• Develop community-level intervention to control or prevent causes of the problem.
• Implement interventions to improve the health of the population.
• Monitor interventions to assess effectiveness.
Source: U.S. Public Health Service. (1994). For a healthy nation: Returns on investment in
public health. Washington, D.C.: United States Department of Health and Human Services.
Ten Essential Public Health Services
• Monitor health status to identify community health problems.

• Diagnose and investigate health problems and health hazards in the community.
• Inform, educate, and empower people about health issues.
• Mobilize community partnerships to identify and solve health problems.
• Enforce laws and regulations that protect health and ensure safety.
• Link people to needed personal health services and assure the provision of health care
when otherwise unavailable.
• Assure a competent public health and personal care workforce.
• Evaluate effectiveness, accessibility, and quality of personal and population-based health
services.
• Research for new insights and innovative solutions to health problems.
Source: Public Health Functions Steering Committee Members. (July, 1995). Public health in
America statement. Retrieved from: http://www.health.gov/phfunctions/public. htm
Public Health: What It Does

• Focuses on primary prevention.
• Leads the development of sound health policy and planning.
• Educates people about health risks and health promotion.
• Prevents epidemics.
• Protects the environment, workplaces, housing, food, and water.
• Enforces laws and regulations that protect health and ensure safety.
• Promotes healthy behaviors.
• Links people to needed personal health services.
• Monitors the health status of the population.
• Mobilizes community action for health.
• Responds to disaster.
• Assures the quality, accessibility, and accountability of medical care.
• Targets high-risk and hard-to-reach populations with clinical services.
• Maintains diagnostic laboratory services.
• Collects health statistics.
110
• Researches to develop new insights and innovative solutions.

Health and Welfare legislation: Historical perspective
• Individuals with Disabilities Education Act of 1990: mandates a free and appropriate
public education for all children and youth with disabilities.
• Americans with Disabilities Act of 1990: protects the rights of the disabled for equal
access and opportunity to employment, transportation, education, public
accommodations, and telecommunications.
• Family and Medical Leave Act of 1993: provides up to 12 weeks unpaid, job-protected
leave to eligible employees for family and medical reasons.
• State Workers’ Compensation Acts: are the oldest form of government health and
welfare insurance with the first initiated in 1911. These programs vary from state-to-
state, but provide compensation to those with work-related injuries, illness, or disability.
• Health Insurance Portability and Accountability Act of 1996 (HIPAA) Title I: ensures
health insurance coverage for workers and their families when they lose or change jobs;
Title II: requires DHHS to establish national standards for electronic health care
transactions and identifies a list of providers and options of health plans; it addressed
security and privacy of health data.
• Americans with Disabilities Act (ADA) / Olmstead Decision: interprets Title II of ADA,
requiring States to administer their services, programs, and activities “in the most
integrated setting appropriate to the needs of qualified individuals with disabilities”. The
ADA and the Olmstead decision apply to all qualified individuals with disabilities,
regardless of age.
111

Study Guide 4.3
Values and Ethical Decision Making
Overview: Nurses deal with issues related to birth, death, pain, separation, loss, and/or illness
each time they go to work. Nurses must examine their own morality and feelings around these
issues before they can effectively support clients in decision-making. Health care professionals
must assist clients as they struggle with decisions concerning these life-changing issues.
Responsible ethical decision-making is based on ethical principles and codes, not on emotions,
costs, policies, or precedent. A good decision is made in the client’s best interest while
preserving the integrity of all involved.
The community-based nurse faces very different ethical dilemmas than those in the acute care
setting. When care is provided in the home or community, the clients’ and families’ needs and
values are foremost. When the nurse’s values conflict with the clients’ or families’, it can be
difficult for both. Opposing value systems may influence the family to pursue a different health
care provider.
Moral Theories
Three types of theories often used in moral decision-making:

• Consequence-based theories that judge the outcome of an action as right or wrong.
o Utilitarianism is one theory that views a good act as one that results in the least
harm and the most good for the greatest number.
• Principles-based or deontological theories emphasize individual rights, duties, and
obligations independently of the consequences.
• Relationships-based or caring theories judge actions in the perspective of concern and
responsibility. They stress courage, generosity, commitment, and the need to nurture and
maintain relationships.
American Nurses Association’s (ANA’s) Nurse Code of Ethics (1985) includes:

• Respecting human dignity and providing service without prejudice
• Safeguarding the right of privacy and the confidential nature of the client’s health
information
• Protecting the public from the incompetent, unethical, or illegal practice of any health
care provider
• Assuming personal responsibility for decisions and actions
• Maintaining professional competence
• Using good judgment in seeking consultation, accepting responsibility, and delegating
nursing activities
• Contributing to the body of nursing knowledge
• Participating in the improvement of standards of care
• Promoting workplace conditions that affect the quality of care
• Protecting the public from misinformation and maintaining the integrity of nursing
• Collaborating in efforts, at all levels of society, to meet the public’s health care needs
112
Bioethics
Using deontological (principles-based) approach, modern bioethics was influenced by two

historical events:
• Medical experiments in Germany during World War II
• Increasing development and use of modern technology
Primary principles of modern bioethics:

• Respect for the autonomy of an individual. Autonomy is having independence or
freedom from control by external forces. Health care providers should:
o Not interfere.
o Promote independence.
o Ensure the client’s right to privacy.
o Protect the client’s right to confidentiality.
o Require informed consent prior to the client’s participation in a procedure,
treatment, or research.
 Example: advanced directives or informed consent
• Nonmaleficence is the ethical principle of doing no harm. The principle is prioritized:
o First priority is to inflict no harm.
o Second priority is to prevent harm.
o Third priority is to remove harm.
o Fourth priority is to do or promote good.
 Examples: seatbelt laws, smoke-free environments, legislation regarding
leaded paint
• Beneficence has to do with acting in ways that benefit or provide good to others. There
are two aspects of beneficence:
o Positive beneficence includes protecting and defending the rights of others,
preventing harm from occurring to others, helping persons with disabilities, and
rescuing persons in danger.
o Utility relates to balancing the benefits against the risk of harm (e.g., cost-
effectiveness, cost-benefit, risk assessment).
 Examples: screening for communicable diseases, implementation of cost-
effective health and wellness programs
• Justice consists of persons with similar circumstances and conditions being treated alike.
The major issue in the context of bioethics is the right to health care.
o Examples: making community programs available, accessible, and fairly
distributed to all
• Fidelity is the principle of keeping one’s promise; building trust between the client or
community and the nurse.
o Examples: completion of all scheduled programs, meeting deadlines, and being
on time to appointments
• Veracity is the duty to tell the truth, and often includes doing so in a timely manner.
o Examples: notifying the community of an outbreak of Hepatitis A or exposure to
a communicable disease as soon as possible.
113
Ethics of Care
• The focus is on the whole individual.

• The caregiver has a responsibility to meet the needs of those for whom they care.
• There is an element of compassion in the relationship.
Ethical Decision Making
There are several theories for ethical decision-making. Generally, each includes:
• Assessing the situation.
• Identifying the problem.
• Determining the ethical issues associated with the problem (autonomy, beneficence, non-
maleficence, justice, veracity, fidelity).
• Exploring the values of all persons involved (including the nurses’ own values).
• Development options.
• Involving individuals who should make decisions.
• Deciding on an option to implement.
• Implementing the option considering the nursing code of ethics, all federal and state laws
affecting the actions, and the values of all involved.
• Evaluating the outcome of the actions.
Specific Ethical Issues in Health Care

• Acquired Immune Deficiency Syndrome (AIDS) and Human Immunodeficiency Virus
(HIV)
• Abortion
• End-of-life decisions
• Euthanasia
• Assisted suicide
• Stopping fluids or nourishment
• Ability to pay for treatment
• Abuse
• Discontinuation of treatment
• Quality of life
Nursing Considerations
In working with values, morals, and ethical decision-making, nurses should:

• Clarify their own values.
• Be familiar with the ethical aspects of nursing.
• Consider the ANA’s code of ethics for nursing.
• Be sensitive to the values and opinions of clients’ and other health care providers relative
to their own.
• Utilize ethics committees, when available.
114

Study Guide 4.4
Values and Ethical Decision Making – Critical Thinking Activity
Values and ethical decision-making are an important part of all health care. Every nurse must
understand these issues and be able to assist clients with health care decisions.
• Nursing ethics are defined as:
• Ethics committees are:
• Ethics committees may be involved in issues regarding:
• A value system is:
• Define nonmaleficence:
115
Values and Ethical Decision Making – Critical Thinking Activity – Answer Key
Values and ethical decision-making are an important part of all health care. Every nurse must
understand these issues and be able to assist clients with health care decisions.
• Nursing ethics are defined as:
Nursing ethics are ethical issues that occur in the practice of nursing.
• Ethics committees are:
Ethics committees are multidisciplinary teams available at many health care institutions to
assist in decisions with ethical issues.
• Ethics committees may be involved in issues regarding:
The ethics committee is often involved in end of life decisions, placement of persons of
abuse, neglect or otherwise unable to care for themselves, and guardianship.
• A value system is:
A value system is a personal organization of one’s values from most important to least
important.
• Define nonmaleficence:
116
Nonmaleficence is an ethical principle of doing no harm. The principle is prioritized as
follow:
First priority is to inflict no harm.

Second priority is to prevent harm.
Third priority is to remove harm.
Fourth priority is to do or promote good.
• Define beneficence:
Beneficence has to do with acting in ways that benefit or provide good to others. There are
two aspects of beneficence:
o Positive beneficence includes protecting and defending the rights of others,

preventing harm from occurring to others, helping persons with disabilities, and
rescuing persons in danger.
o Utility relates to balancing the benefits against the risk of harm (e.g., cost-
effectiveness, cost-benefit, risk assessment).
• List several areas of ethical concern in health care today:
117
Fundamentals
118
5 Module 5 – Communications – Client Teaching – Cultural Awareness

Study Guide 5.1
Communications Guidelines
Communication is a vital part of nursing practice. Nurses who communicate effectively are
better able to initiate change that promotes health; establish a trusting relationship with
clients, families, and colleagues; and prevent legal problems associated with nursing
practice. Effective communication is essential to establishing a positive nurse-client
relationship.
Therapeutic communication techniques can help promote understanding between nurse

and client. These techniques include the following:
• Being silent when appropriate

• Asking open-ended questions
• Using touch when appropriate
• Restating or paraphrasing
• Seeking clarification
• Summarizing
In some situations, ordinary methods of communication are not sufficient, for examples,
when caring for a client who is angry, confused, or speaks a language foreign to you. Some
cultural issues also require sensitivity and understanding.
Communicating with the Angry Client
Anger can be the result of fear, frustration, or a feeling of losing control. Often clients
direct their anger toward the nurse, simply because the nurse is there. Angry outbursts
from clients may be due to worries about their job, family, or illness. Fatigue or physical
discomfort can also provoke anger. It is important that you try to identify the cause of the
anger and not to feed that anger; maintain your composure.
The following are guidelines for responding to the angry client:
• Listen to what the client is saying.

• Do not let the client’s anger cause you to react and not listen.
• Use techniques such as reflection, clarification, and focusing to determine the
problem. Only when you understand the problem can you formulate a plan for
resolution.
119
• Once the problem is identified, find ways to resolve it. Remember; do not make
promises you cannot keep. A trusting relationship is key in diffusing angry
outbursts.
• If you cannot resolve the client’s anger, or if you feel any threat of violence, ask your
instructor or the primary nurse for assistance.
• Be sure to document the conversation or incident, no matter how minor it may
seem.
120
Communicating with the Confused Client
Confusion in a client can be caused by medications, disease process, or the disruption of

circadian rhythms. Whatever the cause, working with the confused client can be
frustrating, so it is important to know your trigger points and what soothes them.
The following are guidelines for responding to the confused client:
• If this confusion is a new occurrence, review the client’s medications and the
potential side effects. Sudden onset of confusion is a sign that must be reported.
Review your findings. Review your findings with your instructor.
• At every interaction with the client, orient the client to person, time, and place. Try
to interact with the client as often as possible.
• Actively listen to the client, and clarify any points of confusion. Be attentive.
• Reassure the client, but do not be condescending.
Communicating with the Anxious Client
Fear of the unknown causes anxiety. All of us experience it at one time or another. As a
nurse, it is important that you identify the causes or origin of a client’s fear or anxiety.
The following are guidelines to use in responding to the anxious client:
• Talk to the client and actively listen. Answer all questions you can answer
accurately. Use the skills of reflection, clarification, and focusing to get the client to
talk about the true problem.
• Questions such as “Am I going to die?” or “Do I have AIDS or cancer?” are the
most disconcerting. Ask clients what makes them believe that they are going to die
or that they have AIDS or cancer. Your goal is to get them to verbalize their fears.
• If the client has questions about the medical diagnosis, find out what the client has
already been told. Clarify any points you can. If the client has not been told
anything, ask whether the client would like to speak to the physician. It is the
physician’s responsibility, not yours, to communicate the diagnosis.
• Be attentive to the client. Check in on the client as much as possible. This
establishes trust and communicates a caring attitude.
• Above all, do not be condescending or dismiss the client’s anxiety. Put yourself in
the client’s position.
Communicating Across Language Barriers
121
There are many types of language barriers. Foreign language, hearing deficits, expressive
disorders (such as aphasia), and intubations are all barriers to effective communication
and require some creativity, patience, and perseverance. It is crucial for the client to be
able to communicate needs and for the nurse to be able to communicate understanding.
Health care facilities usually have resources that can help you, such as translation services
for the non-English-speaking client and for the hearing impaired. The speech therapy
department can help you find ways to communicate with a client who has speech deficits.
The Non-English-Speaking Client
• Find out whether the health care facility has an interpretive service.
• Find out if any staff members speak the language.
• Do not yell at the client. Speaking more loudly may only make the patient think you
are angry. If the client does not understand English, increasing the decibel level will
not help.
• If a particular language is commonly spoken at the facility (e.g., Spanish), purchase
a phrase book and take the opportunity to add to your skills. You may also wish to
develop a resource binder containing frequently used terms in many languages.
• All health care providers must provide some type of health care interpreting.
The Hearing-Impaired Client
• Stand in front of the hearing-impaired client and talk distinctly at a normal tone.
Make sure the client can clearly see you. Many clients who are hard of hearing read
lips.
• Keep paper and pencil at the bedside and write notes, especially when privacy is
important.
• For the client who uses sign language, enlist the help of a translation service, if
available.
• If no services are available to help you and writing is not possible, act out what you
would like to do.
• Take the opportunity to learn sign language.
The Client with Aphasia
• Listen carefully. Encourage the client to take her time. Do not be afraid to ask the
client to repeat herself.
• Use paper and pencil, or picture board, if appropriate.
• If the aphasia is a long-standing condition, ask a family member for assistance.
• Call the speech therapy department of any additional help, if needed.
122
The Intubated Client
• Use paper and pencil for communication or a letter board on which the client can
spell out words.
• If yes or no answers are needed, have the client blink once for yes and twice for no.
Cultural Issues
In almost every area of the country, nurses come into contact with people from cultures
different from their own. Although it is not within the scope of this module to describe the
differences in all cultures you may encounter, some universal guidelines can be of help.
Examine your own attitudes. What are your attitudes toward different cultures? What
experiences have you had with different races and ethnic groups? What influences your
acceptance or non-acceptance of a cultural group? Are your beliefs about a certain culture
based on experience or on what you have heard or read? Refer to Primary text for a
thorough discussion of cultural issues.
The following are guidelines for responding to clients of different cultures:
• Always treat the client with respect.

• Different cultures may use different behaviors to denote respect or understanding.
Do not assume you know the meaning of a specific behavior.
• Familiarize yourself with the customs and beliefs of cultural groups in your area.
• Try to incorporate cultural symbols and practices into the care plan of the client
where feasible; these can bring comfort to a client.
• Remember that the color of a person’s skin does not necessarily indicate the
person’s cultural background.
• Learn how the client views health, illness, grieving, and the health care system.
Communicating with Elders
Elders may have physical or cognitive problems that necessitate nursing interventions for
improvement of communication skills. Some of the common ones are:
• Sensory deficits, such as vision and hearing.

• Cognitive impairment, as in dementia.
123
• Neurological deficits from strokes or other neurological conditions, such as aphasia

(expressive and/or receptive), and lack of movement.
• Psychosocial problems, such as depression.
Recognizing specific needs and obtaining appropriate resources for clients can greatly
increase their socialization and quality of life. Interventions directed toward improving
communication in clients with these special needs are:
• Ensuring that assistive devices, glasses, and hearing aids are being used and are in
good working order.
• Making referrals to appropriate resources, such as speech therapy.
• Making use of communications aids, such as communication boards, computers,
and pictures, when possible.
• Keeping environmental distractions to a minimum.
• Speaking in short, simple sentences, one subject at a time-reinforce or repeat what is
said when necessary.
• Always facing the person when speaking-coming up behind someone may be
frightening.
• Including family and friends in conversation.
• Using reminiscing, either in individual conversations or in groups to maintain
memory connections and to enhance self-identity and self-esteem in the elder.
• Believing the nonverbal when verbal expression and nonverbal expression are
incongruent (Clarification of this and attentiveness to their feelings will help
promote a feeling of caring and acceptance.)
• Finding out what has been important and has meaning to the person and trying to
maintain these things as much as possible. Even simple things such as bedtime
rituals become important if they are lost in a hospital or extended care setting.
124
Module 5 – Communications – Client Teaching – Cultural Awareness

Study Guide 5.2
Therapeutic Communication and the Nursing Process
Therapeutic Communication and the Nursing Process
• Assessing – gathering information is verbal and nonverbal forms, data

Concerning patients is collected and analyzed.
• Diagnosing – nursing diagnosis formulated, conclusion drawn from data
• Implementing – verbal and nonverbal communication allows nurses to enhance care
giving measures, to teach, counsel and support patients and their families
• Evaluating - verify that objectives and goals are achieved and revisions of the care
plan are made and documented
• Documentation – written record to pass information and progress to others, to
promote continuity of care and document care given and patient responses
Therapeutic Communication and the Helping Relationship

• Contrast the helping relationship versus a social relationship. Helping
Relationships occurs for a specific reason while a social relationship may occur
spontaneously but will have the components of care, concern, trust and growth.
• Helping relationship is characteristic of an unequal sharing of information.
The patient shares personal information and the nurse shares information in terms of a
professional role.
• In friendships and social situations, the needs of both participants are
considered. A helping relationship is a time-limited interaction.
Characteristics of the helping relationship

• Dynamic the nurse and the person being helped are active participants
• Purposeful and time-limited since specific goals are intended to be met within
A certain period.
• Professional accountability for outcomes and the means to attain them.
Goals of the helping relationship

• Goals are determined cooperatively and defined by the patient’s needs
• The nurse selects interventions that will help the person move toward the goals
• The focus is on the patient’ needs
Phases of the helping relationship

Helping relationships have a preinteraction phase where planning and information
gathering activities occur. Helping relationships are also known as therapeutic relationships.
The nurse’s approach must be accepting and nonjudgmental of the client and his life
circumstances. In therapeutic relationships mutually determined goals are aimed toward meeting
125
the patient’s needs and improving coping skills. In helping relationships, the nurse strives to
help patients understand behavior, explore problems and work on development of coping skills.
• Preinteraction
• Phase I orientation phase – orientation, introduction, and establishing rapport
Roles of people in relationship clarified, agreement on goals, frequency of contacts,
services, routines and pertinent information
• Phase II working, learning, developing skills
Usually longest phase where purposeful interactions designed to meet the objectives
and goals agreed upon are achieved. Nurse provides assistance, makes arrangements,
or referrals.
• Phase III termination, evaluation, discussion of accomplishments
Conclusion of initial agreement is acknowledged. Achievements are reviewed and
evaluated.
Factors promoting effective communication for helping or therapeutic relationships

• Traits for the effectiveness of the nurse role
• Warmth and friendliness – conveys acceptance of patient and interest in the patient’s
concerns and feelings
• Openness and respect – accepting, frank and respectful without prejudice.
• Empathy – identifying with the way another person feels, sensitive to how another
person feels, but objective enough to help the person work toward positive outcomes
• Honesty, authenticity, and trust – nurse as professional helper convey that they can be
trusted to do everything within level of expertise to help meet patient’s needs
• Caring – communicate genuine caring to make the patient feel cared for and accepted
• Competence – demonstrated cognitive, interpersonal, technical, and ethical/legal
skills to meet healthcare needs.
Building rapport for effective communication – A feeling of mutual trust, which

facilitates open communication.
• Purpose, specific objectives – guides the nurse to achieve meaningful encounter and
meet patient centered objectives
• Comfortable environment – interactions are promoted when the environment allows
the nurse and patient to be at ease with suitable furniture, lighting and temperature in
relaxed and unhurried atmosphere
• Privacy – every effort to carry on conversations where others do not overhear them.
Sense of privacy is important for patient to express desires and needs.
• Confidentiality – how information will be treated meets patient needs and considers
client rights at the same time.
• Patient centered focus – communication should focus on the patient and not on the
nurse or nursing activities
• Nursing observations – seeing and interpreting are useful for validating information.
Helps nurse be aware of nonverbal messages, primary source of information when
client unable or unwilling to communicate verbally.
126
• Pacing – Allow patient to set the pace and let the patient know if there is a time limit
so that the patient does not feel pushed or rushed.
• Personal space – Invasion of personal space can evoke uncomfortable feelings, nurse
must be aware and sensitive to personal space to promote patient comfort.
Developing Therapeutic Communication Skills

• Conversation skills - exchange of verbal communication, a social interaction
In which tone of voice, accurate information, flexibility, clear, concise words,
truthful, open, and takes advantage of available opportunities.
• Listening skills – involves hearing and interpreting what another person says.
It requires attention and concentration, alert and relaxed posture, culturally
appropriate, attentive and active involvement.
• Silence – periods of silence can allow participants to reflect on what has been
Shared, take the time to wait for the patient to continue talking. Fear of silence can
lead to too much talking and loss of opportunities for real communication.
• Touch – powerful means of communication that can connect people, affirm,
Reassure, decrease loneliness, share warmth, approval and emotional support.
Touch must be used at the right time and with consideration of benefits vs anxiety
and discomfort it can cause.
• Humor – may be a valued interpersonal skill for the nurse and offer healing
For patients. Laughter can release tension, reduce stress, anxiety, worry and
frustration. It can be inappropriate and must be used with care.
127

Study Guide 5.3
Therapeutic Communications
Essential Conditions for Therapeutic Communication

1. Rapport—interpersonal relationship characterized by a spirit of cooperation, confidence,
and harmony.
2. Trust—risk-taking process whereby a person’s situation and feeling of well-being
depends on the action of another.
3. Respect—a relationship in which one considers the other in high esteem or regard.
4. Empathy—the ability to try and UNDERSTAND what another person is feeling; NOT
actually feeling what the other person is feeling. Restating what someone states they are
feeling is often most helpful and conveys the impression you, as the nurse, are trying to
understand their feelings.
5. Genuineness—being as one appears, sincere, honest.
Therapeutic Communication Techniques

1. Listening: The nurse focuses on or attends to all the clients’ behaviors; this is
communicated nonverbally to the client by means of facing and leaning toward him/her
and using eye contact and open, relaxed body posture. Listening alone is quite useful
when clients are disclosing painful memories or experiences. Though it may be difficult
to remain silent, it is most useful for the client.
2. Broad Opening: The nurse uses open-ended comments that help the client express
himself/herself (e.g., “go on,” “Tell me what happened,” “How are you today?”).
3. Clarification: The nurse communicates an understanding of the thought or feeling tone
of the client’s message back to him/her to offer another perspective on the situation (e.g.,
“You did not see any other way to cope with the problem.” “You feel your family is
ashamed of you.”).
4. Reflection: The nurse reflects back to the client the feeling or thought message that the
client expressed to help him/her identify the emotions and events that trouble him (e.g.,
“You think your mother loved your brother more than you,” “You feel trapped in your
current job.”).
5. Confrontation: The nurse describes contradictions in the client’s behavior or feelings
that are sending mixed messages to others (e.g., “You complain about your wife’s lack of
concern for you, but you refuse to respond to her gestures for reconciliation.”).
6. Giving Information: The nurse provides facts or information that the client requests
(e.g., “Your doctor is ill today, so your appointment will be held tomorrow instead.”).
7. Seeking validation: The nurse asks the client to give feedback about the accuracy of the
nurse’s perceptions (e.g., “is that what you’re experiencing?” “Do I understand you to
say…?”).
8. Self-disclosure: The nurse occasionally and cautiously reveals something from her own
experience to make a connection with the client and his/her experience.
9. Silence: The nurse uses silence to communicate presence and acceptance of the client.
10. Summarizing: The nurse summarizes the work of the session, progress made, or client’s
goals at the end of the interview (e.g., “We have been discussing how you perceive your
128
sister’s comments to you and ways to handle your anger differently than you have in the
past.”).
Barriers to Therapeutic Communication

1. Changing the subject: The nurse communicates an unwillingness to continue with the
client’s topic, usually due to being uncomfortable with the topic.
2. Interrupting: The nurse shows disrespect for the client by breaking into and interfering
with his/her communication.
3. Approving: The nurse uses approval and disapproval to control the client and his/her
behavior.
4. Moralizing: The nurse passes judgment on the client by telling him/her what is right and
wrong, good and bad, instead of letting them decide.
5. Social response: The nurse uses superficial, social conversation that is not client-
centered.
6. Belittling: The nurse discounts the client’s feelings and experiences as not being
valuable or worthwhile.
7. Giving Advice: The nurse gives advice to the client, indicating that he/she is incapable of
solving his/her own problems.
EXERCISES IN ANSWERING COMMUNICATION QUESTIONS
Communication Questions
Communication is an essential skill in the practice of nursing. The goal of nursing is to help the
client attain and maintain an optimal level of functioning. Communication skills are needed to
achieve this nursing goal. Since the NCLEX-RN Exam measures your ability to practice safely,
communication skills are an integral part of the exam.
If you cannot communicate therapeutically,

it is difficult to practice safely.
For this reason, your nursing course exams may also include many communication questions.
Communication skills are recognized as vital at all levels of nursing practice.
129
Therapeutic Techniques
Use of Silence Using absence of verbal communication
Accepting Indicating reception, nonjudgmental
Giving Recognition Acknowledging, indicating awareness
Offering Self Making one’s self available
Giving Broad Openings Encouraging client to pick topic
Offering General Leads Encouragement to continue
Placing Events in Sequence Clarifying the relationship of events in time
Making Observations Verbalizing what is perceived
Encouraging Description Clarifies how client may perceive an event
Encouraging Comparison Noting similarities and differences
Reflecting Directing back to the client stated ideas
Focusing Redirecting to an important topic
Exploring Delving further into a topic
Seeking Clarification Making /clearing something that is vague
Presenting Reality Stating what is real
Verbalizing What is Implied Voicing what the client has hinted at
Encouraging Evaluation Asking for appraisal of the experience
Translate into Feelings Reflect to the client what is indirectly expressed
Suggesting Collaboration Offering to work together for benefit of client
Encouraging a Plan Considering behavioral alternatives for future
Non-Therapeutic Techniques
Reassuring Indicating there is no cause for anxiety
Giving Approval Sanctioning the client’s ideas/behavior
Rejecting Refusing to consider the client’s ideas
Disapproving Denouncing the client’s ideas
Agreeing/Disagreeing Client may be seeking approval
Advising Telling the client what to do
Probing Persistent questioning of the client
Challenging Demanding proof from the client
Defending Protecting from verbal attack
Requesting Explanation Wanting reasons for feelings or actions
Belittling Feelings Misjudging the client’s degree of discomfort
Giving Literal Responses Taking a figurative comment as fact
Using Denial Refusing to accept the problem exists
Introducing an Unrelated Topic Changing the subject
Stereotyping Using trite expressions
Study Guide 5.4
Communication Questions – Tools and Blocks
Today there are communication test questions on every type of certification exam in nursing
practice, including the specialty levels. Learning how to answer communication questions will
enhance your score on the NCLEX-PN exam and on other nursing exams.
130
Identifying the Client in a Communication Question

When you identify the critical elements, however, two elements require particular attention.
First, you must take care when you identify the client in the question. This is not always obvious
to the unskilled test-taker, because the client is not necessarily the person identified with the
health problem.
The client in the question is the person to whom the nurse must respond—and this is almost
always someone in the case scenario who has asked the nurse something, or perhaps someone
who has done something that affects the nurse. Depending upon the question’s case scenario and
the stem of the question, the client may be a relative, another client, or even another nurse.
Communication Tools and Blocks

Once you have identified the critical elements, particularly the client in the question, the issue,
and the type of stem, you need to select your answer. To do this, you need to apply your
knowledge of therapeutic communication. The following guidelines summarize the tools and
blocks to therapeutic communication.
Communication tools are mechanisms that enhance therapeutic communication. The blocks are
responses that interfere with communication. Examples of the therapeutic communication tools
are shown in the following table.
131
Module 5 – Communication – Client Teaching – Cultural Awareness

Study Guide 5.5
Communication - Activity
Provide definitions for the following terms and give an example of each:
• Advocacy
• Empathy
• Open-ended question
• Paraphrasing
• Reflection
• Therapeutic use of self
List the five (5) essential therapeutic communication techniques used in a helping relationship
• ___________________________________________________________
• ___________________________________________________________
• ___________________________________________________________
• ___________________________________________________________
• ___________________________________________________________
List and explain the three (3) phases of the nurse-client relationship/helping relationship:
• _______________________________
• _______________________________
• _______________________________
132
Identify five (5) non-therapeutic responses that block the development of therapeutic
communication:
• _________________________________________________________________
• _________________________________________________________________
• _________________________________________________________________
• _________________________________________________________________
• _________________________________________________________________
Scenario:
You are meeting a 78 year old client for the first time in the assisted living facility to which you
are assigned as a student nurse. About a week ago, he sustained a fall and had to be taken to the
hospital for evaluation and observation. Prior to this incident, he has maintained independence
in mobility and activities of daily living, and has therefore has not required monitoring or safety
devices. You are attempting to develop a therapeutic relationship and plan to assist him in setting
some goals to ensure safety and maintain as much of his independence as possible. When you
begin to talk to him about safety issues, he becomes agitated and states that he just had a spell of
“lightheadedness”, now feels just fine. He further states that he wants those “little bars” taken
off his bed and wishes that everyone would just leave him alone.
Using the scenario above, identify three (3) factors that would initially affect the development of
a therapeutic relationship with this client.
• ________________________________________________________
• ________________________________________________________
• ________________________________________________________
Interactive Activity:
Select a partner and use the following scenarios to select the communication technique or
response being used. Place the letter preceding your choice in the blank in front of the scenario.
If the response is non-therapeutic or inappropriate, develop a response that would be therapeutic
or appropriate.
______ Client: “I have been feeling badly for so long and have had a lot of tests but the doctor
will not come and tell me what has been found.”
Nurse: “ I will go and check to see if the laboratory results are available and call the
doctor to see when he plans to make rounds today.”
133
_______ Client: A young mother who has been discharged is found sitting on the side of her
bed, looking at her newborn and crying.
Nurse: “I notice that you have some concerns, how can I help?”
________ Client: “I have had a lot of teaching about monitoring my blood glucose with the
meter and I have demonstrated the procedure accurately for the past two days.
Do you think that I will be able to manage it at home?”
Nurse: “ Do I understand that you have performed the blood glucose monitoring
procedure accurately for the past two days?”
________ Client: “ I am afraid to hear the test results.”

Nurse: “I will be present while the doctor gives you the results of the tests
and arrange my work so that I can remain with you for a while after he
leaves in case you want to talk.”
_________ Client: “I don’t care about having a hysterectomy because I already have two (2)
children.” (Stated with tears in her eyes, looking out of the window with a sad
look on her face).
Nurse: “ You tell me that you don’t care, but you look sad.”
_________ Client: “ I can’t decide whether or not I should have this surgery. I am so afraid.”
Nurse: “ I can understand that, but let’s talk about what you are concerned about.”
________ Client: I came to the hospital because I had this terrible pain in my right side that
just kept getting stronger and stronger.”
Nurse: “ The reason for your coming to the hospital is because of an intense pain
in the right side? “
A. Advocacy
B. Empathy
C. Open-ended question
D. Therapeutic use of self
E. Paraphrasing
F. Reflection
134

Study Guide 5.6
Nurse/Client Process Recording Interview Form
INTRODUCTION;
STUDENT’S NAME: __________________________________ 1. Identify Responses B = Blocking T = Therapeutic

2. Under each response, identify the technique you utilized
CLIENT’S INITIALS: __________ DATE:____________ (i.e., t=Clarifying, paraphrasing, exploring; B=Giving
advice, probing, minimizing)
3. For each block, be certain to identify an alternative
Response. For example: B=Changed subject. Should
have said …. “______________”.
4. Identify your FEELINGS at the time the client is stating
their feelings.
STUDENT’S VERBAL AND CLIENT’S VERBAL AND ANALYSIS OF STUDENT’S VERBAL

NONVERBAL BEHAVIORS NONVERBAL BEHAVIORS RESPONSES/STUDENT’S FEELINGS
135

136

SUMMARY
137

Study Guide 5.7
Practice Therapeutic Communication Questions
Therapeutic Communication Questions
1. The nurse says, “Did you sleep well a. sender

last night?” The client answers, “No, I b. message
just was not sleepy.” What c. response/feedback
component of the communication d. decoding
process does the client’s response
represent?
a. cultural differences
2. The nurse says to the client, “Your b. language barriers
M.D. is still in ICU, but he has c. encoding/decoding misinterpretations
ordered an ABG to be drawn prior to d. distance/space constraints
your pre-op.” The nurse is risking
which threat to effective a. “Have you read the pamphlets I gave you
communication. on diabetes?”
3. A client who is newly diagnosed with b. “Don’t worry. A lot of people have
diabetes says that she knows that her diabetes, and they manage.”
illness is complicated. She says, “I c. “What is it about your illness that you
wonder if I’ll ever be able to don’t understand?”
completely understand it.” What d. “You should probably talk to your
would be the most helpful reply by the physician about this.”
nurse? a. preinteraction phase
b. introductory phase
4. During which phase of the relationship c. working phase
process does clarification of the d. termination phase
problem occur? a. preinteraction phase
process are the nurse and client most d. termination phase
likely to experience feelings of loss?
a. preinteraction phase
process does the nurse assist the client d. termination phase
to explore thoughts, feelings and
actions? a. defensive
b. clarifying
7. A client complains that his 9:00 p.m. c. challenging
snack was not delivered until 10:30 d. disagreeing
p.m. The nurse responds by saying
that there was an emergency and she
was not able to bring it in earlier. a. “How are you feeling today?”
What kind of response is this? b. “You seem upset. Is your friend worse
8. A nursing caring for a dying client sees today?”
the client’s life partner crying. In c. “Crying is good for you. Things will look
order to facilitate the discussion of brighter tomorrow.”
feelings, the best comment she could d. “I see you have been crying. Would you
make to the visitor would be: like to talk about it?”
Vocational Nursing Program Curriculum
9. While taking an admission history a. inappropriate communication.

from the mother of an 18-month-old b. inadequate language skills.
being admitted for surgery, the nurse c. the violation of personal space.
notes that the mother is twisting her d. incongruent nonverbal communication
rings, running her hands through her
hair, and moving about restlessly.
When the nurse asks the mother about
any problems or concerns, she replies,
“Everything is just fine.” The
mother’s behavior is an example of:
10. In order to listen attentively to a client, a. maintain good eye contact.

the nurse needs to: b. lean back in her chair.
c. sit with hr legs crossed.
d. respond quickly to the client’s statements.
11. The nurse violates a client’s personal a. sits at the client’s bedside.
space when he: b. adjusts the client’s IV flow rate.
c. removes the client’s abdominal sutures.
d. enters the client’s hospital room.
12. The biggest inhibitor of effective a. failing to listen.

communication is: b. giving false reassurance.
c. disagreeing with the client.
d. passing judgment on the client.
13. One feature of an effective group is a. disagreement among members is not

that: tolerated.
b. the leader dominates the group.
c. feelings are kept out of group discussions.
d. the group is able to examine its own process
14. The client says, “I’m a failure.” The a. being genuine.

nurse replies, “The plant downsized, b. showing respect for the client.
and you lost your job.” The nurse is: c. confronting the client.
d. helping the client to be concrete & specific
15. A few hours after the birth of her a. “It is the father who determines the sex of a
daughter, the nurse notices that the baby. Perhaps we should tell your husband
client is crying. When questioned, she that.”
says, “My husband is so disappointed b. “It’s not your fault. Don’t feel bad.”
in me, and I really did not want c. “You seem very upset. Would it help to
another girl either.” The nurse’s most talk to me about it?”
therapeutic reply at this moment d. “You shouldn’t cry. Your baby is healthy.
would be: You can have a boy next time.”
16. How can the nurse obtain the most a. Observe the client’s body language.
accurate and truthful information b. Ask “What are you feeling right now?”
about what a client is feeling when he c. Ask a family member what the client is
is talking about a bad experience he feeling.
has had? d. Say, “That must have been hard for you.”
17. What is a small voluntary group of a. self-help group

people who share a similar health b. teaching group
problem (e.g., Alcoholics c. task group
Anonymous)? d. self-awareness group
18. A client says to the nurse, “That night a. “We are always understaffed on nights. I’m
nurse needs to go back to school. She sure the nurse did the best she could.”
gave me a shot in the wrong arm, she b. “Well, the least competent nurses do sort of
forgot to fill my water pitcher, and she drift to the night shift. I don’t blame you
wouldn’t answer my light!” What for being upset.”
would be a therapeutic response by the c. Sounds like you had a bad night. Tell me
nurse? more about it, and lets see if there is
anything I can do to help you now.”
d. “You seem fine this morning. I guess it
couldn’t have been all that bad.”
19. The client tells the nurse, “I still hurt a. “Are you saying that none of the therapies
after taking two doses of my medicine. relieve your pain?”
The physical therapy makes me hurt b. “Perhaps the medication has not had time to
worse, and the heating pad doesn’t work.”
help either.” Which of the following c. “You’re saying the heating pad is not
responses would enhance working?”
clarification? d. “Let’s try changing your position in the
bed.”
20. Which question would be most a. “Do you understand what you need to do
effective in evaluating the client’s prior to your X-ray procedure?”
understanding of teaching? b. “What do you need to do prior to your X-
ray procedure?”
c. “Do you have any questions about your X-
ray procedure?
d. “Have I been clear about what you need to
do prior to your X-ray procedure?”
21. Which nursing intervention would a. responding openly about the purpose of an
meet a client’s physical comfort need? IV medication to establish trust.
b. accepting a client’s anger and frustration
about a delay in a treatment.
c. asking the client’s arm preference prior to
the insertion of an IV line.
d. painlessly inserting the needle for an IV
medication.
22. The nurse recognizes that a client who a. verbalize reduced pain following a pain
has constant pain from severe burns to medication.
both hands has reached Kolcaba’s b. perform complex hand exercises slowly, in
state of transcendence when the client the same amount of time as usual.
is comfortable enough to: c. perform complex hand exercises slowly, but
with ease.
d. complete two sets of the exercises in the
amount of time he previously completed
first set.
23. Which of the following is true about a. It is a passive process by the client.
comfort? b. It involves cooperative actions of both
client and nurse.
c. It is nurse-led.
d. It is client-controlled.
24. The nurse tells the client that she will a. vigilance.
return in 30 minutes to see if the pain b. therapeutic touch.
medication was effective. This nurse is c. positive talk
utilizing the comfort communication d. empathy
strategy termed:
25. The nurse is changing a client’s new a. Ask if the client is experiencing any pain.
colostomy appliance. The client is not b. Turn the face away from the appliance.
talking but looking intently at the nurse’s c. Smile slightly while conducting the
face. Which of the following would be procedure.
an appropriate non-verbal response by d. Sit down on the side of the bed and look
the nurse? concerned.
26. From the doorway, the nurse announces a. Not tell the client about the CT scan.
to the client in the bed next to the b. Use personal distance to tell the client about
window that she will be going down for the CT scan.
a CT scan in 15 minutes. The client in c. Phone the client to tell them about the CT
the bed next to the doorway asks the scan.
nurse how long she has to wait until she d. Announce the CT scan to the client by
can go for her test too. The nurse using the room-to-nurses-station
responds with “I’ll go and see” while the communication device.
client next to the window is confused
and has no idea what the test is for. To
avoid this exchange of communication,
which of the following should the nurse
have done?
27. The introductory phase of the helping a. The client tells the receptionist that he
relationship is ending between the nurse won’t be making another appointment.
and a 25-year-old male client. Which of b. The client is overheard telling his wife that
the following statements is an indication the nurse “was a piece of work.”
that the outcome of this phase was c. The client feels relieved after talking with
successful? the nurse.
d. The client feels ashamed and wants another
nurse to see him the next time.
28. After completing the assessment of a 28- a. anxiety related to impaired verbal
year-old soft-spoken female client, the communication.
nurse selects a nursing diagnosis to b. powerlessness related to impaired verbal
address the client’s fear of being alone. communication
Which of the following diagnoses would c. low self-esteem related to impaired verbal
be appropriate for this client? communication
d. fear of social isolation

29. The nurse decides that a process a. are best when written down
recording is necessary to analyze the b. include the dialogue of both the client and
communication and behavior of a the nurse
client. Which of the following are true c. paraphrases the verbal exchange
about process recordings? d. includes the client’s nonverbal behaviors
e. are not recommended in current nursing
literature.
30. The nurse is concerned that her a. asking probing questions

communication style is restrictive and b. changing the subject while communicating
wants to improve. She analyzes her with a client
own communication patterns and c. paraphrasing a client’s response
realizes she is using many techniques d. giving clients information
that are considered barriers. Which of e. reassuring clients that “everything will be
the following might this nurse identify all right”
as a barrier to effective
communication?


Study Guide 5.8
Documenting Teaching
Documenting of the teaching process is essential because it provides a legal record that the
teaching took place and communicates the teaching to other health professionals. If teaching is
not documented, legally it did not occur.
It is also important to document the responses of the client and support people to teaching
activities. What did the client or support person say or do to indicate that learning occurred?
Has the client demonstrated mastery of a skill or the acquisition of knowledge? The nurse
records this in the client’s chart as evidence of learning. Many agencies have multiple-copy
client teaching forms that include the medical and nursing diagnosis, the treatment plan, and the
client education. After the teaching session is completed, the client and the nurse sign the form
and a copy of the form is given to the client as a record of teaching and as reinforcement of the
content taught. A second copy of the completed and signed form is placed in the client’s chart.
The parts of the teaching process that should be documented in the client’s chart include the
following:
• Diagnosed learning needs
• Learning outcomes
• Topics taught
• Client outcomes
• Need for additional teaching
• Resources provided
The written teaching plan that the nurse uses as a resource to guide future teaching sessions
might also include these elements:
• Actual information and skills taught
• Teaching strategies used
• Time framework and content for each class
• Teaching outcomes and methods of evaluation
Teaching like the nursing process, consists of six activities: assessing the learner, diagnosing
learning needs, developing a teaching plan, implementing the plan, evaluating learning outcomes
and teaching effectiveness, and documenting instructional activities.
• Teaching strategies chosen by the nurse should be suited to the client and to the material to
be learned.
• A teaching plan is a written plan consisting of learning outcomes, content to teach, and
strategies to use in the teaching the content. The plan must be revised when the client’s
needs change or the teaching strategies prove ineffective.
• Evaluating the teaching-learning process is both an ongoing and a final process in which the
client, nurse, and support people determine what has been learned.
• Documentation of client teaching is essential to communicate the teaching to other health
professionals and to provide a record for legal and accreditation purposes.


Study Guide 5.9
Case Study Teaching Activity
Mrs. Jones is a 59-year old African American bank vice president who is heavily relied on by her
boss and coworkers. Three days ago she was admitted to the hospital with complaints of
shortness of breath and mild chest pain. A diagnostic evaluation indicates that she has
significant coronary artery disease but has not yet suffered a heart attack. Her physician has
indicated that Mrs. Jones will need to make significant lifestyle changes to reduce her heart
attack risk. As her nurse, you have been requested to teach Mrs. Jones about her disease process,
diet, exercise, and stress reduction. As you begin teaching Mrs. Jones, you note that she is very
pleasant and frequently nods her head, but she also seems preoccupied and is readily distracted.
1. How would you evaluate Mrs. Jones’ readiness to learn?

2. Of what benefit would learning needs assessment be inasmuch as Mrs. Jones is
obviously a well-educated client?
3. You recognize that you have a great deal of information to deliver to Mrs. Jones, and
you are concerned that you will not be able to teach it all. What can you do to help
Ms. Jones and still feel that you have accomplished your teaching goals?
4. How will you know if your teaching is effective?
5. How might your teaching differ if you were teaching Mrs. Jones at home rather than
in a hospital or acute care setting?
6. Design a teaching plan for Mrs. Jones.


Study Guide 5.10
Teaching Plan – Practicing What We Preach Activity
The purpose of this activity is to provide you with an opportunity to describe (translate) a health
problem in layperson terms as if you were educating the patient and their significant others
(often abbreviated as “SO” reflects family, friends, common-law relations).
You will work in small teams to complete this activity. Your first task as a team will be to
decide upon a presenter and recorder. You will present your work to the rest of the class as an
informal verbal presentation. Use the next page as your guide.
Remember to keep these points in mind…
• Avoid medical jargon and abbreviations.

• The more syllables and longer the word the more likely it can be misunderstood.
• Start simply, becoming more complex IF and only IF your patient/SO demonstrates
knowledge.
• Think about principles of teaching and learning, the principles of communication from this
module.
Here is an example:
Pertussis is a highly contagious communicable disease which is spread by droplet transmission

of the bacteria Bardetella pertussis. It results in paroxysms of coughing that may be followed by
episodes of emesis. Young children who have this disease have a cough that has a whooping
sound. This characteristic cough gave the illness its common name of “Whooping Cough”. Due
to the contagious nature of the disease, and the public health concern about the disease, it is the
law that the health department must be notified of all cases so that contacts can be found and
placed on prophylasis.
Translation:
Pertussis is often called “Whooping cough.” The germ that causes it is easily spread though the
air for about 3 feet when someone who is sick from this coughs into the air. It causes children to
cough a lot and the cough has a whooping sound. Sometimes children cough so hard they throw
up. The health department wants to stop the spread of this germ that causes this sickness. When
someone has this sickness the doctor, nurse, or hospital will let the health department know so
that the nurses in the public health department can help. People who have been with the sick
person will usually be given medicine to kill the germ so that they will not get sick.

Practicing What We Preach
Your topic is: ________________________________________________________________
How would you briefly describe the pathophysiology of this condition?
What are common clinical manifestations/signs or symptoms?
What are usual treatments?
What health promotion can you include related to this topic?


Study Guide 5.11
Practice Teaching Questions
1. A 74-year-old client who takes multiple medications tells the nurse, “I have no idea
what that little yellow pill is for.” What is the best nursing diagnosis for this client?
a. Knowledge Deficit
b. Health-Seeking Behavior
c. Deficient Knowledge (Medication Information)
d. Noncompliance
2. In which situation is the client ready to learn?

a. A 45-year old man whose doctor just informed him that he has cancer.
b. A 3-year old child whose parents are reading a story book about going to the
hospital.
c. A 60-year old female who received/medication 5 minutes ago for relief of
abdominal pain
d. A 70-year old man, recovering from a stroke, who has returned from physical
therapy.
3. How can the nurse best assess a client’s style of learning?

a. Ask the client how he learns best.
b. Observe the client’s interactions with others.
c. Ask family members
4. A newly diagnosed diabetic client needs to learn about her diet. Which teaching
strategy would promote the best retention of the material?
a. Give her a videotape about diabetic diets.
b. Ask a nutritionist to visit the client to present information and handouts about the
diabetic diet.
c. Ask the client to make a list of her favorite foods and how to work them into her
diet.
d. Have the client attend a group meeting for diabetic clients to discuss their
adaptation to this chronic health condition.
ANSWERS:
1. a
2. d
3. a
4. b


Study Guide 5.12
Communication and Cultural Considerations
When answering communication questions the nurse needs to be aware of certain cultural
characteristic that relate to the communication process that may be different from his or her own
cultural uniqueness. Questions may address the concept of communication with a client from a
specific cultural group. If you note that a question contains information identifying a specific
cultural group, you need to think about specific cultural characteristics to answer the question
correctly.
With regard to communication, there are three cultural characteristics to consider, these include:
• Communication style
• Use of eye contact
• The meaning of touch
It is important to review the characteristics associated with a specific culture and to become
familiar with them. Identified below are some of the characteristics of specific cultural groups
that you need to consider.
COMMUNICATION STYLE
The following sections provide some background information to consider when developing your
communication style with specific cultural groups.
African Americans
• Personal questions asked on initial contact with the client may be viewed as intrusive
• Head nodding by the client does not necessarily mean agreement
Asian Cultures
• Asian cultures may believe that feelings and emotions are considered to be private, and an
open expression of emotions is valued by the client
• Silence is valued by the client
• Criticism or disagreement is not expressed verbally by the client
• Head nodding by the client does not necessarily mean agreement
• The client may interpret the word “no” as disrespect for others
• The client does not use hand gestures
European (White) Americans

• Silence can be used by the client to show respect or disrespect for another, depending on the
situation.
French and Italian American

• The client may use expressive hand gestures and animated facial expressions during
conversation

German and British Americans

• The client may show little facial emotion because these clients highly value the concept of
self-control.
Hispanic Americans
• The client may use dramatic body language such as gestures or facial expressions to express
emotion or pain.
• The client may tend to be verbally expressive, yet confidentiality is important
• Hispanic Americans may believe that direct confrontation is disrespectful, and the expression
of negative feelings is impolite.
Native Americans
• To Native Americans, silence indicates respect for the speaker
• Many of these clients speak in a low tone of voice and expect others to be attentive
• Body language is important
• Obtaining input from members of the extended family is important
USE OF EYE CONTACT
The following sections provide information regarding how the use of eye contact is viewed by
clients of specific cultural groups.
African Americans
• Direct eye contact may be interpreted as rude or aggressive behavior
Asian Americans
• Eye contact is limited and may be considered inappropriate or disrespectful

• Eye contact may be viewed as indicating trustworthiness
Native Americans
• Eye contact may be viewed as a sign of disrespect
• The nurse needs to understand that the client may be attentive even when eye contact is
absent
Hispanic Americans
• Some Hispanic Americans believe that avoiding eye contact with a person in authority
indicates respect and attentiveness.

MEANING OF TOUCH
The following sections discuss how touch is viewed in specific cultural groups.
African Americans
• African Americans may be comfortable with close personal space when interacting with
family and friends.
Asian Cultures
• These clients prefer a formal personal space except with family and close friends
• They usually do not touch others during conversation
• Touching is unacceptable with members of the opposite sex; if possible, a female client
prefers a female health care provider.
• The head is considered to be sacred; therefore, touching someone on the head may be
considered disrespectful.
• The nurse would avoid physical closeness and excessive touching and would only touch a
client’s head when necessary, informing the client before doing so.

• European Americans tend to avoid close physical contact
• The nurse needs to respect the client’s personal space
Hispanic Americans
• Hispanic Americans are comfortable with close proximity with family, friends, and
acquaintances and value the physical presence of others.
• The nurse needs to protect the client’s privacy
• Hispanic Americans are very tactile and use embraces and handshakes
• The nurse needs to ask if it would be all right to touch a child before examining him or her.


Study Guide 5.13
Cultural Awareness/Cultural Assessment
Overview: In providing care for clients that have differing cultural beliefs and practices, health
care professionals must genuinely explore their own feelings and beliefs and consider how their
ethnocentrism may impact the care delivered to clients. Health care professionals should be
aware of these attitudes and influences about individuals, families, groups, and communities they
serve.
It is the client’s right to be cared for within the context of his/her cultural beliefs, while it is the
nurse’s responsibility to influence health care to optimize the health of the individuals and the
whole of the community in which they work. One theory holds that when culture and health care
are congruent, the well-being or the health of the individual is at risk.
Terms
• Acculturation (or) assimilation is the assumption of values, beliefs, attitudes, or practices
of a dominant group in a society by a minority group.
• Bicultural: of, relating to, or including the identity of cultures, lifestyles, and value
systems.
• Culture incorporates the learned, shared, and transmitted values, beliefs, norms, and
practices of a particular group that guide thinking, decisions, and actions in patterned
ways.
• Cultural assessment is a consideration of the cultural beliefs, values, and practices of an
individual, group, or community to determine needs and interventions within a specific
cultural context.
• Cultural awareness is a recognition and understanding of the differences and similarities
between cultures and ethnic groups.
• Cultural blindness occurs when one does not recognize one’s own beliefs and values, or
those of others.
• Cultural care is health care in a cultural context, which includes acknowledging the
client’s cultural beliefs about disease and treatment.
• Cultural competence is knowing, appreciating, and using the culture of someone else to
resolve a problem.
• Cultural encounter is a direct contact with members of cultural communities.
• Cultural identity is a sense of the social and cultural heritage of past generations.
• Cultural sensitivity is a respect and appreciation of behaviors reflecting another person’s
culture.
• Culture shock is disorientation or inability to respond to different cultural environments.
• Culture-specifics are values, beliefs, and behaviors that are unique to a culture.
• Culture-universals are the commonalities of values and norms of behaviors among
different cultures.
• Discrimination is the act of treating someone or a group different based on race, ethnicity,
sexual orientation, gender, etc.
• Diversity is the state of being different.

• Emic care is the care determined by the local or insider’s views and values.
• Ethnic refers to a group that shares a common and distinctive culture, including racial,
national, tribal, religious, and/or linguistic characteristics.
• Ethnic group: shares common social and cultural heritage, which is passed from
generation to generation.
• Ethnic identity is one’s sense of belonging to a group distinguishable from another group.
• Ethnicity is knowingly belonging to a group differentiated from others by culture,
biology, territory, etc.
• Ethnocentrism is the thought that one’s cultural values and beliefs are superior to those of
other cultures.
• Ethno relativity refers to the ability to respect the beliefs and values of other cultures.
• Etic care is the care determined by the professional or outsider’s views and values.
• Indigenous health care system refers to traditional folk methods of health care, home
remedies, and folk medicines.
• Life ways are beliefs about dress, diet, and other activities of daily living within a culture
passed from generation to generation.
• Material culture refers to material objects and how they are used in a culture.
• Nonmaterial culture refers to the beliefs, customs, languages, and social institutions of a
culture.
• Prejudice is an irrational opinion about something, someone, or a group.
• Professional health care system refers to a structured system maintained by persons who
have received a formal education.
• Race is the classification of people by shared biologic characteristics, genetic markers, or
features.
• Racism is discrimination where race is considered the primary determinant of human
traits and capacity, and one race is superior.
• Stereotyping is an assumption that everyone in a culture or group is alike.
• Subculture refers to a group with a distinct identity that belongs to a larger cultural group.
• Tran cultural nursing is the use of caring behaviors, nursing care and health-illness
values, beliefs, and patterns of behaviors of other cultures. It requires providing culture-
specific and culture-universal nursing care.
Characteristics of Culture:
• Culture is learned.
• Culture is taught.
• Culture is social.
• Culture is adaptive.
• Culture is difficult to articulate.
• Culture exists at many levels.

Components of Culture:
• Language
• Art
• Music
• Values systems (beliefs, morals, rules)
• Religion
• Philosophy
• Family interaction
• Patterns of behavior
• Childrearing practices
• Rituals and ceremonies
• Recreational and leisure activities
• Festivals and holidays and associated practices
• Nutrition
• Food preferences
• Health practices
Subcultures
Subcultures exist in every community. These are groups of individuals who share a common
interest or goal, social standing, economic status, or ethnic background. Typically, the group is
characterized by commonality, cohesiveness, or perceived identity.
Culturally Sensitive Care

• Culturally sensitive care requires:
o Realizing one’s own cultural heritage
o Becoming aware of the client’s culture as described by the client.
o Developing adaptations the client made to live in a North American culture
o Forming a nursing care plan with the client that incorporates his/her culture
• Barriers to cultural sensitivity
o Ethnocentrism
o Stereotyping Prejudice
o Discrimination
o Racism
• Conveying cultural sensitivity
o Address clients by their last name unless they give you permission to use other
names.
o Introduce yourself by name and explain your position.
o Be authentic and honest about what you do or do not know about the client’s
culture.
o Use language that is culturally sensitive.
o Find out what the clients know about their health problems and treatments; assess
cultural congruence.

o Do not make assumptions about clients; encourage them to ask about anything
they may not understand.
o Respect the client’s values, beliefs, and practices.
o Show respect for the client’s support people.
Components of Cultural Assessment
Use of a cultural assessment will assist the health care professional in providing care that is more
effective to each individual client. The cultural assessment should include the client’s attitudes
about:
• Communication: A continuous process by which one person may affect another through
written or oral language, gestures, facial expressions, body language, space, or other
symbols. The nurse must understand some common beliefs of cultures within the
population for which they care, regarding communication. Native Americans use silence
to consider what has been said and formulate a response; whereas Americans tend to
answer immediately. In Eastern cultures, agreeing verbally or nonverbally, whether or
not one truly agrees or understands, is considered polite. In these cases, the health care
provider should pursue clarification. In Western cultures, lack of eye contact may be
seen as impolite and showing a lack of interest. In Native American and Southeast Asian
cultures, lack of eye contact is a gesture of respect, patience, and thoughtfulness. Some
cultures consider extensive eye contact offensive and disrespectful. Traditionally,
women of Asian and Eastern decent maintain modesty by avoiding eye contact. These
culture gaps can hinder the nurse-client relationship if the nurse mistakes the client’s
actions as disregard or apathy. Therefore, nurses should communicate openly, while
respecting different methods of interaction. Use the following communication
techniques:
o Avoid use of jargon and colloquialisms.
o Observe the client for non-verbal cues, such as facial expressions, gestures, and
body language.
o Use clear articulation with a normal volume of speech.
o Be attentive to client’s responsiveness to interpersonal space and use of silence,
touch, and eye contact; adjust communication style, as necessary.
o Choose words that do not have more than one meaning.
o Select an interpreter with knowledge of medical terminology, if needed.
• Space: This is the area around a person’s body that includes the individual, body,
surrounding environment, and objects within that environment. Again, the spatial needs
of individuals may vary from culture to culture. In Middle Eastern cultures, close face-
to-face conversation is the norm. In the U.S., most individuals would consider being
closer than an arm’s length during conversation, too close. In Italian and Mexican
cultures, physical presence and touching are valued and expected. Africans and
Mexicans also maintain a closer physical proximity. Conversely, most Eastern and
European citizens honor a distant proximity. In Muslim cultures, it is improper for men
and women to even shake hands before marriage, so care by a primary care provider or
nurse of the opposite sex would be highly inappropriate. Most people judge comfortable
distance based on their relationship with the other person. This should be considered as
well because in Asia, distance is dependent on the status of the parties. They view health
providers with authority and maintain distance out of respect. Prior to caring for
individuals, whether asking personal questions in an interview or doing a physical
assessment, it would be necessary for the health care provider to understand the client’s
beliefs about personal space and physical contact.
• Social Organization (family patterns): This area includes the family and other groups
within societies that dictate culturally acceptable role behaviors of different members of
the society and rules for behavior. Behaviors are prescribed for significant life events,
such as birth, death, childbearing and childrearing, and health practices and illness. Most
cultures have strong beliefs involving family ties. Some families have nuclear family and
extended family living within the same house. This, along with the role each family
member assumes, can strongly influence health care decisions. The nurse should
consider:
o What is the definition of family (nuclear or extended)?
o Are there gender or age roles that affect the choice of whom the nurse should
address when entering the home or in consultation about a client’s health?
o What are the traditional roles within the family that affect care giving?
o What value is placed on children and the elderly?
o What is the perception of females within the culture?
o What is expected from the family in health care decisions?
o How is information regarding the health of a family shared with the community?
o What role does religion play in health care practices and decisions?
• Time: This area refers to the meaning and influence of time from a cultural perspective.
Time orientation refers to an individual’s focus on the past, present, or future. Most
cultures contain all three, but one is often a stronger influence than the others.
• Environmental control (health beliefs and practices): This area refers to the ability or
perceived ability of an individual from a particular culture to control nature, causes of
illness, and treatment. Most cultures have traditional beliefs that connect health to
religion. Prayer, ceremony, and meditation may be involved in the healing process,
which may be guided by a community healer, “medicine man”, or minister. Traditional
healing therapy also may include the use of traditional remedies, medicine, and herbs.
There are three views on the relationship between the environment and nature that are
generally considered. These include:
o Magic or religious view: views illness as having a supernatural force; evil spirits
cause illness as a punishment from God. People from Hispanic and Caribbean
cultures may have this belief. They also may believe there is a supernatural
counterforce and will seek out recognized individuals to remove “spells.”
o Biomedical view: perceives illness and disease to be caused by microorganisms
or a malfunction of the body. People with this belief seek out surgery, medicines,
or medical treatment to cure illnesses.
o Humoral view: looks for a balance with nature. Latin and Asian cultures may
accept the hot and cold theory, believing that the body is characterized by evenly
distributed warmth; illness results from an attack of hot or cold. Many Eastern
cultures ascribe to the theory of yin and yang, and a balance of opposite forces,
with imbalances in these forces resulting in illness.

• Biologic variations: This area refers to the biologic differences among racial and ethnic
groups; this can include physical characteristics, such as skin color; physiologic
variations, such as lactose intolerance, or susceptibility to certain disease processes, or
genetic differences. Some common physiologic variations that will be important to the
community health nurse in his or her education, screening, and care of certain
populations include:
o African and African Americans have a much higher rate of sickle cell disease.
o Hypertension in common in Asians and Africans. Thirty percent of black males
have G6PD.
o Many Asians, Africans, Hispanics, and Native Americans have G6PD, which is
expressed as lactose intolerance.
o Native Americans have a very high incidence of diabetes mellitus and a high
incidence of arthritis.
o Native American infants less than one year old are six times as likely as the
general population to have asthma or bronchitis.
o Myocardial infarction is the leading cause of heart disease in Native Americans,
accounting for 43% of deaths from heart disease.
o Japanese Americans have a low incidence of myocardial infarction and ulcers.
o Japanese Americans have a high incidence of colitis.
o Up to 50% of Eskimo children less than two years old have chronic otitis media.
• Nutritional patterns are often strongly influenced by culture. This may be due to the
staple foods of a population, (e.g., Asia’s staple is rice, Italy’s staple is pasta, and Eastern
Europe’s staple is wheat). The preparation and presentation of food also reflects culture.
Some cultures prefer unleavened breads. Some cultures oppose the idea of breastfeeding
and may introduce solid food to infants at a very early age. Some cultures classify foods
as “hot” or “cold” and use a “hot” food to treat a “cold” illness. Religion also may have a
strong affect on diet. Some faiths avoid pork; prohibit meat, caffeine, or alcohol. As the
nurse in the community offers education on diet and nutrition, an understanding of the
individual’s cultural influence on his/her diet is essential for developing an effective plan
that the client will follow.
• Pain responses must be assessed with culture in mind. The pain response must be
evaluated relative to the actual perception of pain and to the meaning or significance of
pain to the client. In some cultures, pain is considered a punishment and the client will
tolerate the pain to atone for sins. For others, self-inflicted pain is a sign of mourning or
grief. Pain may be part of a ritual or rite of passage and tolerance is a sign of courage and
strength. Treatment for pain may vary from culture to culture. In the U.S., medication is
considered the treatment of choice for analgesia; in other cultures, it may be heat, cold,
relaxation, or traditional treatments. The nurse should assess the client’s perception,
response, and accepted treatment to pain within the context of the individual’s culture and
religion. The nurse must then provide choices that would provide effective pain relief
and that do not conflict with the culture and beliefs of the client.
• Death and dying practices are vitally important in the grieving process to the client and
the survivors. Some groups have specific practices around death and the dead that should
be included in the care of the client and family. Dying alone is generally unacceptable in
most cultures and the nurse must know whom to contact if death becomes imminent.

o Autopsy may be prohibited, opposed, or discouraged by Eastern Orthodox

religions, Muslims, Jehovah’s Witnesses, and Orthodox Jews. Some religions
require that all body parts be give a proper burial or prohibit removal of any body
parts.
o Jehovah’s Witnesses and Muslims prohibit organ donation. Buddhists in America
consider organ donation an act of mercy and encourage it.
o Cremation is discouraged or prohibited by Mormon, Eastern Orthodox, Islamic,
and Jewish faiths, while Hindus prefer cremation with the ashes being scattered in
a holy river.
o Prolongation of life is usually encouraged. Buddhists may permit euthanasia in
terminal illness, those of Jewish faith usually oppose prolonging life once
irreversible brain damage has occurred, and those of Christian Science faith
generally will not use the medical system to prolong life.
After death, it is important for the nurse to know the wishes and beliefs around preparation of
the body. Are there special burial clothes or are there rituals around preparation of the body?
Once the nurse is aware of these practices, they can be communicated with the funeral home
or other professionals involved with the client and the survivors.
Each individual has the right to consideration of his/her culture in the care received. The
community health nurse should always remember to respect the beliefs and values of their clients
while planning, educating, and providing the care the client needs for optimal health and
maintenance of their dignity through illness, recovery, rehabilitation, or death.
Community Based Trans-Cultural Nursing
Community based, trans-cultural nursing is the application of concepts, principles, research,

knowledge, and practices that focus on diverse populations. The goal of culturally competent
care involves promoting health and preventing illness and injury, regardless of race, gender,
religion, language, socioeconomic situation, or ethnicity.

Study Guide 5.14
Cultural Aspects of Nursing - Activity
• Acculturation
• Culture
• Cultural blindness
• Cultural sensitivity

• Culture shock
• Discrimination
• Ethnicity
• Ethnocentrism
• Transcultural Nursing
List the cultural phenomena that influence nursing care:
1. ___________________________________________________________
2. ___________________________________________________________
3. ___________________________________________________________
4. ___________________________________________________________
5. ___________________________________________________________
6. ___________________________________________________________
List four (4) methods for conveying cultural sensitivity:
1. _____________________________________________________________
2. _____________________________________________________________
3. _____________________________________________________________
4. _____________________________________________________________
List two (2) examples for each of the following:
• Communication

o ___________________________________________________
o ___________________________________________________
• Social Organizations
o ___________________________________________________
o ___________________________________________________
• Environmental Control
o ___________________________________________________
o ___________________________________________________
• Biological Variations
o ___________________________________________________
o ___________________________________________________
Select a partner. Utilizing the scenario below, identify the data that relates to the cultural
phenomena listed below:
Scenario: In the clinic today, you encounter an Iranian female client who is the mother of two
(2) children, a four (4) year old and a seven (7) month old. Her English is limited and her
primary responsibilities are those of a homemaker and caregiver for her children. The family
socializes exclusively with other Iranian families and her husband believes that they should take
care of their own. There are two adult siblings who reside with the family and attend college and
they assist with the children when they can. Following the birth of the youngest child, the client
developed a prolapsed uterus. She has arthritis and osteoporosis which causes frequent pain and
fatigue and limit her ability to care for her children due to the limitations for lifting. The doctor
has ordered birth control pills and advised her that another pregnancy would be very detrimental
for her. You are responsible for teaching and follow-up with this client.
• Communication _______________________________________________
_______________________________________________
• Space _______________________________________________
_______________________________________________
• Social Organization _______________________________________________
_______________________________________________
• Environmental Control _______________________________________________
_______________________________________________
Discuss implications for health care delivery ___________________________________
_______________________________________________


Study Guide 5.15
Spirituality
Spirituality is the life principle that pervades a client’s entire being, integrating and transcending
one’s biological and psychosocial nature. It is considered a core dimension and critical
determinant of health-related quality of life. Spiritual well-being typically affirms the unity of
the person with the environment and is important for social connection. Spiritual distress is
demonstrated by concern by the meaning of life, inner conflict, questions about one’s existence,
and the inability to practice one’s religion.
• Spirituality is important to a client’s health-related quality of life.

• The goals of collaborative management include:
o Promoting spiritual well-being
o Incorporating of therapeutic presence, listening and dialogue
o Promoting a positive sense of meaning
o Facilitating of religious rituals and practices
o Protecting clients’ religious beliefs
Spiritual Distress – The Client

• Expresses concern with the meaning of life
• Shows anger toward a higher power
• Verbalizes inner conflict about beliefs
• Questions the meaning of his/her own existence
• Is unable to participate in his/her usual religious practices
• Is concerned about moral/ethical implications of therapeutic regimen
Therapeutic Nursing Management

• Promote spiritual well-being by informing a clergy member (with permission of the client)
and arranging a visit
• Provide spiritual art work, music, or reading material
• Be therapeutically present with active listening and dialogue
• Promote a positive sense of meaning by facilitating experiences that are known to create a
sense of purpose
• Facilitate religious rituals and practices

Situation
During an interdisciplinary team meeting on a medical unit, a staff member mentions that
spirituality has no place in the discussion of a client’s care. Several other staff members agree;
however, you do not. Feeling somewhat uncomfortable, you do not say anything. Two weeks
later, the team discusses a client who was admitted with multiple sclerosis. You admitted the
client and indicated in the record that one nursing diagnosis for the client was spiritual distress.
The team is discussing this diagnosis and again some disagree with is use. You must defend
your decision by educating the staff members about spirituality and relevant nursing care.
A. You begin by given them a definition of spirituality, which is:
Spirituality is the life principle that pervades a client’s entire being, integrating and
transcending one’s biologic and psychosocial nature. It affirms the person’s unity with the
environment.
B. What data might you identify in the client’s behavior to support the nursing diagnosis of
spiritual distress?
• Expresses concern about the meaning of life.

• Verbalizes inner conflict about beliefs and may express anger toward a higher power.
• Questions meaning of own existence.
• Is unable to participate in usual religious practices.
• Questions moral/ethical implications of the therapeutic regimen.
C. You anticipate that one of the client’s concerns likely to be verbalized is: “What can we
possibly do about this problem?” How will you answer this question?
• Promote spiritual well-being by asking if the client would like to see the chaplain or
his/her own clergy. If so, provide privacy during the visit.
• Be present for the client by listening and discussing concerns that client may have during
this time.
• Facilitate religious rituals and practices with client’s agreement. Client may not realize
that it is possible to do this in the hospital.
• Encourage the client to identify positive aspects of his/her life.

Fundamentals

Module 6 – Critical Thinking and the Nursing Process

Study Guide 6.1
Critical Thinking in Nursing
The complex legal, educational, and professional problems confronting nurses today emphasize
the need for more than rote memory, knowledge of skills, and the ability to follow directions.
Indeed, today critical thinking is an expected competency of nurses at all levels of education and
practice. But you may be asking, “What exactly is critical thinking, and how do I learn to think
critically if I’m not doing so already?”
In the next few paragraphs you will be introduced to the concept of critical thinking and its
common characteristics—characteristics that, when used, will become habit and will enhance
your ability to think critically.
Historical Perspective
Florence Nightingale is generally credited as the founder of modern nursing. There is evidence
that Nightingale subscribed to methods of teaching that required critical thinking. Her students
were required to keep case books in which they recorded, analyzed, and reflected upon activities
on the ward. She regarded these diaries as useful because they required higher-order thinking
and superior powers of observation.
During the 1920’s, the lecture was the primary method used to teach nursing students. However,
some nurse educators advocated the use of discussions, written assignments, and time for
thinking. Despite the emphasis placed on thinking by nursing leaders of the ‘20s, ‘30s, and ‘40s,
it was not until the late 1950s that a change in curricular structure actually took place. In 1953
Louise McManas proposed a set of functions unique to the professional nurse, today known as
the nursing process and nursing diagnosis (McManas, 1953). McManas maintained that nurses
who were taught the nursing process could be assumed to possess the ability to think reflectively
and use higher analytical skills such as reasoning, judging, and drawing inferences. Today this
assumption is highly debated. Many assert that the teaching nursing process is not, by itself,
enough to produce critical thinkers.
Most recently, NLN representatives have begun to promote the use of activities that foster
student thinking abilities. This move follows the national trend of the ‘80s to promote critical
thinking at all levels of education. The NLN’s most recent accreditation standards require
nursing schools to provide evidence of student achievement of critical thinking. The need to
include critical thinking in the nursing school curriculum is no longer an issue. Nutting’s vision
is now reality.
Critical Thinking
Critical thinking has as many definitions as there are authors writing about it. However, the
following definitions are the most prevalent in critical thinking literature:

• Critical thinking is reflective and reasonable thinking that is focused on what to believe
or do.
• Critical thinking is an attitude of inquiry involving the use of principles, abstractions,

deductions, interpretations, and analysis of arguments.
• Critical thinking is disciplined, self directed thinking that exemplifies the perfections of
thinking and displays mastery of intellectual skill and abilities; it is the art of thinking
about your thinking while thinking in order to make your thinking better.
• Critical thinking is an investigation whose purpose is to explore a situation, phenomenon,

question, or problem to arrive at a hypothesis or conclusion about it that integrates all
available information and can, therefore, be convincingly justified.
Critical thinking is a complex process that cannot be explained with a single definition. It is
more important to familiarize yourself with the characteristics of critical thinking and to develop
critical thinking habits. The purposes of this module and its activities are to acquaint you with
the skills and attitudes associated with critical thinking and to provide you with practice
opportunities for using the skills in your nursing courses.


Study Guide 6.2
Critical Thinking Practice Exercise
Session One
Answer the following questions:
• What is your social security number?
• How many days are in the month of September?
• What is the normal temperature of the human body?
What kind of thinking did you use to answer the above questions?
Session Two
You have been notified by your employer that the primary parking lot for your building will be
inaccessible for the next few months. Your employer further explains they have obtained
parking spaces for you that are about half a mile down the road and there will be shuttle buses
available every 15 minutes to take you to your building. You are strongly urged to use the
remote parking. You suddenly realize that you will have to start leaving for work at lease a half
hour earlier to be able to park in the remote parking lot. While taking with a friend about your
concerns, she advises you to park where ever you want to, as there is no specific company policy
indicating that you must park off-site in the remote parking lot.
• What is your first reaction about where you should park?
• What would you do about where to park?
• Who or what most influenced you to make the decision you made?
• What thinking attitudes influenced your thinking?
• What cognitive skills did you use?

Session Three
A forty-two year old woman, who is 5 foot 2 inches tall, has recently had a weight change and
now weighs 150 pounds. You notice that she is wearing a loose-fitting jogging suit.
• What conclusions can you make about this woman?
• What assumptions did you base your conclusions?
• What data do you need to verify your conclusions?
• What biases are apparent in this case?
• What perceptive attitudes influenced your thoughts about the woman?
• What cognitive skills did you use when considering the woman’s appearance?
Possible Answers to Critical Thinking Practice Sessions
Session One
• These answers are facts.
• Memory, recall, and the cognitive skill of basic support.

Session Two
• Several reactions are plausible: follow your work guidelines and take the shuttle; ignore
your work guidelines and park wherever you want; or consider another area all together.
• No recommendations.
• Possibilities: your obligation to follow directions; fear of the consequences; your sense
of honesty to your employer; or a previous experience with a similar situation.
• Possibilities: faith in reason and responsible sense of reasoning.
Session Three
• Many conclusions are possible, but none may be correct. For example, the woman may
have added on weight and is trying to hide it; she could have recently lost weight and
then gained a bit of it back; she could be pregnant; or she may want to just be
comfortable. No exact conclusions can be drawn on the basis of the information
provided.
• Possible theories: people whom are overweight try to hide it; or people whom are
overweight like to were large clothes and are a bit sloppy (these are both biased
assumptions).
• Data needed: what is the woman’s recent weight gain or loss; is she dressed this way for
comfort; is she exercising or possibly pregnant?
• Biases depend on suspicions and beliefs. If you conclude that the woman was try to hide
her weight, based on erroneous suspicions, then your bias opinion is against overweight
people.
• Intellectual humility and intellectual empathy.
• Possibilities: analysis, assorted thinking and reflection.


Study Guide 6.3
Components of the Nursing Process
The nursing process is a systematic, rational method of planning and providing

individualized nursing care. Its’ goal is to identify a client’s health status and actual or
potential health care problems, to establish plans to meet the identified needs, and to
deliver specific nursing interventions to meet those needs. The nursing process is cyclical;
that is, the components of the nursing process follow a logical sequence, but more than one
component may be involved at any one time. The five components of the nursing process
are:
• Assessing – collecting, organizing, validating, and recording data about a client’s

health status to establish a database. Activities include obtaining a health history,
performing a physical assessment, reviewing client records, reviewing literature,
and consulting support people and health professionals.
• Diagnosing – the process of analyzing and synthesizing data, which results in a
diagnostic statement or nursing diagnosis. Activities include clustering data;
comparing data against standards; generating tentative hypotheses; identifying gaps
and inconsistencies; determining the client’s health strengths, risks, and problems;
and formulating nursing diagnoses statements.
• Planning – a series of steps in which the nurse and the client set priorities, goals, or
desired outcomes and establish a written care plan designed to resolve or minimize
the identified problems of the client and to coordinate the care provided by all
health team members. Activities include setting priorities with the client, writing
evaluation goals and outcome criteria with the client, selecting nursing strategies,
consulting with other health care personnel, writing nursing orders and nursing
care plans, and communicating the care plan to relevant health care providers.
• Implementing – putting the nursing care plan into action to help the client attain
goals. Activities include reassessing the client, updating the database, reviewing and
revising the care plan, and performing or delegating planned nursing interventions.
• Evaluating – measuring the degree to which goals/outcomes have been achieved and
identifying factors that promote or impede goal achievement. Activities include
collecting data about the client’s response, comparing the client’s response to
evaluation criteria, relating nursing actions to client outcomes, making decisions
about problem status, and modifying the care plan.


Study Guide 6.4
Introduction to the Assessment Process – Activity
There are several sources which can be used for the collection of data as part of client
assessment. Identify sources for the collection of data and where each may be found (a
minimum of 5 sources). Prioritize the order in which you expect to use these sources.
1.
2.
3.
4.
5.
Scenario: You are admitting a client who is complaining of pain in the lower right
quadrant of the abdomen. When you approach the bed, you find her lying on her right
side with the knees drawn up. Her fist are clenched and there are furrows in her brow.
Her skin is hot and diaphoretic. She states that she is nauseated. There is another person
at the bedside who came to the hospital with her.
Provide a definition of each of the following terms and give an example of each.
1. Assessment
2. Subjective Data
3. Objective Data
4. Inspection
5. Auscultation
6. Palpation

From the scenario above, identify and list the objective data.
Objective Data:
1. ______________________________
2. ______________________________
3. ______________________________
4. ______________________________
Subjective Data:
1. ______________________________
2. ______________________________
Select a partner from your assigned clinical group. Using the scenario below, conduct
an assessment interview in the Skills Lab. Respond to the requests located at the end.
The client is an 18-year-old female who has been a diabetic since the age of 8. Since
she has been in the nursing program, attending classes full time, she has continued a
full-time evening job. Her intense schedule has contributed to a change in her sleeping
and eating patterns. Three days ago, she developed flu-like symptoms. Today, she feels
worse and called her physician who has instructed her to come to the office. Her pulse
is 100 and respirations are 26. Diagnostic tests have been ordered.
Conduct a nursing interview which includes the items discussed in the classroom.
From the information in the scenario and the focused interview, identify the objective
data:
Identify the subjective data:
Conduct a first level physical assessment which includes inspection, auscultation and
palpation. Identify the information that is obtained from each of these:
______________________________________________________________________
______________________________________________________________________

______________________________________________________________________
___

Study Guide 6.5
The Use of Nursing Diagnosis Activity
Go to the web site http://www.nanda.org for the North American Nursing Diagnosis
Association.
Describe based on this website what the abbreviation NANDA means:
_____________________________________________________________________________
_
_____________________________________________________________________________
_
Download and print a list of current Approved Nursing Diagnosis that are on this website. Keep
this current list with you at all times in the clinical lab.
How many Nursing Diagnosis is currently listed on NANDA website? Answer: _________
Review in your primary Foundations textbook the history and evolution of nursing diagnosis.
Describe the early controversy over the use of “diagnosis.” Answer (Narrative form):
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_

_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
Differentiation between Nursing Diagnosis and Medical Diagnosis
Nursing diagnosis focuses on and defines the nursing needs of the patient (Gordon, 1994). It
reflects the patient’s level of health or response to a disease, an emotional state, a sociocultural
phenomenon, or a developmental stage (Carpenito, 1995).
A medical diagnosis predominately identifies a specific disease state. The medical focus is on
the diagnosis and treatment of the disease.
Nursing diagnosis is an outcome of nursing assessment utilizing the Nursing Process.

Diagnosing is the interpretation of patient assessment. Nursing diagnosis helps identify patient
strengths and health problems that independent nursing intervention can prevent or resolve.
Nursing diagnoses may change from day to day a the patient’s responses to health and illness
change. The primary benefit that nursing diagnosis offers the patient is the individualization of
patient care.

Carpenito, L.J. (1995). Nursing diagnosis: Application to clinical practice (6th ed.).
Philadelphia: J.B. Lippincott.
Gordon, M. (1994). Nursing diagnosis: Process and application (3rd ed.). St. Louis: C.V.
Mosby.
ACTIVITY
Complete the following activities and share your answers with your clinical lab group.
In your clinical area find a patient with an established medical condition. List the medical
diagnosis and nursing diagnoses. Explain the differing purposes of medical and nursing
diagnosis. What is nursing’s diagnostic contribution to the interdisciplinary team’s effort to care
for this patient.
Medical Diagnosis List possible nursing diagnosis using current

NANDA list:
Interview an experienced nurses, and find at least one nurse who is strongly committed to using
nursing diagnoses and another who believes they are a waste of time. Explain their different
experiences with nursing diagnoses. Identify the benefits and limitations of using nursing
diagnoses based on your interviews. Write a narrative answer.
_____________________________________________________________________________
_

_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_


Study Guide 6.6
Introduction to Formulating a Nursing Diagnosis - Activity
• Assessment
• Evaluation
• Implementation
• Planning
• Nursing Diagnosis
• Nursing Intervention Classification (NIC)
• Nursing Outcome Classification (NOC)
• Outcome identification
List the five (5) components of the Nursing Process:
• ___________________________________________________________
• ___________________________________________________________
• ___________________________________________________________
• ___________________________________________________________
• ___________________________________________________________
The NANDA Nursing Diagnoses are classified and formulated to address the client’s health
problems, which can be:
• _______________________________
• _______________________________
• _______________________________
• _______________________________

Scenario: You are assigned to care for a 70 year old client who has just been diagnosed with
Parkinson’s Disease. You note that he has severe tremors and his hands move in a “pill rolling”
fashion. Prior to the onset of symptoms, he had continued to work part-time as a pharmacist and
drove himself . His wife died approximately one year ago and he lives alone.
Select () the Nursing Diagnosis that is most appropriate for this client. You may use the
NANDA Nursing Diagnosis table to validate your selection.
____ Loneliness, risk for ______ Social isolation _____ Altered body image
List defining characteristics for the diagnosis you selected:
• ______________________________________________________________
• ______________________________________________________________
• ______________________________________________________________
In a team conference four (4) weeks later, the discharge planner reports that on a follow-up home
visit, the client had lost 5 pounds. His appearance was disheveled: clothing soiled and in need of
a shave. She had made a referral to a home health agency for in home supportive services and to
Meals on Wheels for nutritional support.
Select () the Nursing Diagnosis that is most appropriate for this client at this time..
_____ Disturbed personal identiy _____ Self care deficit, feeding,hygiene, dressing
_____Adjustment, impaired
List defining characteristics for the diagnosis you selected:
• ______________________________________________________________
• ______________________________________________________________
• ______________________________________________________________
Select a partner and correct the following nursing diagnoses using the three part statement,
including diagnostic label, related factors and defining characteristics
Self-care deficit, Feeding: due to left cerebrovascular accident manifested by not eating

Disturbed body image due to hysterectomy
Outcome identification is the most recent addition to the nursing process. Outcome
identification serves four (4) purposes. They are:
• __________________________________________
• __________________________________________
• __________________________________________
• __________________________________________
Correctly stated outcome criteria are specific, measurable, and realistic.
Correct the following so that is meets the above criteria:
Walks in the hall
• __________________________________________________________________________


Study Guide 6.7
Formulating a Nursing Diagnosis - Activity
• Clustering Data
• Defining characteristics
• Etiology
• Nursing Diagnosis
• Risk factors
A nursing diagnosis describes an actual, risk or wellness human response to a health problem
that nurses are responsible for treating independently or collaboratively.
List the components of the two-part Nursing Diagnostic statement:

• ___________________________________________________________
• ___________________________________________________________
List the components of the three-part Nursing Diagnostic statement:

• ___________________________________________________________
• ___________________________________________________________
• ___________________________________________________________
Interactive Activity: Select a partner and complete the following activities using the scenario
presented.
Scenario: A 70 year old client was diagnosed with Parkinson’s Disease. Upon diagnosis,
he had severe tremors and his hands moved in a “pill rolling” fashion. He was referred to a
home health agency for in home supportive services and to Meals on Wheels for nutritional
support. The doctor prescribed Carbidopa/levadopa (Sinemet ® 10/100 mg) 30-60 min prior
to meals twice a day. The client comes for a clinic visit today. You note that the tremors of
his hands have increased. You question him about his home regime, and he tells you that he
stopped taking the medication because it always “upset” his stomach.
Use the scenario above to cluster the subjective and objective data;

Objective data: _____________________________________________________________
_____________________________________________________________
Subjective data: _____________________________________________________________
______________________________________________________________
List the defining characteristics:
_______________________________________________________________
_______________________________________________________________
Use the data to complete the nursing diagnosis below with a three-part statement for the client:
Knowledge deficient,______________________________________________________
_______________________________________________________________________
With your partner, review the following scenario and list the defining characteristics. Identify
the error in the nursing diagnostic statement and write a correct nursing diagnosis:
You admit an elderly gentleman following a fall in his home. He fractured his left wrist and a
rib, has multiple bruises on his left elbow, knee and hip. He reports that he was attempting to go
to the bathroom and doesn’t remember what happened before he fell. He uses a walker but was
not using it at the time. His son found him lying on the floor beside his bed. The following
nursing diagnosis was written:
Impaired tissue integrity r/t confusion
Defining Characteristics Errors
_____________________________________
______________________________
_____________________________________
______________________________

Nursing Diagnosis
______________________________________________________________
______________________________________________________________
An 80 year old female has been depressed since the death of her spouse of 45 years, six months
ago. She has neglected her appearance, not eaten well, has skipped her medication frequently
and remains in bed often. Her daughters attempt to visit her as often as possible but have very
stressful management jobs. She is brought to the clinic today by one of her daughters because
she has lost about 10 pounds and developed a reddened area on her coccyx. This client is alert
and oriented and vital signs are within normal limits but. She states that she doesn’t have much
to live for anymore since her husband died and she doesn't want to become a burden on her
daughters.
Cluster the subjective and objective data;
Objective data: _____________________________________________________________
_____________________________________________________________
Subjective data: _____________________________________________________________
______________________________________________________________
List the defining characteristics:
_______________________________________________________________
_______________________________________________________________
Write a nursing diagnosis with a three-part statement for this client:
_______________________________________________________________________
_______________________________________________________________________


Study Guide 6.8
Scenario for Care Plan
Mr. Duncan was admitted to Central West Hospital three days ago for surgical amputation of the
left leg. He was diagnosed with gangrene in the left foot several weeks ago. Medical treatment
has been unsuccessful in treating the gangrene. Mr. Duncan, age 45, was diagnosed with Type I
diabetes and has taken insulin for 20 years. Six months ago, he injured his left foot while
working as a fireman. You enter his room and find him looking out the window. You introduce
yourself but he doesn’t look at you. He states, “You don’t need to do anything for me today.
Concentrate your care on someone who is a whole person.”
Using this information, complete a Care Plan for Mr. Duncan.

Nursing Care Plan
Student’s Name: __________________________________________________________Date:

_________________________
Client’s Initials: ________ Room #: ________
ASSESSMEN ASSE
T SSM
ENT
OBJECTIVE SUBJECTIVE NURSING GOAL INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OF GOAL /
Use NANDA MODIFICATION
Taxonomy Only
The client will: The nurse will:


Study Guide 6.9
Documentation – Charting Guidelines
Documentation Guidelines
Charting/documentation is a written method of conveying client information, the nursing process

and essential data related to assessments, interventions, goals and client response to care. The
chart is a client’s legal record. The following list of guidelines can help you chart/document
accurately:
• Make sure the nursing record is stamped with client’s name before you begin writing.
• Write legibly, print, if necessary. Always write in permanent ink. Check agency policy
for color of ink.
• Begin each entry with the time and date of the recording. End each entry with a signature
that consists of first initial, last name, and abbreviated title.
• Never erase or use white-out. Cross through a mistake with a single line, write the word,
“error” above it and initial the change.
• If a blank space appears in a notation, draw line through the blank space so that no
additional information can be recorded at any other time by any other person.
• Write your notes as soon as possible after giving nursing care.
• Be precise. State your assessments objectively. Report the client’s subjective opinions by
quoting directly. Avoid using words that convey judgment or inference – just state the
facts.
• Chart the client’s response to interventions.
• Use only commonly accepted abbreviations, symbols, and terms specified by the agency.
• Record your teaching.
• Review your notes – are they clear and what you want to say?
• Remember that from a legal perspective, if you did not chart it, you did not do it!
Essential Client Information
The following may assist you in selecting essential client information to record. Note that you
should emphasize data that denote a change in the client’s health status or behavior and data that
indicate a deviation from what is usually expected.
• Any behavior changes, such as:

o Indications of strong emotions, such as anxiety or fear.
o Marked changes in mood.
o A change in level of consciousness, such as stupor.
o Regression in relationships with family or friends.
• Any changes in physical function, such as:
o Loss of balance.

o Loss of strength.
o Difficulty hearing or seeing.
• Any physical sign or symptom that:
o Is severe, such as severe pain.
o Tends to recur or persist.
o Deviates from normal, such as elevated body temperature.
o Gets worse, such as gradual weight loss.
o Indicates faulty health habits, such as lice on the scalp.
o Is a known danger signal, such as a lump in the breast.
• Any nursing interventions provided, such as:
o Medications administered.
o Therapies.
o Activities of daily living, if agency policy dictates.
o Teaching clients self-care.
• Select data gathered from visits by a physician or other members of the health
team.
There are various types of documentation but the most frequent forms of charting that is done
now is via narrative notes in various forms, Focus (DAR) and Point of Care (POC) in addition to
various flowsheets and clinical pathways.
Narrative Notes – This is a method for recording relevant client information and nursing
activities. It is commonly used in agencies where the chart is organized according to disciplines
and each discipline completes documentation on their specific pages. The narrative note
includes date and time of entry, specific activities accomplished with client response, signature
and abbreviated title.
Focus Charting – is a method of documentation that organizes information by data (D), action
(A), and response ( R ). Entries are made on significant events, problem areas, positive or
negative growth, knowledge areas. The ( D) data describes subjective and objective symptoms
that support the focus of the entry. The (A) action is the intervention or treatment done to
address the data. The ( R ) response section contains the client’s response to the intervention or
treatment. It is possible to have an entry which includes all three (3) sections but may have any
one of the three.
Point of Care – reflects documentation that occurs as care is given. The goal of this form of
documentation is to promote efficiency, accuracy and timeliness. This form of documentation
has become more common with the use of technology. Bedside computers, mobile terminals,
stationary terminals located in various patient care areas are now available. In some instances,
health team members may carry handheld or portable computers.
Flowsheets – Flowsheets are designed to document routine procedures and free health members
from continuously writing procedures that are frequently repeated. Examples of flowsheet
commonly in use are:

• Vital Graphic Sheets – Vital signs (temperature, pulse, respirations and blood
pressure) are documented graphically on a record and trends can be readily
evaluated.
• Intake and Output – An ongoing record of the intake and output
• Medication Administration Record (MAR) – Medications with dose and
frequently are entered on the record at the time they are prescribed. When
medications are administered at the prescribed time, the nurse enters initials
which are identified at the bottom of the page by a signature ( PRN medications
are usually placed on a separate sheet and in addition to initials, the time is
entered when given).
• Assessment Record - Areas of assessement are placed on a flowsheet with
common terms to describe the specific asssessment area and the nurse can
indicate, according to agency policy, client findings.
• Critical Care Flowsheets - Used in intensive care and emergency room to
document frequently changing data, specific interventions, client responses,
medications and IV fluids common to the unit. Documentation is completed
according to agency policy and standards.
When flowsheets are used, further documentation is required any time there is an unusual
response or client’s status changes significantly


Study Guide 6.10
J.A.C.H.O. Documentation Standards
Standard 1
• Each patient’s need for nursing care related to his admission is assessed by registered
nurse.
o The assessment is conducted either at the time of admission or within a time
frame preceding or following admission that is specified in hospital policy.
o Aspects of data collection may be delegated by the registered nurse.
o Needs are reassessed when warranted by the patient’s condition.
• Each patient’s assessment includes consideration of biophysical, psychosocial,

environmental, self-care, educational, and discharge planning factors.
o When appropriate, data from the patient’s significant others are included in the
assessment.
• Each patient’s nursing care is based on identified nursing diagnoses or patient care needs
and patient care standards and is consistent with the therapies of other disciplines:
o The patient and significant others are involved in the patient’s care as appropriate.
o Nursing staff members collaborate, as appropriate, with the doctors and other
clinical disciplines in making decision regarding each patient’s need for nursing
care.
o Throughout the patient’s stay, the patient and, as appropriate, his significant
others receive education specific to the patient’s health care needs.
 The preparation for discharge, continuing care needs are assessed and
referrals for such care are documented in the patient’s clinical record.
o The patient’s clinical record includes documentation of:

 The initial assessments and reassessments.
 The nursing diagnoses and patient care needs.
 The interventions identified to meet the patient’s nursing care needs.
 The nursing care provided.
 The patient’s response to and the outcome of the care provided.
 The abilities of the patient and significant others to manage continuing
care needs after discharge.
o Nursing care data related to patient assessments, the nursing care planned, nursing
interventions, and patient outcomes are permanently integrated into the clinical
information system (ex: medical records).
 Nursing care data can be identified and retrieved from the clinical
information system.

Standard 5
The nurse executive and other nursing leaders participate with leaders from the governing body,
management, medical staff, and clinical areas in the hospital’s decision-making structures and
processes.
Required Characteristics
The nurse executive, or a designee, participates in evaluating, selecting, and integrating health
care technology and information management systems that support patient care needs and the
efficient utilization of nursing resources.
• The use of efficient interactive information management systems for nursing, other
clinical (ex: pharmacy, dietary, physical therapy), and non-clinical information is
facilitated wherever appropriate.


Study Guide 6.11
The Nursing Process & Focus Charting
Nursing Process Focus Charting Example
Assessment – “D” stands for data. This 16:00 D: The patient states “I
Gathering data and reflects information you Focus: have so much pain I can’t
information about your obtained from the patient or Pain move” and “the pain is 10
patient to determine their family and your assessment on a scale of 1 to 10.”
unmet needs in order to set findings. Patient lying on right side
goals and select grimacing and hands
interventions clenched.
Problem Identification – Pain related to recent

Writing your nursing surgery as manifested by
diagnosis statement utilizing patient’s statements and
NANDA terminology, observation of grimacing
etiology, and manifestations and clenched hands.
if present
The patient will
Goal Setting –
demonstrate reduced, or
The measurable behavioral
no pain as evidenced by
objectives. What direction,
statements of relief,
criteria, and time frame will
statement of pain is
you use to set a goal for your
decreased to 4 or less on
patient to establish a means
the pain scale, no longer
of determining if their unmet
grimacing, and hands
needs are met?
relaxed and open within
45 minutes of analgesia
administration.
Interventions “A” stands for actions and A: Instruct patient in use

What actions will you take reflects the nursing of pain scale, PRN
that will move the patient interventions you will take to analgesic given,
towards meeting their unmet intervene and address the repositioned for comfort
needs? patient’s unmet needs. and diversion offered.
Evaluation “R” stands for response and 16:40 “R” Patient states pain is
Was the goal met? Using represents an evaluation of Focus: now 4 on scale of 1 to 10.
the measurable criteria and your patient’s response to the Pain Patient no longer
your time frame did the interventions. This should be grimacing, hands are open
patient meet the established made based on the criteria in and appears relaxed.
goal? your original goal.


Study Guide 6.12
The Nursing Process & SOAP Charting
Nursing Process SOAP Charting Example

1. Assessment - gathering “S” stands for subjective assessment The patient states “I have so
data and information about findings. This reflects information much pain I can’t move” and
your patient to determine you obtained when the patient or “the pain is 10 on a scale of 1 to
their unmet needs family made statements to you 10.”
and set goals and
intervene.
“O” stands for objective assessment The patient is lying on their right
findings. These are findings that you side grimacing and hands are
directly observed through your clenched.
senses. These are things you
palpated, percussed, auscultated, or
observed.
2. Problem Identification – “A” stands for assessment. What do Pain related to recent surgery as
writing your nursing you assess the problem to be given manifested by patient’s
diagnosis statement the subjective and objective statements and observation of
utilizing NANDA findings? What is the goal? grimacing and clenched hands.
terminology, etiology, and
manifestations if present.
3. Goals Setting “P” stands for plan which represents The patient will demonstrate
measurable behavioral the interventions which will be reduced, or no pain as evidenced
objectives. What direction, implemented. by statements of relief, statement
criteria, and time frame will of pain is decreased to 4 or less
you use to set a goal for your on the pain scale, no longer
patient to establish a means grimacing, and hands relaxed
of determining if their unmet and open within 45 minutes of
needs are met? analgesia administration
4. Interventions – What Patient will be instructed in use
actions will you take of pain scale, PRN medication
that will will be given, pt. will be
move the patient towards repositioned for comfort and
meeting their unmet needs? diversion will be offered.
5. Evaluation – Was the “S” & “O” (again) at time frame for “S” Patient states pain is now 4
goal met? Using the evaluation (next entry) Remember, on scale of 1 to 10.
measurable criteria and your the nursing process is circular and
time frame did the patient your evaluation is really a “re” “O” Patient is no longer
meet the established goal? assessment of progress towards the grimacing, hands are open and
goal. appears relaxed.


Study Guide 6.13
Charting/Recording Terms
CONCERNING FACTORS TO BE CHARTED SUGGESTED TERMS TO USE
ABDOMEN 1. large and extends outward 1. protuberant, distended

2. hard, board-like 2. hard, rigid, distended, tympanic, taut
3. soft, flabby 3. relaxed, flaccid
4. hurts when touched 4. sensitive to touch, tender, painful,
intense
5. appears swollen, rounded 5. distended, edematous
6. filled with gas 6. tympanites, tympanic, flatulent
7. hangs down over pubis 7. pendulous
1. Anatomical description of abdomen: a. right hypochondriac region

b. epigastric region
c. left hypochondriac region
d. right lumbar region
e. umbilical region
f. left lumbar region
g. right inguinal (right iliac) region
h. pubic (hypogastric) region
i. left inguinal (left iliac) region
j. right upper quandrant
k. left upper quadrant
l. right lower quadrant
m. left lower quadrant

AMOUNTS 1. large amounts of drainage and/or emesis 1.profuse, copious, large, abundant
(indicate amount in cc)
2. medium amount of drainage 2. moderate
3. small amount of drainage 3. small amount, scanty, slight, very little
APPETITE 1. condition of appetite 1. has definite likes and dislikes

concerning food; appetite
good, fair, poor, or refused food
2. loss of appetite 2. anorexia
3. craving for certain foods 3. parorexia
ARM 1. shoulder to elbow 1. upper arm, right or left humerus

2. elbow to wrist 2. lower arm, right or left ulna and radius
BACK 1. upper back 1. inter-scapular region, shoulder area

2. small of back 2. lumbar region
3. end of spine 3. sacral region, coccyx or coccygeal area
4. buttocks 4. gluteal area
BATHS 1. all inclusive bath 1. complete bath

2. bath with assistance dependent on client’s 2. partial bath
degree of self-care
3. taken in shower 3. shower
4. taken in tub 4. tub bath
5. special baths 5. identify type; e.g., sitz, etc.
BELCH 1. belching 1. eructation

BLEEDING 1. very little 1. degree of oozing, small amount, scanty,

slight
2. nosebleed 2. episthxis
3. blood in urine 3. hematuria
4. spitting of blood 4. hemoptysis
5. when bleeding is stopped 5. hemorrhage controlled, terminated
6. spurting of blood 6. in spurts, ejecting, intermittent
7. uncontrolled 7. continuous
8. emesis of blood 8. hematemesis
BLISTER 1. blister 1. vesicle
BREAST 1. depressed nipple 1. inverted nipple
BREATHING 1. breathing 1. respiration

2. act of inhaling 2. inspiration
3. act of exhaling 3. expiration
4. difficult breathing 4. dyspnea
5. short periods when breathing has ceased 5. apnea
6. inability to breath while lying down 6. orthopnea
7. normal breathing 7. eupnea
8. rapid breathing 8. hyperpnea
9. increasing dyspnea with period of apnea 9. Cheyne-Stokes respiration
10.large volume of air inspired or expired 10. deep breathing
11.small volume of air inspired or expired11. shallow breathing
12. abnormal variations in rhythm 12. irregular respiration
13. laborious and noisy 13. stertorous
CHILL 1. type as to severity 1. severe, moderate, or slight

2. duration 2. specify time

CONSCIOUSNESS 1. fully conscious, aware of surroundings 1. alert, fully conscious

2. only partly conscious 2. semi-conscious
3. unconscious, but can be aroused 3. stuporous
4. unconscious, cannot be aroused 4. comatose
CONVULSION 1. continuous shaking 1. tonic tremor, palsy

2. shaking with intervals of rest 2. clonic tremor
3. subjective sensation 3. aura
4. began without warning 4. sudden onset
COUGH 1. type of coughing 1. continuous, persistent, productive, non-

productive,
dry hacking
2. occurring in spasms 2. spasmodic
3. expulsion of mucus or phlegm from 3. expectorate
throat or lungs
DECAY 1. of teeth 1. dental caries

2. of tissue 2. necrosis
DEFECATION 1. bowel movement

a. material a. feces, stool
b. act of b. act of defecation, elimination,
evacuation
2. frequent liquid defacation 2. diarrhea
3. color of stool 3. clay or dark brown, black, mustard, yellow,
green,
tarry streaked with blood
4. description of stool 4. liquid, soft- or hard-formed, watery,
semi-formed,

constipated, undigested foods, mucoid
DIZZINESS 1. dizziness 1. dizziness
DRAINAGE 1. water, from nose 1. coryza

2. containing pus 2. purulent
3. bloody 3. sanguineous
4. consists of feces 4. fecal
5. of serum 5. serous
6. contains mucus and pus 6. mucopurulent
7. tough, sticky 7. tenacious
8. from vagina (after delivery) 8. lochia
9. bloody, serum 9. sero-sanguineous
EARS 1. wax in ears 1. cerumen

2. ringing, buzzing, clicking, roaring noise 2.ringing, buzzing, clicking, roaring
noise in the ears
In the ears
EMESIS 1. produced by conscious effort of client 1. induced

2. ejected a few feet distant 2. projectile
3. if blood is noticeable 3. blood-tinged, dark or bright red;
hematemesis
4. agent given to produce emesis 4. emetic

EYES 1. sharpness of vision 1. visual acuity

2. yellow in color 2. jaundiced
3. puffy, swollen 3. edematous
4. drooping eyelids 4. ptosis of lids
5. motionless, not moving 5. fixed
6. unusually sensitive to light 6. photophobia
7. double-vision 7. diplopia
8. cross eye, squinting 8. strabismus
9. abnormal protrusion of eyeball 9. exophthalmos
10. inflammation of conjunctiva 10. conjunctivitis
11. dilatation of the pupil 11. mydriasis, pupil dilated
12. contraction of the pupil 12. myosis, pupil constricted, pin point
13. nearsightedness 13. myopia
14. farsightedness 14. hyperopia
15. sees objects indistinctly 15. blurred vision
16. other characteristic terms 16. bright, clear, dull, sunken, inflamed,
bloodshot, burning
FAINT 1. fainting 1. fainting
FEVER 1. without fever 1. afebrile

2. temperature above normal 2. pyrexia
3. temperature greatly above normal 3. hyperpyrexia
4. temperature suddenly returns to normal 4. crisis
5. temperature gradually returns to normal 5. lysis
GAS 1. gas in the digestive tract 1. flatus or flatulence
GUMS 1. inflammation of the gums 1. gingivitis

2. gum boil 2. abscessed gum

HALLUCINATION 1. of hearing 1. auditory hallucination

2. of sight 2. visual hallucination
3. of smell 3. olfactory hallucination
4. of taste 4. gustatory hallucination
HEAD 1. forehead 1. frontal region

2. region over temple 2. temporal region
3. back of head 3. occipital region
4. base of skull 4. basilar region
5. having a large head 5. macrocephalous, hydrocephalus
6. having a small head 6. microcephalous
7. top of head 7. parietal—right or left
HIVES 1. hives 1. urticaria

2. itching 2. pruritus
JOINTS 1. bending 1. flexion

2. to straighten 2. extension
3. turn downward 3. pronation
4. turn upward 4. supination
5. revolve around 5. rotation
6. move away from 6. abduction
7. move toward median line 7. adduction
8. stiff joint 8. ankylosis
LEGS 1. thigh to knee 1. upper leg—right or left

2. knee to ankle 2. lower leg—right or left

LICE 1. body, pubic 1. pediculi

2. head 2. pediculi capiti
LIPS 1. blue in color 1. cyanotic

2. presence of tiny cracks 2. fissured, cracked
3. fever blister present 3. presence of herpes simplex
MEDICINE 1. by mouth 1. orally

(administration of) 2. by rectum 2. rectally
3. breathing in 3. inhalation
4. rubbing into skin 4. inunction
5. under the skin 5. subcutaneous
6. within the skin 6. intradermal
7. within the muscle 7. intramuscular
8. within the spinal canal 8. intraspinal
9. within the vein 9. intravenous
10. pouring into body cavity 10. instillation
11. blowing into body cavity 11. insufflation
MENSTRUATION 1. if present when admitted 1. catamenia present, menses present

2. if starts after admission 2. catamenia established, menses
established
3. painful 3. dysmenorrhea
4. total absence of 4. amenorrhea
5. profuse or prolonged flow 5. menorrhagia
6. occurring between periods 6. metrorrhagia
7. cessation of 7. menopause

MENTAL ATTITUDE 1. distrustful 1. questions staff repeatedly regarding care

and
administration of medication
2. happy 2. smiles and laughs frequently, interacts
verbally with ease
3. sad 3. flat effect—eyes downcast, does not
join in client activities,
answers in monosyllables when
questioned
4. afraid 4. startles when spoken to, checks rooms
before entering
by peering into the room
5. lacks emotional control 5. vacillates between weeping openly and
laughing
boisterously
6. loss of memory (amnesia, fugue) 6. recalls nothing for a period from ____ to
____
NOURISHMENT 1. very small amount of water 1. sips of water

2. small pieces of ice 2. chipped ice, ice chips
3. drink of water 3. water—number of cc
4. given through tube into stomach 4. gavage, tube feeding
ODOR 1. not unpleasant 1. aromatic

2. like ammonia 2. ammoniacal
3. very unpleasant 3. offensive, foul
4. belonging to particular drug, et. 4. characteristic

PAIN 1. great pain 1. severe

2. little 2. slight
3. comes in seizures 3. paroxysmal, spasmodic
4. spreads to distant areas 4. radiating
5. started all at once 5. sudden onset
6. hurts worse when moving 6. increased by movement
7. other descriptive terms 7. sharp, sudden, darting, gnawing, burning,
stabbing,
cramping, shooting, persistent, transient,
constant,
shifting, localized, agonizing, dull, fixed,
deep, superficial
8. referred or reflex pain felt in a part 8. synalgia
distant from the part of its origin
PARALYSIS 1. of the muscles of the face 1. facial

2. of the legs 2. paraplegia
3. of one side of body 3. hemiplegia
4. of a single limb 4. monoplegia
5. of all four limbs 5. quadriplegia
CLIENT (Admission) 1. walking 1. ambulatory

2. carried (infant) 2. in arms
3. by wheelchair 3. per wheelchair
4. by stretcher 4. per stretcher, gurney, cart
5. by ambulance 5. per ambulance
(Discharge) 1. was not dismissed by doctor, signed 1. signed own release AMA (against
medical advice)
necessary papers accompanied by friend, family; or
unaccompanied

PERSPIRATION 1. large amount or profuse 1. diaphoresis

2. small amount 2. scanty
POSITION 1. flat on back, arms straight at side 1. supine

2. on side, knees flexed 2. lateral
3. on left side, left arm behind back, 3. Sims’—left or right
left leg slightly flexed
4. head of bed erect 4. High Fowler’s—modified, knees and
legs not flexed
5. head of bed semi-erect 5. Semi-Fowler’s 40-45—modified, knees and
legs not flexed
6. on back, buttocks near edge of table, 6. lithotomy
knee well flexed and separated
7. on back, knees flexed and apart, 7. dorsal recumbent
feet flat on table or bed
8. resting on knees and chest 8. knee-chest
9. on back, pelvis and legs high than head 9. Trendelenburg
10. on abdomen, face turned to one side 10. prone
PULSE 1. number of beats per minute 1. rate

2. rhythm 2. regular or irregular, coupling, galloping
3. beats missed at intervals 3. intermittent
4. over 100 beats per minute 4. rapid, tachycardia
5. less than 60 beats per minute 5. slow, bradycardia
6. one scarcely perceptible 6. thready, weak
7. with excessive recoil wave 7. dicrotic
8. pulseless 8. imperceptible
9. pulse volume, quality 9. good, fair, poor, barely perceptible
10. normal 10. normal in rate and rhythm

RESPIRATION 1. act of breathing 1. respiration

2. fast or rapid respiration 2. hyperpnea
3. induced by artificial means 3. artificial
4. snoring 4. stertorous
5. difficult breathing 5. dyspnea
6. without breathing 6. apnea
7. other descriptive terms 7. quiet, sighing, gasping, shallow, deep,
costal, noisy
RESTRAINTS 1. flannel wrist and ankle 1. soft restraint

2. leather wrist ankle 2. leather restraint
3. waist 3. posey
SENSATION 1. tingling 1. tingling

2. of extreme heat, burning 2. of extreme heat, burning
3. stinging 3. stinging
4. prickling 4. prickling
SKIN 1. normal 1. healthy

2. pink, red 2. pink, rosy or flushed
3. blue in color 3. cyanotic
4. very white 4. extreme pallor, ashen
5. shines 5. glossy
6. raw surface 6. excoriation
7. yellow in color 7. jaundiced
8. torn 8. lacerated
9. containing colored areas 9. pigmented
10. wet 10. moist
11. scraped 11. abraded, denuded
12. cold and moist 12. clammy

SKIN (continued) 13. birth mark 13. birth mark

14. wart 14. verruca
15. boil 15. furuncle
16. other descriptive terms 16. mottled, discolored, dry, hot, cold,
warm, oily,
broken, calloused, wrinkled, tight, coarse,
of fine texture, tanned
17. indicate presence of 17.rash, abrasion, laceration, insect bites,
tumors,
eruptions, acne, crusts, scars, ulcers,
moles,
fissures, abscesses
18. a discolored spot 18. macule
19. large irregular-formed hemorrhagic 19. ecchymosis
spots on skin
20. small hemorrhage spots on skin 20. petechiae
21. pimple with pus 21. pustule
SLEEP 1. tired when awakens 1. tired when awakens

2. slept very little 2. slept very little
3. moans while sleeping 3. moans while sleeping
4. inability to sleep 4. insomnia
SPEECH 1. not understandable 1. incoherent

2. meaningless, wandering 2. rambling
3. words run together 3. slurring
4. difficulty speaking 4. dysphasia
5. unable to speak 5. aphasia

TEETH 1. false teeth 1. dentures—upper and/or lower, partial,

removable bridge,
permanent bridge
2. collection of dark brown foul matter2. sordes
on lips or teeth
THROAT 1. difficulty in swallowing 1. dysphagia

2. inability to swallow 2. aphagia
3. other descriptive terms 3. red, swollen, inflamed, ulcerated
TONGUE 1. descriptive terms 1. pink, moist, dry, cracked, swollen,

coated,
Inflamed, ulcerated
UNCONSCIOUSNESS 1. complete unconsciousness 1. comatose

2. partial unconsciousness 2. stuporous and semi-comatose
3. pretended unconsciousness 3. feigned unconsciousness
URINATION 1. to urinate 1. void, to micturate

2. no control over urination 2. incontinence
3. burning when voids 3. burning sensation on micturition or
voiding
4. large amount of urine voided 4. diuresis
5. total suppression of urine 5. anuria
6. frequent voiding at night 6. nocturia
7. increased amount voided 7. polyuria
8. painful urination 8. dysuria
9. pus in urine 9. pyuria
10. blood in urine 10. hematuria
11. hemoglobin in urine 11. hemoglobinuria
12. albumin in urine 12. albuminuria

13. acetone in urine 13. acetonuria

URINATION (continued) 14. bile in urine 14. choluria

15. scantiness of urine 15. oliguria
16. sugar in urine 16. glycosuria
17. bedwetting 17. enuresis
18. stones 18. calculi
VOMIT 1. (Refer to Emesis)
WEIGHT 1. overweight 1. obese

2. abnormal thinness 2. emaciated, wasting
3. very underweight 3. cadaverous, cachectic
WOUNDS 1. deep 1. deep, perforating, puncture

2. slight, surface 2. superficial, contusion abrasion,
subcutaneous,
Stage I, II, III, IV
3. not infected 3. clean
4. discharging pus 4. suppurating
5. infected 5. infected
6. torn 6. lacerated, severed
7. chart size of depth mm 7. size in cm
*Adapted with permission from Golden West College, Associate Degree Nursing Program.


Study Guide 6.14
Clinical Facility Research Worksheet – Activity
Patient Data: Initials _____ Allergies ______________________ Rm. _______ Student ________________________
Age _____ Sex _____ Code Status ______________________ Agency ________________________
LISTED MEDICAL DIAGNOSIS (PICK ONE – Give Medical Dictionary definition)
ETIOLOGY/PATHOPHYSIOLOGY (what’s happening in the body?)
Subjective:
Objective:
TWO POSSIBLE NANDA PROBLEMS (nursing diagnostic categories)
DEFINING CHARACTERISTICS FOR EACH NURSING DIAGNOSIS

YOUR ASSESSMENT DATA
A. Subjective Data | Objective Data

|
|
|
|
|
|
|
|
|
|
|
|
NANDA PROBLEMS IDENTIFIED
PRIORITY NURSING DIAGNOSIS


Study Guide 6.15
Nursing History Interview
A. Client’s Initials: Use client’s initials only related to confidentiality, i.e., A.S., E.A., etc.
Likes to be called: Since all people are greeted with formality and dignity, it is important to
determine how the individual likes to be addressed. Approach as Mr. or Mrs., unless
requested differently.
Primary Language: English, Spanish, Chinese, or …
B. Home Environment:
1. Safety devices, lives on the 1st floor, bathroom access. Lives in a board-and-care, lives in
a 3-story home with hardwood floors, many throw rugs, and 3 cats indoors, small
apartment. Interviewer clues to safety factors and style of living: quiet neighborhood,
senior citizen living, etc
2. Occupation:
a. Present: retired, volunteers at senior center taking BPs on other seniors
b. Past: bank president, sales, secretary, and homemaker (never worked).
3. Hobbies: paint, bingo, crochet, reading, cards, pool, computers.
4. Daily Schedule: time client generally arises, goes to senior center, what does the resident
generally do during the day. Returns home at 4:30. Prepares meal. Watches TV.
Prepares for bed at 10:00 pm.
5. Usual Sleep Pattern: sleep soundly, awakes 2-3 times to urinate, wakes often with craps
in legs, etc.
6. Lives with (ages). Alone, husband, wife, grandchildren (ages 3, 7, 11), son (age 27),
daughter-in-law (age 27), 3 cats, 4 dogs, and mother (age 97).
C. Identity Concerns:
1. Psychosocial Stressors – fears, identified physical or emotional limitations, i.e. work,
brother with AIDS, loss of job, changes in living arrangements.
2. Physiological Stressors – high blood pressure, chronic back pain, frequent headaches, and
respiratory problems.
3. Behavior responses to stressors - how does the client manifest the stress – psychosocially
and physiologically? – bites nails, insomnia, overeats, cries, yells at spouse, denial,
avoidance, sleep exercise.
D. Coping Strategies:
1. Describe: talks with spouse, walks on beach, prays, keeps a journal
2. Needing guidance: stress and anxiety reduction, meditation, pastoral support, counseling,
social services, guidance counselor, medical intervention, stop smoking clinic, exercise
program, nutritional guidance.
3. Cultural beliefs influence individual and societal coping strategies.
Vocational Nursing Program Curriculum 20

E. Medical History: Include

1. Surgical history
2. Family history
3. Tobacco use – denies – packs/daily
4. Alcohol use
5. Drug use
F. Limitations: Include
1. Visual – glasses, contacts, lens implants
2. Auditory – hearing aid
3. Ambulatory – walkers, W/C, cast, cane, splints, prosthesis use
4. Dentures – edentia
5. Other
G. Nutrition:
1. Height and weight (may be estimated by client.
2. Research knowledge concerning adequate diet, limitations in effect, favorite things, and
cultural preferences
H. Medications:
1. May be responses such as “water pill”, “a pink one for my heart.


Study Guide 6.16
Reporting Patient Status – Activity
List the most common methods nurses use to report patient status during the shift and from shift
to shift:
1. ________________________________
2. ________________________________
3. ________________________________
4. ________________________________
Place an “X” beside what best describes the information that should be included in a change of
shift report. The change of shift report should:
Provide basic information such as room number, date of admission, and medical
diagnosis.
Provide specific information regarding the client’s needs.
Provide information on significant changes in the client’s condition.
Provide information on follow-up client care.
Provide information on clients transferred or discharged from the unit (varies in some
hospitals).
Case Study: 0700 (morning audio taped report on the following two patients)
“Mr. Jones in room 461 is a 76 year old man. He was admitted last night with sepsis. He
has an IV of D5W infusing at 75 cc/hr. He is NPO. His output for the shift is 150 cc
total. The 0600 temperature is 100.6º F and his blood pressure is 146/94.
Mr. Harris in room 462 has been here for 3 days with pneumonia. His temperature at
0600 was 102.4º F and I gave him 2 Tylenol tablets. He has an IV infusing at 100 cc/hr
and there are 300 cc left. He has a productive cough and is bringing up thick whitish
phlegm. I sent the sputum specimen to the laboratory. He has taken in only 50 cc of oral
fluid and his output was 275 cc for the shift.”

Write the Definition and a Nursing Note for end of shift on above case study:
TERMINOLOGY DEFINITION NURSING NOTE
Nursing
Rand/Kardex ______________________ ___________________________________
Worksheet ______________________ ___________________________________
Reporting ______________________ ___________________________________
Interactive Activity: With a partner, answer the questions regarding (a) the change of shift report
for the following case study and (b) fill in the worksheet and discuss basic information and
significant information given in the report.
1500 (change of shift audio taped report)

“Mr. Williams, 92 years old, in room 357 was admitted yesterday with anemia. His hemoglobin
(Hgb) this morning is 7.2 mg/dl and his hematocrit (Hct) is 26%. He is hard of hearing and
weighs 127 lb. His Foley drained only 100 cc all shift. He has an IV of normal saline infusing at
75 cc/hr. He will receive two units of blood this evening. The lab will call when the blood is
ready. The family and client will make a decision soon regarding his code status. He is very
weak and needs a lot of assistance.
Identify the basic information give in the report: ______________________________________
_____________________________________________________________________________
_
Identify the significant information given in the report: _________________________________
_____________________________________________________________________________
_

Fundamentals

7 – Physical /Health Assessment

Study Guide 7.1
Methods of Nursing Physical Examining
The four primary techniques you will use in the physical examination are inspection, palpation,
percussion and auscultation.
Inspection
Inspection, or visual examination, should be done systematically, with sufficient light.
Palpation
Palpation is the use of the sense of touch to determine texture, temperature, vibration, position,
size consistency, mobility, distention, pulse rates, and tenderness or pain.
Percussion
In percussion, the body surface is struck to elicit sounds that can be heard or vibrations that can
be felt.
Percussion is used to determine the size and shape of the internal organs by establishing their
borders. It indicates whether tissue is fluid filled, air filled, or solid. Percussion elicits five types
of sounds:
• Flatness (dull) – bone and muscle

• Dullness (thud-like) – liver, spleen, heart
• Resonance (hollow) – air-filled lung
• Hyper-resonance (booming) – emphysematous lung
• Tympani (drum like) – air-filled stomach
The two types of percussion methods are direct/immediate and indirect/mediate.
Direct Percussion
• Strike the area to be per cussed with two or more fingers, using the pads of the fingers
only.
• Use rapid wrist movements.
Indirect Percussion
• Place the middle finger of your non-dominant hand firmly on the skin of the area to be
per cussed. (Use only the distal phalanx and joint of the finger.)
• Using the flexed middle finger of the dominant hand, strike the middle finger of the non-
dominant hand. Be sure to use rapid wrist movements.

Auscultation
Auscultation is the process of listening to sounds produced within the body. The use of an
unaided ear is the direct method of auscultation. The use of a stethoscope is considered an
indirect method. Auscultated sounds are described according to the following:
• Pitch – frequency of vibrations

• Intensity – loudness or softness
• Duration – length of the sound
• Quality subjective description of the sound

Module 7 – Physical/Health Assessment

Study Guide 7.2
Assessment for Protection
Temperature:
• Reading you obtained. Example: 99.2, 101.6, etc.
• Shivering: Check √ if present and state duration or write for none present.
• Diaphoresis: Describe location and amount (profuse, scant)
Skin, Hair, Nails (Describe Condition):

• Skin: Cool/warm. Describe – Example: clammy, cold, hot, dry, most, diaphoretic,
oily.
• Hair/Scalp:
o Cleanliness: Describe clean, greasy, dry and flaky, infections or infestations
of scalp (lice, louse nits, ringworm).
o Distribution: Describe bald, thin, patchy loss of hair, hirsutism, or even
growth.
o Texture: coarse or fine, thick or thin.
• Nails: Firm, smooth, follows curve of finger. Increased brittleness,
changes in thickness or texture, clubbing, spoon nail (curves upward), Beau’s lines,
Paronychia (infection around base of nail).
Lesions: Check √ if present and complete information requested below. If none write Ø.
• Location: Anatomical location. Example: coccyx, rt. Forearm, left knee, etc.
• Description: Abrasion, laceration, abscesses, acne, birthmark, bites, ecchymosis
(large irregular formed hemorrhagic spots on skin), exzema (small raised vesicles
that are usually reddened), erythema, excoriation, fissures, furuncle (boil), insect,
keloid, macule, moles, nevus, papule, petechiae (small hemorrhage spots on skin),
pustule (filled with pus), rash, scars, tumors, ulcers, urticaria (hives), verruca (wart,
vesicle (blister).
• Size: Measure and record in centimeters. Example: 12 cm. in diameter, 2 cm. x 3
cm., etc.
• Drainage: Purulent, sanguineous, serious, sero-sanguineous, mucopurulent,
tenacious.
Incision Site: Check √ if present. If none, write Ø.

• Location: Describe anatomical location. Example: Lt. lower quadrant, right
lumbar region, etc.
• Condition of—Describe:

o Appearance—color of wound and surrounding area, approximation of edges,

size, and location of dehiscence, if present.
o Drainage—describe if present, location, color, consistency, odor.
o Swelling—state if present (minimal to moderate swelling is normal in early
stages of wound healing).
IV Site: Check √ if present. If none, write Ø.

• Location: Describe anatomical location. Example: right hand.
• Edema: Check √ if present. If none, write Ø.
• Redness: Check √ if present. If none, write Ø.
• Pain: Check √ if present. If none, write Ø.
AV Shunt: Location, conditions of sight, and auscultate for bruits. If none, write Ø.
Lab and Test Results: Locate most recent Lab and Test Results on the client’s chart.
Check √ if present. If none, write Ø.
• Normal Value WBC: 5,000 to 10,000 mm3
• Normal Value Sed Rate:
o Female: 0-30 mm/hr
o Male: 0-20 mm/hr
• C&S (wound, sputum, etc.). List results on lab report.
Wound Dressing: Site—Describe location (anatomical). Write Ø for none.

• Description: Dry and intact. If not, describe: drainage—color, consistency, odor,
and degree of saturation of dressings.
Drainage Tubes:
• Type: indicate type of tubes or drains present. Example: chest tube.
• Site: Anatomical location. Example: right, lower chest.
• Describe Amount and Character of Drainage: Example: red drainage approx. 100
cc’s for 6 hours; attached to Pleurevac.
Isolation Type: State type. Example: respiratory, strict, body fluid precautions, etc., or
for none.
Side Rails: Up or down, when needed; state how many side rails in use (i.e., x 4, ↓ x 2). If
none used, write Ø.
Bed Position: Position of comfort or therapeutic need (i.e., HOB 45°).

Restraints: Check √ if present. If none, write Ø.

• Type: Wrist – Check √ if present and state location, i.e., left, right, both. Jacket -
Check √ if present.
• Reason: State why restraints are being used for this client.
Medications: List all medications that the client is on that may affect the protection
assessment area, the dosages, and how many times a day, i.e., ASA gr. V q. 4 hours, prn,
fever > 103°F., Penicillin 500 mg. q. 6 hours p.o. x 7 days.


Study Guide 7.3
Assessment of the Dark Skinned Client
Pallor:
• In the light-skinned client, pallor is evidenced by generalized paleness,
lacking red or pink hues. In the brown-skinned client, pallor appears yellow-brown,
dull. Black skin appears ashen gray, dull. Skin loses its healthy glow. Inspect areas
of least pigmentation, i.e., conjunctiva, mucous membranes, palms of hands.
Cyanosis:
• Cyanosis in the light-skinned client will appear dusky blue. In the
dark-skinned client, cyanosis will appear dark, but dull, lifeless. Only severe
cyanosis is apparent in skin; best to assess conjunctiva, oral mucosa, and nail beds.
Jaundice:
• In the light-skinned client, jaundice appears as yellow color in sclera,
mucous membranes, and skin. In the dark-skinned client, best to assess for
jaundice in sclera and palms.
Erythema:
• As in inflammation, fever. In light-skinned clients, may appear red,
bright pink. In dark-skinned clients, may appear with purplish tinge, but difficult
to see. Best to assess by palpating for increased warmth with inflammation, taut
skin, and hardening of deep tissues. In venous stasis (decreased blood flow from
area), you may see engorged venules. In the light-skinned client, it may appear as
dusky color below the affected area. In dark-skinned client, it may be easily
masked; best to assess by palpation for warmth and edema.
Leukoderma:
• A grayish-white benign lesion occurring on the buccal mucosa,
usually absent at birth, hyperpigmentation increases with age. By age 50, 10% of
whites and 50-90% of blacks will show oral hyperpigmentation, a condition that is
believed to be caused by a lifetime of accumulation of post-inflammatory oral
changes.


Study Guide 7.4
Skin Integrity - Activity
• Abrasion
• Blanching
• Debridement
• Eschar
• Excoriation
• Granulation tissue
• Ischemia
• Necrosis
• Pressure ulcer
• Purulent
• Reactive Hyperemia
• Slough
• Subcutaneous tissue
• Tunneling
List the factors that increase the risk of a client developing a pressure ulcer:
2. ___________________________________________________________
3. ___________________________________________________________
4. ___________________________________________________________
5. ___________________________________________________________

6. ___________________________________________________________
7. ___________________________________________________________
8. _____________________________________________________________
9. _____________________________________________________________
10. _____________________________________________________________
11. _____________________________________________________________
12. _____________________________________________________________
13. _____________________________________________________________
List areas of the body where pressure ulcers are likely to develop on a bedridden patient:
5. _____________________________________________________________
6. _____________________________________________________________
7. _____________________________________________________________
8. _____________________________________________________________
Using the scenario below, circle the number that best applies to the client’s risk for developing
pressure ulcers. The lower the number, the greater the risk for the development of pressure
ulcers.
Scenario: You are assigned to care for a client who has has a stroke and is bedridden. He
weighs 280 pounds. There is a three year history of Type 1 diabetes. The client is a smoker and
has a history of smoking two (2) packs per day for 10 years. He is incontinent of bowel and
bladder.
Go to your primary textbook and review the Norton’s Pressure Area Risk Assessment Form
(Scoring System)

Select a partner and describe the phenomenon in each of the four (s) stages of pressure ulcers and
the type of wound healing that would occur in each stage after Stage 1.
• Stage 1 ____________________________________________________________
______________________________________________________________
• Stage 2 ____________________________________________________________
______________________________________________________________
______________________________________________________________
• Stage 3 ____________________________________________________________
______________________________________________________________
______________________________________________________________
• Stage 4 _____________________________________________________________
_______________________________________________________________
_______________________________________________________________


Study Guide 7.5
Assessment – Gas Transportation
Blood Pressure: Write in Systolic and Diastolic BP, i.e., 120/80 or 140/98.
Apical Heart Rate: Number of beats per one minute (i.e., 82). Normal =60-80 bpm.
Peripheral Pulses:
• Radial Pulse Rate: Write in number of beats per 30 seconds x 2. (Normal = 60-80
bpm).
• Rhythm: Regular, irregular
• Strength: Strong, weak, thready, absent, bounding
Pedal Pulses:
• Rt. Pedal Pulse, Lt. Pedal Pulse: Indicate whether pulses are strong, weak, absent.
Compare both feet. DO NOT count this pulse! Objective is to identify its presence
and/or strength, i.e., Rt. Pedal pulse absent, Lt. Pedal pulse weak
Edema: (Write Ø if no edema; write present if edema is visible)

• Degree: If present, indicate degree of “pitting” (slight edema, barely detectable).
+ Leaves a 1 cm in depth “pit” or depression.
++ Leaves a 2 cm in depth “pit” or depression.
+++ Leaves a 3 cm in depth “pit” or depression.
++++ (Severe Edema) Leaves a 4 cm in depth “pit” or greater.
If no edema present, write Ø or none.
• Location: Give location where edema is seen (i.e., sacrum, ankles, periorbital,
hands, lower extremities).
Capillary Refill:
• Upper Extremities: Immediate, delayed (blanching of fingernail beds).
• Lower Extremities: Immediate, delayed (blanching of toenails).
Mucous Membranes:
• Skin:
o Color: Pink, pale beefy red, lesions.
o Skin Temperature: Warm, cold, cool.
o Conjunctiva: Pink, with multiple small vessels, reddened.
Other: Bleeding, infection, drains, etc.

Lab and Test Results

• Locate the most recent lab results and indicate appropriate values.
• Normal HgB: Be certain to write down normal lab values on right side under
“Normal”
o Adult Mail: 14-18 g/dl
o Adult Female: 12-16 g/dl
• Normal Hct:
o Adult Mail: 37-49%
o Adult Female: 36-46%
• Normal RBC:
o Adult Mail: 4.2-6.2 million/ml
o Adult Female: 4.2-5.4 million/ml
• Normal Platelets: 150,000-350,000/cu. mm
• PT: Prothrombin time (indicated when a client is taking oral anticoagulants, i.e.,
Coumarin)
• PTT: Partial Thromboplastin Time (indicated when a client is on an anticoagulant,
i.e., Heparin, administered s.q. or intravenously).
• International Normalized Ratio (INR):
o INR – Client’s PT in seconds
o Means normal PT in seconds
 2.0-3.0 INR = Standard therapy
 3.0-4.5 INR = High dose therapy
• Homan’s Sign (if appropriate): Pain in the calf with dorsiflexion of the foot,
possibly indicating thrombophlebitis or thrombosis.
• Other: Indicate if some other type of diagnostic test has been performed, i.e., EKG,
angiography. If so, indicate location and findings, i.e., normal sinus rhythm, left
coronary artery occlusion, renal angiography normal. Encircle ineffective findings
in red.
Interventions in Use:
• Positioning: Self-ad lib, with assistance, every two hours.
• Heat: Indicate type of heat (K-pad, soaks, sitz bath) and location being applied.
• Cold: Indicate type (ice bag, cold pack) and location being applied.
• Other: Indicate other devices in use (continuous, intermittent pressure devices.
• Medication List: List all medications that the client is on that may affect the gas
transport assessment area, the dosage, and how many times a day (i.e., Heparin
5,000 unites BID, Coumarin 5 mg. daily, Aspirin 365 mg. daily).


Study Guide 7.6
Assessment – Oxygenation – Gas Exchange
Respiratory:
• Rate: Number of respirations per 30 seconds x 2
• Depth: Deep, shallow
• Effort: Eupnea (regular, quiet, effortless, respirations), dyspneic, tachypnea,
bradypnea, Cheyne-Stokes, Kussmaul’s
Breath Sounds:
• Describe:
o Clear: No adventitious breath sounds
o Crackles: Crackling sound produced by air entering distal bronchioles or
alveoli that contain serous secretions.
o Gurgles: Abnormal coarse sound heard especially over trachea
o Wheezing: Breathing with a whistle sound
• Location: Indicate location heard, i.e., upper lobes, middle lobe,
lower lobes, heard at bilateral bases – on inspiration/expiration
Cough: or none, constant, intermittent, dry, hacking, or production (with sputum

production).
Sputum:
• Color: white, frothy, yellow, grayish-white, blood tinged, brown, rust color,
greenish-yellow with streaks of blood. *Especially not if there is any blood in
sputum. Time of day the sputum is most productive, i.e., coughing up large
amounts of thick, yellow sputum upon arising.
• Odor: foul odor, no odor notes, or N/A
Lab and Test Results

• PaO2: Locate the most recent lab values, document, and also write normal values.
If blood gases were not ordered by doctor or done, simply write N/A or (normal =
80-100 mg. Hg.).
• PaCO2: Same as above (normal = 35-45 mg. Hg.).
• Radiology Results: If a chest X-ray has been done, indicate the radiologist’s
findings, i.e., ‘consolidation in the lower lobes.”
• O2 Sat: 95-100%
Sputum Specimen: If obtained, simply √. If none ordered, write or N/A, as appropriate.

• C&S – Culture and Sensitivity: Organism identified.

Interventions:
• Position: Mark as appropriate, i.e. self or with assistance
• Turn: Self or turned q. 2 hr. by nurse
• Deep Breathe: Self ad lib, or taught TCDB, q. 1 hr.
• Cough: Ad lib, every 1 hour taught to cough every 2 hours
• Oxygen Method: Mask or nasal cannula
• Flow Rate: How many liters of O2 per min.; i.e., 2 liters/min.
Incentive Spirometer: Check √ if client is using incentive spirometer during hospitalization

or if one is sitting at the bedside. *Be sure to inquire how many times per hour/day it is
being used. Volume obtained.
HOB (Head of Bed) Elevated: Check √ if client has the head of the bed elevated to breathe
easier.
Pulse Oximeter: Check √ if client has pulse oximeter on finger (may also be utilized on
earlobe, nose, or another location). Give percentage as indicated.
Humidity: Check √ if client is receiving humidification or moisture with the oxygen

therapy.
Oropharyngeal Suctioning: Check √ if applicable and describe color and amount of

secretions being suctioned. N/A or not applicable.
Medications
List all medications that the client is on that may affect the gas exchange assessment
area. Also indicate the dosage and how many times a day; i.e., Aminophylline, 300
mg BID, Prednisone, 5 mg daily, Beclovent inhaler prn, Morphine Sulfate, 10 mg. Q
4 hrs.


Study Guide 7.7
Assessment of Activity and Rest
Activity Level and Tolerance:

• Usual Activity Level vs. Present: What is the level of the client’s ability to perform
ADL (activities of daily living)? Has there been a sudden or gradual change in this?
What type of physical activity or physical exercise is part of the client’s daily
lifestyle? Has the client been ambulatory or bedridden? If so, how long? Was the
client able to perform ADL: prepare meals, grocery shop, pay bills, self-hygiene,
clean house? What about endurance? Describe how much and what types of
activities made the client tired, dizzy, dyspneic, etc.
Important Note to Student: You may need to utilize the back of the sheet to
document a complete assessment of usual activity vs. present.
Muscles & Joints:

• Description
o Mass (size) – Decreased
o Tone: Assessed by grasping the center of muscle and feeling—firm, soft,
atrophied.
o Movement: Note any involuntary movements while lying, sitting, or
standing; limited, assessed by active or passive range of motion.
o Strength: (be specific as to R/L extremity; upper/lower extremity U/E L/E).
 Full range of motion against normal resistance and gravity.
 Full range of motion against moderate resistance and gravity.
 Full range of motion against gravity only.
 Full range of motion with gravity eliminated.
 Slight muscle contraction palpable, but no movement noted.
 No visible or palpable contraction, paralysis of limb.
• Direction and degree a joint is capable of moving.
• Expecting the joints to move freely, smoothly, without pain.
• Size and function of joints on both sides of body.
• Joints may be symmetrical, tender to touch, contracted.
Describe where abnormality is.
• Strength: (be specific as to R/L extremity; upper/lower
extremity U/E L/E). Ask client to squeeze your hands; note equality and
strength of grip.
• Coordination: (requires intact neurological motor/sensory:
imbalance notes, i.e., hand movements uncoordinated.
Posture: Erect, slumped, rounded shoulders, severe scoliosis, Lordosis, Kyphosis.

Gait: Manner of walking. Assess if person walks easily, comfortably, with self-assurance,
good balance, or limps, loss of balance, has fear of falling, unsteady.
CSM (Circulation, Sensation, Movement): Describe: (color – pink; skin temperature –

warm; denies tingling; states numbness down left leg and left buttock; wiggles toes and
fingers on command; unable to move toes and fingers.)
Rest and Sleep Patterns: Usual Rest Patterns Compared with Current
• Daily Rest:
o Observation of rest periods throughout the day other than nightly sleep;
quality and quantity.
• Sleep Pattern:
o Compared with current, how long it takes to fall asleep, restlessness during
sleep, number of times awakened to go to the bathroom, early awakening,
sleepiness during the day; number of hours of sleep; feels rested; number of
awakenings.
• Subjective Findings:
o What client states in quotes.
Lab and Test Results: Compare baseline labs with current. May indicate complication of
immobility.
• Serum Ca: Normal = 8.5-10.5 mEq/dl (4-5.5 mEq/L)
• Phosphorus:
• Mg:
• Uric Acid: Normals: Adult Male = 7-8.5 mg/100 ml; Adult Female =
3.0-7.5 mg/100 ml
• X-ray Results:
• MRI:
Interventions In Use:
• Indicate type of equipment being used, i.e., walker, CPM right leg, cast left arm, etc.
• Special beds, specify: (Clinitron, water mattress, circoelectric).
• Other:
Med List: Which medications that the client is taking and what effect they can have on
activity and rest. Example of what medication client takes and what effect that medication
has on REM sleep, i.e., anti-anxiety agents, hypnotics.


Study Guide 7.8
Assessment of Elimination
Abdomen:
• Inspection: Observation from gross to specific/detailed: contour, skin color, scars,

appearance, shape, distention, striae, rashes, lesions, tattoos, etc.
• Auscultation: Normal = present x 4 quadrants, or hypoactive (no bowel sounds
heard in one minute, but did hear bowel sounds before 3-5 minutes), hyperactive
(rapid gurgling bowel sounds), or absent bowel sounds (no bowel sounds heard
listening for 3-5 minutes in each quadrant).
• Palpation: Soft, rigid, tense, warm, tender/pain, bloated, etc.
Urine:
• Amount: cc’s on your shift.

• Color: straw, dark yellow, amber, colorless, cloudy, green/brown, orange,
blue/green, sediment, red, etc.
• Frequency: regular, frequent, small amounts.
• Odor: strong, acid, ammonia, sweet, normal.
Bowel Sounds:
• Describe bowel sounds heard – soft, bubbling, rapid, loud, gurgling.
Flatus:
• Ask client if he is passing gas. State “yes” if yes. Write if not or “denies.”
Stool:
• Amount: small, moderate, large.
• Color: brown, tarry, mustard.
• Consistency: formed, hard, watery (diarrhea), soft.
• Odor: Aromatic (normal), pungent (foul, infection, blood).
• Frequency: everyday, every other day, once a week, etc.
• Effort: effortless, strained, pain.
When was last BM?

• “Yesterday, this morning, last week, I don’t remember when.”

Labs:
• Sp Gravity: 1.010-1.030
• pH: 4.5-8.0
• Albumin: Normal = none
• Stool Specimen Results: parasites, occult blood, ova, N/A, if not applicable.
• Catheter: Foley, suprapubic

• Colostomy/ileostomy bag: liquid stool, semi-solid, bloody stool, malodorous,
continuous, Ø stool in bag, single or double barreled. Ø for none.
• Bladder Irrigation: N/A, if not applicable. Type of irrigation, i.e., continuous,
intermittent. Also identify type of solution used, i.e., 0.9% NaCl.
Medications:
• List all medications that the client is taking that may affect the elimination
assessment area, the dosage and frequency, i.e., stool softeners, laxatives, bulk,
Lomotil, diuretics, Q 6° prn, etc.


Study Guide 7.9
Assessment of Sensation
Pain:
• Location: If none, write or N/A for not applicable. If client does have pain, identify
location (i.e., Rt knee, abdominal, Rt lower quadrant of abdomen).
• Intensity (Scale of 1-10): Ranges from 0—indicating no pain; 1—mild; to 10—
unbearable pain.
• Character: The client’s verbal description of the pain, i.e., “feels like a hot knife,”
burning, throbbing, knife-like, dull, aching, etc.
• Onset and Duration: When did pain begin? (i.e., six months ago, after breakfast,
upon arising, etc.); How long has it lasted, how frequently it occurs, how long does it
last? Use clients’ own words and quotation marks.
Vision: Wears glasses, vision 20/20, 160/200, contact lenses.
Hearing: Uses hearing aid, (R) ear. Deaf – utilizing signing. HOH (L) ear.
Describe Sensory Overload Behaviors, i.e., restlessness, irritability, inappropriate response

to stimuli, lack of concentration, rapid mood changes, exaggerated emotional responses,
noncompliance, etc.
• PCA Pump: (Patient Controlled Analgesia) Check √ if client is utilizing this
method of pain control. Designate medication used, devices used to assist.
• Special Devices: (Gloves, hearing aid, etc.)
• Medications: List all medications that the client is on that may affect the protection
assessment area, the dosages, and how many times a day (i.e., Aspirin 325 mg 4
hours prn; Tylenol # q 4-6 hours prn; Morphine Sulfate 10 mg q 4 hours for 24
hours then q 4 hours prn, etc.). Indicate if relief obtained.
• Effectiveness: State how the medication affected the pain, 30 minutes after med was
given, on the pain scale, i.e., “states pain is much relieved, maybe a 2 now.”


Study Guide 7.10
Assessment of Fluid and Electrolytes
Body Weight:
• Daily weight is often one of the best tools to assess onset of dehydration or edema.
An increase of 1 kg in weight is equal to the retention of 1 liter of fluid in the
edematous patient. Patients should be weighted at the same time each day
(preferably before breakfast and defecation), on the same scale, wearing the same
amount of clothing. A client who is NPO and on IV’s only can be expected to lose
approximately 0.2 to 0.5 kg/day. 1 kg = 1000 cc fluid loss.
• Suggested responses: stable, varied – give numbers.
Level of Consciousness:
• Irritability, confusion, apathy, or change in behavior may be one of the first
behaviors indicative of fluid and electrolyte imbalance.
Thirst:
• Thirst is the primary regulation of fluid intake in the conscious client. Extra-
cellular dehydration is a major stimuli or thirst. The elderly may have a decreased
thirst awareness.
72-Hour Intake and Output:

• Twenty-four hour intake should be somewhat proportional to the 24-hour output,
plus or minus 300cc. Look at last 48-72 hours for a more thorough assessment.
Variances may be attributed to stress response, massive fluid shifts, medications,
increase or decrease in fluid intake-output.
Urine Concentration:
• Gross examination of normal urine reveals pale to dark yellow in color and clear or
slightly cloudy in transparency. Variances in urine concentration may be related to
menses, medication, or vitamins, increase or decrease in fluid intake, infection,
certain foods, age.
Tissue Turgor:
• Tissue turgor is the capacity of the skin and underlying tissue to return to its prior
condition after being pinched or lifted. If turgor is poor, skin returns to its original
shape more slowly, remaining pinched or “tented” longer. Best areas to assess
tissue turgor are sternum, forehead, inner aspect of thigh. Forearm not reliable,
due to dryness/damage caused by sun.
• Suggested responses: immediate recoil, delayed recoil, tenting, poor tissue turgor.

Mucous Membranes:
• Gloves must be worn. Gently pull down on lower eyelid to expose confunctival sac.
Note color. Should be pink, uniform in color. Have client open mouth. Pull lip
away from teeth to expose buccal cavity. Oral cavity should appear pink, uniform
in color. Brown flecked pigment normal in 90% of blacks over 50 years of age and
in 10% of whites over 50 years of age.
o Moist/dry: Should be moist. If dry, client could possibly be mouth breather.
Insert finger where cheek and gums meet—it should be moist if level of
hydration is normal, dry if dehydrated.
o Tongue: Pink in color, one longitudinal furrow, slightly rough on top and
possibly with a thin whitish coating, with normal hydration. Smaller
appearing tongue could possibly mean FVD or dehydration. Sodium excess
causes tongue to appear red and swollen.
o Suggested responses: moist/smooth, soft, glistening, elastic in nature, dry,
sticky.
Edema:
• If excessive fluid in interstitial spaces, skin appears swollen, shiny,
taut, and tends to blanch in color. It may be hard or soft. If an indentation
remains, it is called pitting edema.
o Location: Where is edema identified?
o Suggested responses: hands, lower extremities, sacral, scrotal, periorbital.
• Adults may accumulate 10 lbs. of fluid (5000cc additional fluid) before
a “pit” may be detected.
Diaphoresis:
• Adults can lose up to 2,000 ml fluid per hour with profuse diaphoresis.
• Suggested responses: scan, profuse, mildly, subjective assessment.
o Location: upper extremities, trunk
o Quality: see suggested responses
Other:
• Suggested responses or may refer to:
o Diarrhea x 3 (refers to 3 bouts of diarrhea that were not measured)
o Vomited x 2 (two emeses, if not measured)
o Body weight – stable – give numbers
o Facial appearance: may exhibit decreased tearing, sunken eyeballs,
decreased salivation
o Excessive thirst
o Pulse – bounding, neck veins distended

IV: cc/hr gtts/min:

• Aimed at correcting fluid and electrolyte losses, meeting daily fluid
and electrolyte needs, preventing imbalances, and preserving renal function.
• Suggested responses: D5 & W 100 cc/hr, 42 gtts/min
• Charting = IV insuing 100 cc/hr left forearm
Serum Na:
• Normal values: 135-145 mEq/liter
o Above normal = hypernatremia
o Below normal = hyponatremia
Serum C1:
• Normal values: 95-105 mEq/liter.
o Above normal = hyperchloremia (possible excessive normal saline solution).
o Below normal = hypochloremia (associated with metabolic alkalosis and
hypokalemia).
Serum K:
• Normal values: 3.5-5.0 mEq/liter.
o Above normal = hyperkalemia.
o Below normal = hypokalemia.
Specific Gravity (Urine):

• Normal values: 1.010-1.030
o Above normal = any condition causing hypoperfusion of kidneys.
o Below normal = when renal tubules cannot reabsorb water and concentrate
urine.
pH (Blood):
• Normal values: 7.35-7.45.
o Above normal = 7.45-7.70 (alkalosis); 7.70-7.80 = (severe) life-threatening
alkalosis, immediate intervention required.
o Below normal = 7.00-7.35 (acidosis); 6.80-7.00 (severe) life-threatening
acidosis, incompatible with life if untreated, immediate intervention
required.
Meds:
• List medications and possible examples, and dosage as it relates to
fluid and electrolyte balance.

o Diuretics
o Electrolyte replenishers
o Sodium Bicarbonate
o Corticosteroids
o Antihypertensives


Study Guide 7.11
Assessing Neurological Function
Glasgow Coma Scale: Assessment of level of consciousness along a continuum with score of
15 for alert and a score of 7 or less for coma.
• Best Eye Opening (Describe behaviors – Do not give a number.
o Spontaneous
o To verbal command
o To pain stimuli
o No response
• Verbal Response (Same as above)
o Oriented (time, place, person)
o Confused (conversation confused in content)
o Inappropriate words
o Incomprehensible sounds
o No response
• Motor Response (Same as above)
o Moves on commands
o Localizes a painful stimuli
o Withdrawal
o Abnormal flexion (decorticate)
o Abnormal extension (decerebrate)
o Flaccid
• Seizures (state whether partial or generalized):
o Describe: Location of onset, spread of movement, type of movement.
o Timing: Time of onset, duration of seizure.
• Lab and Test Results:
o EEG: A graph of electric activity of the brain. Check chart for baseline and
changes.
o CAT Scan: Check chart for baseline and changes.
o MRI: Check chart for baseline and changes.
• Altered Mental Status: Mood, hygiene, grooming, change of dress, response to
direction.
• Behaviors of Aphasia: Memory, knowledge, thinking, association, judgment.
• Other: Quotes, client statements.
• Interventions In Use: Any precautions such as side rails, padded, fall precautions,
sensory stimuli manipulation.
• Medications: List any medications that may have an affect on neurological system
such as pain meds, sleeping meds, etc., and what effect they can have on a
neurological system.


Study Guide 7.12
Assess Endocrine Status
The endocrine system, in conjunction with the nervous system, integrates and controls all
of the body’ physiological systems responsible for adaptive responses. Integrity of
endocrine function, or lack of, has profound effects on physiological integrity as a whole
and ultimate functioning of the individual in all of the other modes.
• Decreased Hormonal Regulation: Describe behaviors that demonstrate ↓.

• Increased Hormonal Regulation: Describe behaviors that demonstrate, i.e., male
breast enlargement, voice changes, hair distribution.
• Stress Stimuli: Identify stress factors of external or internal environment which
may be affecting the client such as fear, discomfort, pain, anger, i.e., separated from
loved ones, while in the hospital. Ask “How is being in the hospital affecting you?”
This answers: Behaviors Caused by Stress. Identify how this is modifying
behaviors, i.e., BP, pulse, bowel changes.
• Behaviors Caused by Stress: Restless, avoidance behaviors, non-compliance, and
describe.
• Lab Test: Test results as well as normals, i.e., FBS – normal level = 80-120 mg.
• Interventions In Use: i.e., monitoring blood glucose levels via accuchecks, etc.,
stress reduction techniques, imagery.
• Med Lids: Medications which affects hormonal regulation: Estrogen,
Progesterone, Thyroxin, Tamoxifen, Corticosteriods, Insulin, Calcitonin.


Study Guide 7.13
Assess Self-Concept
Physical Self
• Body Sensation: Description of how a client feels about himself, physically.
o Subjective Response: “I feel ill, tired, exhausted, sore, weak, healthy,
energized, stressed, tense,” etc.
o Objective Behaviors: Describe the behavior, i.e., dark circles under eyes, no
eye contact, lack of grooming, slow-moving.
• Body Image: How the client feels about his appearance.
o Subjective Response: “I am thin, heavy, too short, pretty, just perfect,” etc.
o Objective Behaviors: Describe the behavior, i.e., neat, clean, well-groomed,
disheveled, soiled nails, overweight for height.
 Posture: Upright, unsteady, steady, slouched, needs walker, needs
assistance.
 Grooming: Performs grooming functions self (alone – well done),
needs assistance.
• Personal Self:
o Subjective Responses: “I’m a failure.” “I feel successful.”
o Objective Behaviors: Describe the behavior, i.e., doesn’t make eye contact,
smiles at nurse, neat in appearance, positive statements about self.
Interventions In Use: i.e., therapeutic communication, counseling (individual or marriage),

L.A. Fitness, workout program.
Med List: List all medications the client is taking that may affect the self-concept, i.e.,
mood elevators, antidepressants, prednisones, etc.


Study Guide 7.14
Self- Concept - Activity
• Body image
• Identity
• Role
• Role ambiguity
• Role performance
• Self-concept
• Self- esteem
• Social self
List the four (4) components of self-concept, the mental image of the self:
1. ___________________________________________________________
2. ___________________________________________________________
3. ___________________________________________________________
4. ___________________________________________________________
For each of the self-concept components, identify two stressors that affect and contribute to
altering the component of:
• Identity ___________________________________________________
• Body image ________________________________________________
• Self – esteem _______________________________________________
• Role performance ____________________________________________

Self concept is the way a person thinks about her/himself, whereas self perception is how a
person explains behavior based on self –observation. List the four (4) dimensions of self-
perception:
1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________
4. ______________________________________________________________
Interactive Activity: Select a partner. Using the scenario that follows, cluster the objective and
subjective data relating to:
• Self – concept Objective data: ___________________________________
________________________________________________
Subjective data: ___________________________________
_________________________________________________
• Body image Objective data: _____________________________________
__________________________________________________
Subjective data: _____________________________________
__________________________________________________
• Role performance Objective data: ______________________________________
__________________________________________________
Subjective data ______________________________________
A 30 year old mother brings her three (3) month old infant in for a well-baby visit. During
your assessment of the infant the mother states that she is tired and makes remarks about
being fat and her breasts still being “too big.” She tells you that she and her husband are so
happy about the baby. She hopes that she will soon be able to return to the gym on a regular
basis and as soon as the baby is a little older, she and her husband can resume some social
activities of their own but they feel they should not be away from the baby so much with her
returning to work on a part-time basis.


Study Guide 7.15
Basic Physical Assessment – Activity
Describe the nurses role in physical assessment and define each of the following terms:
 Inspection _______________________________________________________
 Palpation _______________________________________________________
 Auscultation _______________________________________________________
 Percussion _______________________________________________________
Write in the most appropriate method of examination(s) for each of the following:
 Mouth _______________________________________________________
 Pulse points – List_______________________________________________________
_______________________________________________________
 Blood Pressure _______________________________________________________
 Lungs _______________________________________________________
 Lower Legs-feet _______________________________________________________
 Heart _______________________________________________________

Case Study: A 36-year-old female came to the ER with complaints of upper abdominal pains.
She was admitted and had an cholecystectomy the day of admission. She is 2 days post-op and
will be going home in the morning. Your job is to perform a physical assessment and narrative
by charting your findings.
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
Explain how you assessed each of the following systems:
1. Respiratory
______________________________________________________
2. Cardiac
______________________________________________________
3. Skin
______________________________________________________

4. Neurological
______________________________________________________
5. Gastrointestinal
______________________________________________________
6. Urinary
______________________________________________________
7. Musculoskeletal
______________________________________________________
8. Psychosocial
______________________________________________________
Describe when doing a physical assessment how do you determine the following (also state
if this is objective or subjective):
 Orientation
____________________________________________________________
___________________________________________________________
_
 Bowel Sounds
____________________________________________________________
___________________________________________________________
_
 Skin Temperature ___________________________________________________________
___________________________________________________________
_
 Skin Color
____________________________________________________________
___________________________________________________________
_

 Musculoskeletal
____________________________________________________________
___________________________________________________________
_
 Cranial Nerves
____________________________________________________________
___________________________________________________________
_
 Edema
____________________________________________________________
___________________________________________________________
_
 Chief Complaint
____________________________________________________________
___________________________________________________________
_
 Vital Signs
____________________________________________________________
___________________________________________________________
_

Study Guide 7.16
Database Assessment Guide
Name: __________________________________________________________ Date:
_________________________
Client’s Initials: ________ Admission Date: __________________ Room #: ________ Allergies:
________________________________________________ Client’s Age: ________ Sex: ________
Medical Diagnosis: State and Define
_____________________________________________________________________________________________________________________________________________
Date of Surgery: ________________________ Surgical Procedure:
___________________________________________________________________________________________________________________
Anesthesia: _______________________ Code Status: ___________________ Advance Directive:
___________________________________________________________________________________
CIRCLE ALL ABNORMAL FINDINGS IN RED
PHYSIOLOGICAL Interventions Interventi
Oxygenation in Use
Position ons in
o Gas Exchange Edema
___________________________________
___________________________________
Use
Respiratory: Describe Positioning
Turn
Rate Degree
______________________________________ _________________________________
___________________________________ _________________________________
Deep Breathe Heat
Depth Location
_______________________________ ______________________________________
__________________________________ _________________________________
Cough Cold
Effort Capillary Refill
_____________________________________ ______________________________________
___________________________________ Upper Extremities
Oxygen: Method Other
Breath Sounds ________________________
_____________________________ _____________________________________
___________________________ Lower Extremities
Flow Rate Med List
Describe ________________________
__________________________________ ___________________________________
_______________________________ Skin/Mucous Membranes:
Humidity _____________________________________
Location Other (bleeding, infection, etc.)
___________________________________ _____
_______________________________ __________________________________
Pulse Oximeter _____________________________________
Cough _____
_______________________________ _____
__________________________________ __________________________________
Incentive Spirometer • Protection
Describe ____
__________________________ Temperature
_______________________________ __________________________________
Time Used ________________________________
Sputum ____
_________________________________
_________________________________ Volume Lab & Test Results Shivering
Lab & Test Results ____________________________________ Normal _________________________________
Blood Gases-Client Normal Oropharyngeal Suctioning HgB Diaphoresis
Values Describe _____________________________________ ______________________________
PaO2 ___________________________________ Hct Describe Condition:
____________________________________ Med List ______________________________________ _________________________
PaCO2 ____________________________________ RBC ____________________________________
__________________________________ _______________________________________ _____________________________________ _____
Other ____ Platelet ____________________________________
___________________________________ _______________________________________ __________________________________ _____
_____________________________________ ____ PT/PTT Lesions
___ Gas Transportation _____________________________ (sec.) Location
_____________________________________ Blood Pressure Homan’s Sign (if appropriate) __________________________________
___ ______________________________ ____________________________________ Description
Sputum ____________ C&S Apical Heart Rate ____ _______________________________
_______________ ____________________________ Other ____________________________________
Radiology Results Peripheral Pulse: _____________________________________ _____
_________________________ Radial-Rate ______________________________________ ____________________________________
_____________________________________ ________________________________ ____ _____
___ Rhythm ______________________________________ Size
Other _________________________________ ____ _____________________________________
______________________________________
Strength Drainage
__________________________________ _________________________________
Rt Pedal Pulse Incision
_____________________________ Site
Lt Pedal Pulse _____________________________________
______________________________ Description
_______________________________
____________________________________
_____

Interventi
I.V. Site Interventi ons in
• Activity & Rest
Location ons in Use
Activity Level and Tolerance Catheter
_________________________________ Use
Description ___________________ Assistive Equipment (cast, _________________________________
______________________________ ______________________________________ trapeze, traction, ____________________________________
__________________________________ ____ CPM, etc.) _____
______ ______________________________________ _______________________________ Colostomy/Ileostomy
AV Shunt – Describe: ____ __________________________________ ________________________
______________________ Muscle & Joints _____ ____________________________________
__________________________________ Description __________________________________ _____
______ _______________________________ _____ Bladder Irrigation/CBI
Lab & Test Results ____________________________________ Special Beds (specify) ______________________
Normal _____ ______________________ ____________________________________
WBC Movement __________________________________ _____
___________________________________ ________________________________ _____ Meds List
Sed Rate ____________________________________ Other _________________________________
________________________________ _____ _____________________________________ ____________________________________
C&S (wound, sputum, etc.) Strength Meds List _____
__________________ __________________________________ __________________________________ ____________________________________
__________________________________ ____________________________________ _____________________________________ _____

_____ _____
______ • Nutrition
Coordination _____________________________________ Height
______________________________
Interventi _____ ____________________________________
____________________________________
ons in _____
• Elimination Weight
Use Posture/Gait
Abdomen ____________________________________
Inspection Nutritional Intake

Wound Dressing Describe
________________________________ ____________________________
____________________________ _________________________________
Auscultation NPO
Site ____________________________________
______________________________ ____________________________________
____________________________________ _____
Palpation Reason
Description CSM (Circulation, Sensation,
________________________________ __________________________________
______________________________ Movement)
Urine: Describe ____________________________________
__________________________________ Describe
____________________________ _____
______ _________________________________
_____________________________________ Intolerance

Drainage Tubes ____________________________________ _____ Food Allergies
____________________________ _____ Bowel Sounds What
Type Rest & Sleep Patterns ______________________________ __________________________________
___________________________________ Describe Flatus How Manifested
Describe _________________________________ ____________________________________ _________________________
________________________________ ____________________________________ Stool: Describe: ____________________________________
__________________________________ _____ ____________________________ _____
______ Subjective Findings _____________________________________ Nausea
Isolation (specify) ___________________________ _____ __________________________________
___________________________ ______________________________________ When was last BM? Emesis: Describe
_____________________________________ _____ _________________________ __________________________
_____ ______________________________________ Lab & Test Results ____________________________________
Side Rails _____ Normal _____
_________________________________ Lab & Test Results Urine: Sp. Gr. Swallowing Ability
_____________________________________ Normal _________________________________ __________________________
_____ Serum Ca+ Ph ____________________________________
Bed Position _______________________________ _____________________________________ _____
_______________________________ Phosphorous Protein (albumin) Gag Reflex
_____________________________________ ______________________________ __________________________ _______________________________
_____ Mg Blood: BUN Oral Cavity: Inspect & Describe,
including
Restraints ______________________________________ ___________________________________
teeth, gums, tongue
Type Radiologic Results (X-ray, MRI, CAT RBC ________________________
____________________________________
_____________________________________ Scan, etc.) ____________________________________
_____
Reason ____________________________________ Creatinine
____________________________________
___________________________________ _____ ________________________________
_____
_____________________________________ ____________________________________ WBC
_____ _____ ____________________________________
Meds List Stool Specimen Results:
____________________________________ ______________________
_______________________________________ _____________________________________
_____ _____
Cultural Preferences 24 Hr. Intake/24 Hr. Output • Neuro

_______________________ • Sensation ____________________/_________________ Level of Consciousness (Glasgow
__________________________________ _____
______ Pain: Urine Concentration Coma Scale)
__________________________________ Location __________________________ Eye Opening: Describe behaviors
______ __________________________________ Abnormal Loss (Check if applicable) __________________________________
__________________________________ Intensity (Scale of 1-10) Third Spacing (Edema) ______
______ _____________________ _____________________ __________________________________
__________________________________ Character Drainage ______
______ ________________________________ ________________________________ __________________________________
Onset & Duration Diuresis ______
Other ___________________________ Diaphoresis Verbal Response: Describe
___________________________________ ____________________________________ ______________________________ behaviors
__________________________________ _____ Tachypnea __________________________________
______ Vision ______________________________ ______
Lab & Test Results _____________________________________ Diarrhea __________________________________
Normal ______________________________________ ________________________________ ______
Cholesterol _____ Emesis __________________________________
______________________________ ______________________________________ _________________________________ ______
HDL _____ Tissue Turgor Motor Response: Describe
__________________________________ Hearing ________________________________ behaviors
LDL ____________________________________ Mucous Membranes __________________________________
___________________________________ ______________________________________ ___________________________ ______
FBS _____ _______________________________________ __________________________________
____________________________________ Describe sensory overload behaviors: ____ ______
Ca+ ______________________________________ Lab & Test Results Seizures
____________________________________ _____ Normal ________________________________
K+ ______________________________________ Serum: Describe
_____________________________________ _____ Na+___________________________________ ______________________________
Na+ ______________________________________ C1- _________________________________
____________________________________ _____ ____________________________________ _____
K+ Timing
Interventi
_____________________________________ ________________________________
Interventi ons in HCO 3 _________________________________
ons in Use __________________________________ _____
PCA Pump
Use Ph Lab Value & Test Results
_____________________________
Type of Diet _____________________________________ Radiology (EEG, MRI, etc.)
Special Devices (Glasses,
________________________________ Urine: Sp. Gr. __________________________________
hearing aid, etc.)
Enteral Feedings & Type _________________________________ ______
__________________________________

N.G. Tube _____ Altered Mental Status
Interventi
______________________________ __________________________________ _________________________
G. Tube _____
ons in ______________________________________
________________________________ __________________________________ Use _____
I.V.: cc/hr
Calories Per Day _____ Aphasia
_______________________________
________________________ Meds List ____________________________________
Type of Fluid
Meds List Effectiveness ______________________________________
___________________________
____________________________________ ____________________________________ _____
N.G. Suction: Describe
_______________________________________ _____ Intellectual Functioning
____________________
_____ ____________________________________ ________________________
__________________________________
_______________________________________ _____ ______________________________________
_____
_____ ____________________________________ _____
__________________________________
_______________________________________ _____ Other
_____ _____
______________________________________
Meds List
____________________________________ Interventi
• Fluid & Electrolytes _______________________________________ ons in
Body Weight _____
Use
_______________________________ _______________________________________ ______________________________________
Level of Consciousness _____ _____
______________________ _______________________________________ Seizures Precautions:
_____________________________________ _____ Describe
_____ ______________________________
Thirst Med List
_____________________________________ __________________________________
_____

SELF-CONCEPT Interventions in Use

• Endocrine Physical Self Catheter
Decreased Hormonal Regulation Body Sensation _________________________________
_____________ Subjective Responses ____________________________________
___________________________________ ______________________ _____
_____ ______________________________________ Colostomy/Ileostomy
___________________________________ ____ ________________________
____ ______________________________________ ____________________________________
Increased Hormonal Regulation ____ _____
_______________ ______________________________________ Bladder Irrigation/CBI
___________________________________ ____ ______________________
_____ Objective Behaviors ____________________________________
___________________________________ __________________________ _____
____ ______________________________________ Meds List
Stress Factors ____ _________________________________
____________________________ ______________________________________ ____________________________________
___________________________________ ____ _____
_____ ______________________________________ ____________________________________
___________________________________ ____ _____
____ Body Image • Nutrition

___________________________________ Subjective Responses Height
_____ ______________________ ____________________________________
___________________________________ ______________________________________ Weight
____ ____ ____________________________________
Anxiety Level: Describe ______________________________________ Nutritional Intake
____________________ ____ ____________________________
___________________________________ ______________________________________ NPO
_____ ____ ____________________________________
___________________________________ Objective Behaviors Reason
____ __________________________ __________________________________
Lab & Test Results ______________________________________ ____________________________________
Normal ____ _____
Thyroid ______________________________________ Intolerance
________________________________ ____ Food Allergies

FBS ______________________________________ What
___________________________________ ____ __________________________________
Other Personal Self How Manifested
__________________________________ Subjective Responses _________________________
______________________ ____________________________________
______________________________________ _____
Interventi ____ Nausea
ons in ______________________________________ __________________________________
Use ____ Emesis: Describe
____________________________________
______________________________________ __________________________
_____
____ ____________________________________
____________________________________
Objective Behaviors _____
_____
__________________________ Swallowing Ability
Med List
______________________________________ __________________________
__________________________________
____ ____________________________________
____________________________________
______________________________________ _____
_____
____ Gag Reflex
____________________________________
_______________________________
_____ Interventi Oral Cavity: Inspect & Describe,
____________________________________ ons in including
teeth, gums, tongue
_____ Use ________________________
____________________________________ ____________________________________ ____________________________________
_____ _____ _____
____________________________________ ____________________________________
_____ _____
Med List
__________________________________
____________________________________
_____
____________________________________
_____


Study Guide 7.17
Assessing Nutrition Status
Height: Locate and document. If not on records, ask client.
Weight: Locate and document the most recent weight. If not on records, ask client.
Nutritional Intake: State percentage of food eaten (100% or 10, etc.)

• NPO: Check √ if client is NPO (nothing by mouth), write N/A if not applicable.
o Reason: i.e., surgery in a.m., CAT scan today, scheduled for UGI.
o Intolerance:
 Food Allergies: Check √ if has. If none, write NKA (no known
allergies).
• What: Be specific as to what the client is allergic to.
• How manifested: Describe, i.e., rash, respiratory distress,
diarrhea, etc.
 Nausea: Check √ if present. If none, write Ø.
 Emesis: Check √ if present. If none, write Ø. Describe color (green,
etc.), when (time: after lunch, with activity, etc.). Example: 50 cc,
greenish brown after lunch (pc).
 Swallowing Ability: Check √ if the client is able to swallow. Write if
client cannot swallow.
 Gag Reflex: Does the client have a gag reflex? Check √ if yes. If
none, write Ø
 Oral Cavity: Inspect:
• Teeth: Clean, white, discolored (yellow, etc.), dental caries,
fillings, dentures (full set, uppers, lowers, partial lower or
upper), bridges (permanent, removable), sordes (collection of
dark brown foul matter on teeth and/or lips).
• Gums: Pink, moist, swollen, inflamed, gum line receded,
gingivitis (inflammation of gums), abscessed gums.
• Tongue: Pink, moist, dry, cracked, swollen, coated, inflamed,
ulcerated.
 Cultural Preferences: Describe if present. Write Ø if
none identified. Examples: spicy foods, bland foods, pasta, rice and
vegetables, meat and potatoes.
 Other: Client statement regarding nutrition, if
applicable, otherwise or N/A.

Labs: Locate most recent value and indicate for cholesterol, FBS (Fasting Blood Sugar),
Ca, K, Na.
• Normal Values for: Cholesterol < 200 mg/Dl
FBS 70-110 mg/100 ml
Ca 8.5-10.5 mg/100 ml
Na 135-145 mEq/liter
K 3.5-5 mEq/liter
• Type of Diet: List diet ordered, i.e., 2 gm Na,
1,200 cal. ADA, etc.
o Enteral Feedings/TPN: Check √ if present.
o N.G. Tube: Type of feeding ordered, i.e., Ensure, Isocal.
o G. Tube: Type of feeding ordered, i.e., Ensure, Isocal.
o Calories Per Day: Calculate as taught in class.
• TPN/Hyperalimentation: See chart for calories
per day, ordered.
Medications: List all medications that the client is on that may affect the nutrition
assessment area, the dosages, and how many times a day (i.e., Ferrous Sulfate 324 mg daily,
Calcium 500 mg bid, Kcl 20 mEq q. AM).


Study Guide 7.18
Nursing Care for Nutritional Problems Affecting Older Adults
Altered Ability to Chew Related to Loss of Teeth, Ill-Fitting Dentures, and Gingivitis
• Encourage and instruct client to care for and retain own teeth and dentures.
• Encourage proper tooth-brushing and use of special toothpaste if gums and teeth are
sensitive.
• Chop, shred, or puree foods that are difficult to chew.
• Select ground meat, fish, or poultry as protein sources more easily chewed.
Loss of Senses of Smell and Taste

• Serve food that is attractive and at proper temperature.
• Eat one food at a time rather than mixing foods.
• Serve foods with different textures and aromas.
Decreased Peristalsis in the Esophagus

• Avoid cold liquids.
• Avoid emotional upsets and stress-producing situations.
• Take anti-cholinergic drugs as ordered by physician.
Gastroesophageal Reflux
• Avoid overeating. Eat small, frequent meals.
• Avoid citrus juices, chocolate, fat, tea, and coffee.
• Avoid alcohol and smoking.
• Elevate the head of the bed 30 to 45 degrees when sleeping.
• Lose weight, if necessary.
• Avoid bending over, reclining or heavy activity after eating.
• Take antacids or other medications as ordered by physician.
Decrease Gastric Secretions

• Chew food thoroughly.
• Eat meals on a regular schedule.
• Be alert for symptoms of deficiency of nutrients, particularly iron, calcium, fat, protein,
and vitamin B12.
• Ensure adequate intake of vitamin D for calcium absorption.
Slow Intestinal peristalsis

• Eat a high-fiber diet.
• Remain as physically active as possible.
• Increase fluid intake.
• Avoid laxative use.
• Eat meals at a regular time.
• Drink prune juice or eat prunes every morning.

Lowered Glucose Tolerance

• Eat more complex carbohydrates.
• Avoid sugar-rich foods.
Reduction in Appetite and Thirst Sensation

• Offer fluids at regular intervals and at preferred temperature.
• Be alert for symptoms of dehydration and electrolyte imbalance.
• Offer small meals at frequent intervals.
Nutritional Deficiencies Related to Alcohol Intake

• Encourage diet high in protein and carbohydrate.
• Offer small, frequent meals to maintain caloric intake.
• Restrict sodium and fluids if edema is present.
• Take multi-vitamin supplements as ordered by physician.
Loss of Appetite Associated with Depression and Loneliness

• Promote mealtime as a social event.
• Set an attractive table in a pleasant setting.
• Eat outdoors whenever possible.
• Invite guests as often as possible.
• Participate in special programs for senior citizens.
Physical Handicaps
• Open cartons and assist with setup of meal.
• Arrange for home-delivered meals.
• Conserve energy when preparing meals (sit on a stool, and so forth).
• Provide transportation and assistance to obtain food.
Low Income
• Buy specials when available at food store.
• Use generic brands.
• Use manufacturer and store coupons.
• Cook larger quantities than necessary and freeze the leftovers for future use.
• Substitute eggs, skim milk powder, and beans for meat.
Malnutrition
• Eat essential foods first.
• Select nutrient-dense foods.
• Monitor for signs of nutritional deficiencies.
• Encourage eating by planning special events.
Drug-Nutrient Interactions
• Avoid unnecessary drugs.
• Be aware of drug actions and interactions.

• Check with pharmacist to determine if medication may or may not be taken with food.


Study Guide 7.19
Nutrition Survey
True Mark “A”, if True

False Mark “B”, if False
Uncertain Mark “U”, in Uncertain
___ 1. Food habits are closely related to cultural influences and psychosocial development.
___ 2. Food processing had little influence on the amount of nutrients in the food or on its
safety, appearance, and taste.
___ 3. Certain foods are called complete foods because they contain all the nutrients needed
for full growth and health.
___ 4. Modern processing and refinement of our foods has reduced the amount of cellulose in
our diet.
___ 5. In low income families a proportionately large amount of the food budget is spent for
fats and proteins.
___ 6. A small amount of cellulose in foods that we eat is digested, but the major portion is
carried through the body and provides important bulk in the gastrointestinal tract.
___ 7. “Cholesterol free” labeled foods means absence of fat.
___ 8. The only source of glucose is from carbohydrates.
___ 9. corn oil is a saturated fat.
___ 10. Fat has approximately the same caloric value as carbohydrate.
___ 11. Polyunsaturated fats usually come from animal sources.
___ 12. Saturated fats and cholesterol cause at atherosclerosis.
___ 13. Cholesterol is obtained only from food sources.
___ 14. Starvation and malnutrition states increase the body’s basal metabolic rate.
___ 15. Calories are nutrients in food.
___ 16. Complete proteins of high biologic value are found in whole grains, dried peas and
beans, and nuts.
___ 17. Proteins play a large role in the resistance of the body to disease.
___ 18. The functional units of proteins are amino acids.
___ 19. Vitamin B complex has numerous functions, but its main one is to aid fat metabolism.
___ 20. In old age the protein requirement decreases because of lessened physical activity.
___ 21. Throughout much of the world the shortage of protein is a paramount health problem.
___ 22. Wheat and rice are complete protein foods of high biologic value.
___ 23. The healthy adult is in a state of nitrogen balance.
___ 24. There is no danger in toxic amounts of any of the fat soluble vitamins.
___ 25. Vitamin D and sufficient dietary calcium and phosphorus prevent rickets.
___ 26. Vitamin K is found in meat, especially liver, as well as in green, leafy vegetables.
___ 27. The richest source of vitamin E comes from vegetable oils.
___ 28. Extra vitamin C is stored in the liver to meet the demands of tissue infections.
___ 29. The main food source of riboflavin is milk.
___ 30. Liver is the body’s main iron storage site.
___ 31. The best food source of iron is milk.

___ 32. The number of new processed food items using food additives has been declining in
recent years because of public pressure and concern.
___ 33. Dietary control of diabetes is through the use of food exchange list.
___ 34. From the time of birth, eating is a social act, building on social relationship.
___ 35. The working units for lipids are glycerol and fatty acids.
___ 36. Citrus fruits make the body acid and produce “acid stomach.”
___ 37. Fruits and vegetables are the main sources of vitamins A and C.


Study Guide 7.20
Common Therapeutic Diets
Clear Liquid
• Eliminates all foods except clear liquids at room temperature.
Liquid (Full Liquid)

• Eliminates all foods except liquids at room temperature.
Soft (Ease Mechanical Digestion

• Eliminate seeds, skins of fruits, fired foods, whole grains, raw fruit, vegetables, highly
seasoned foods.
Fat Controlled
• Total amount of fat is reduced.
• Cholesterol is restricted, when fats are used, replace with mono-saturated and
polyunsaturated
• Restricted Foods: Saturated fat, gravies, sauces, egg yolk, high fat meats, whole milk
Sodium Restricted
• Restriction of sodium intake
• Sodium is restricted as follows:
Mild 2-3 grams
Moderate 1000 mg
Strict 500 mg
Severe 250 mg
• Restricted Foods: Depends on level of restriction, highly salted foods, salt at table, etc.
Low Fiber
• Reduced fiber, cellulose
• Restricted Foods: Raw plant fiber, whole grains
High Fiber
• Normal diet with increased fiber
• Restricted Foods: None
Low Fiber
• Reduced protein
• Adjust protein types; complete vs. incomplete
• Restricted Foods: Protein sources, incomplete proteins
High Protein
• Normal diet with increased protein
• Restricted Foods: None

ADA-Diabetic
• Diet should be rich in complex carbohydrates and dietary fiber
• Low in simple sugars, fats (especially saturated fats), and cholesterol
• Moderate in protein
• Calories are determined on an individual basis


Fundamentals

Module 8 – Nursing Across the Life Span

Study Guide 8.1
Erik Erikson’s (1902-1994 – Stages of Development
Trust vs. Mistrust: The first year of life spent learning that they can/cannot trust their parents to
feed and care for them.
Autonomy vs. Shame and Doubt: Ages 1-3. The child learns that their behavior is theirs to
control, or autonomy. If they are restrained or punished too harshly, they develop shame and
doubt.
Initiative vs. Guilt: Pre-school years. Children are asked to assume responsibility for their
bodies, toys, and their pets. They need to learn to deal with playmates. This increasing
responsibility increases initiative.
Industry vs. Inferiority: Elementary School years. An increasing amount of energy is spent
mastering knowledge and intellectual skills. At risk of developing a sense of inferiority or
incompetence; children need a great deal of positive reinforcement.
Identity vs. Identity Confusion: Adolescence. Individuals must find out who they are, what they
are all about, and where they are going in lie. They are suddenly given new roles and adult
statuses 9vocational and romantic).
Intimacy vs. Isolation: Early Adulthood years. Individuals face the development of intimate
relationships with others. If not, isolation will result.
Generativity vs. Stagnation: Middle Adulthood. In this stage, the adult individual’s ability to
assist the younger generation in their development determines their self worth. If the person
does nothing to help the next generation, stagnation will occur.
Integrity vs. Despair: Late Adulthood. As the older adult looks back and evaluates what they
have done with their lives, they will feel a sense of accomplishment of a life well lives, or they
will look back in despair and feel that they have wasted their lives.


Study Guide 8.2
Senior Health
Overview
Older adults have been socialized to a reactive health care system; therefore, they generally
receive secondary and tertiary care. The community health nurse working with seniors will
become the leader in health promotion and primary disease prevention through education and
interventions related to: good nutrition, regular exercise, family and community involvement,
stress management, anticipatory guidance, and safety checks. In the U.S., 12% of the population
is age 65 or older, yet they account for 36% of total personal health care expenditures. The out-
of-pocket expense is an average of $3,000 per year for every older American, a 33% increase
since 1990. Medicare provides health insurance for 96% of older Americans, but has many gaps,
the most significant being lack of coverage for prescription drugs. The increased number of
elderly people, along with the increased amount of prescription drugs they use, are the greatest
contributors to the rising costs of health care in the U.S. The increasing number of seniors
requires research to determine the best approach to meeting the needs of this population. The
health care professionals working with seniors must remember that aging is not a disease and
there is no single, simple pattern of aging. Healthy People 2010 goals for the elderly population
are focused on maintaining health and functional independence and compressing morbidity and
dependence into the shortest possible time.
Terms
• Ageism is the systematic stereotyping of and discrimination against people because they are
old.
• Geriatrics is a medical term for the branch of health science concerned with the disease and
problems of old age.
• Gerontology is a sociological term for the study of old age and aging.
• Life expectancy is the average observed years of life of a species from birth to death or at
any stated age.
• Longevity usually is the expected length of an individual’s life, based on the lives of their
immediate family members.
• Senescence is the last stage of a lifelong process of aging.


Study Guide 8.3
Acute/Chronic Confusion in the Older Adult
SUBJECTIVE / POSSIBLE CAUSES NURSING DIAGNOSIS

OBJECTIVE DATA
Attempting to crawl out of bed Drug/Drug Interactions Side Effects If onset was sudden, “He’s usually not like this,” then
Narcotics it’s:
Banging on side rails Anesthetics
Digoxin Acute Confusion
Calling for help 4 or more drugs given at one time (delirium, reversible decline)
Prompt interventions can reverse
Unable to state what is needed Fluid Volume Alterations Person needs reorientation and cause removed.
NPO for tests
Babbling, meaningless chatter diarrhea, constipation, edema, If not new behaviors, then it’s
vomiting Chronic Confusion
Disoriented to time and place K levels abnormal Impaired Environmental Interpretation
Dehydrated (dementia, organic brain syndrome,
Poor judgment irreversible decline)
Infections
Unable to remember Urinary tract infections Interventions can present catastrophic events, but the
instructions Respiratory person is unable to be or stay oriented, so do NOT try.
Skin or wound Cause of problem is organic, and NOT fixable.
Labile mood
Pain Avoid both Physical and Chemical Restraints with
Hypervigilence joints, headache, surgical, or chronic either of these conditions.

Fundamentals

Fundamentals

10 Module 10 – Nursing Care of Adults with Altered Functioning

Study Guide 10.1
Biopsychosocial Assessment – Practicum
Students Name
_________________________________________________________________
Date: ___________________________ Time Began __________ Time Ended
_________
Pass _________ Fail ____________
A. NOTE: Introduce student to rules. This is a test observed by a nursing instructor

either and/or Foundations Instructor or Nursing Skills Lab Instructor. Students may
not ask questions regarding methodology. Students who think they have made a
mistake or omission may inform instructor and make the necessary corrections prior
to the end of the exam (maximum 30 minutes). Completing this Biopsychosocial
Assessment as a Practicum is one of the required outcomes for the student to pass the
clinical portion of the Foundations Course. This includes a complete Biopsychosocial
Assessment plus a narrative charting assignment describing the assessment results.
• Critical Elements: Critical elements are any action or inaction which
threatens or potentially threatens a client, staff, and/or student’s physical
or emotional well-being or status. Critical elements are present at all
times in the testing of skills and in the clinical performance. Eliminating
may cause physical/psychological jeopardy. Failure to any “critical step”
may result in failure of assessment.
• Psychological Jeopardy: Any action or inaction on the part of the
student which threatens a client’s emotional status.
• Physical Jeopardy: Any action or inaction on the part of the student
which threatens a client’s physical safety.
• Caring: During entire process provides care in a client centered caring
manner.
B. Preparation For Assessment

1. Washes hands
2. Gathers equipment (B.P. cuff and stethoscope, and dons gloves)
3. Identifies client
4. Provides for client privacy
5. Introduces self
a. States purpose and explains role
b. Speaks to level of understanding of client.
c. Validates client’s understanding
6. Takes notes for completing documentation

C. Assessment
1. Takes vital signs:
• BP, apical heart rate (or radial pulse), respiration, and temperature.
2. Neuro: While student was introducing self, may have been assessing neuro
component.
• Level of consciousness
• Level of orientation
• Appropriateness
• Motor Responses
• Hearing/vision
• Limb movement
• Other: i.e., pain, nausea, sleep
3. Gas Transport:
• Pulls down eyelid to assess conjunctiva.
• Assesses skin color
• Touches skin to assess moisture
• Looks for edema
• Checks capillary refill – cyanosis
• Pedal pulses
• Other _________________________
4. Gas Exchange:
• Assesses rate, rhythm, depth, and quality of respirations by observations.
• Assesses skin and mucous membranes’ color by observation.
• Appropriately gives direction to breathe in and out slowly through the mouth.
• Properly places stethoscope, auscultating lung sounds—anteriorly and
posteriorly.
• Asks pertinent questions regarding O2 (dyspnea, cough, etc.).
• Other _________________________
5. Sensation:
• Asks questions regarding pain (location, character—constant or intermittent,
scale 1-10).
• Other _________________________
6. Activity and Rest:
• Supports body parts, as indicated
• Appearance of muscles, tone, joints
• Coordination, movement, strength
• Asks pertinent questions regarding sleeping last night and pain
• Other _________________________
7. Protection:
• Looks for visible lesions
• Checks IV site for redness, swelling, tenderness
• Checks dressing
• Other _________________________
8. Fluid and Electrolytes

• Assesses tissue tugor, pinching sternum (may have already assessed this as
they were assessing skin)
• Looks at IV, fluid
• Assesses tongue and oral cavity for moisture
9. Elimination
• Inspects abdomen
• Auscultates abdomen for presence of bowel sounds in all four quadrants.
• Palpates abdomen for presence of distention, discomfort, rigidity, and/or
masses.
• Asks questions to determine last time client had a BM, character, consistency,
color, and amount
• Asks if having difficulty passing flatus or voiding
• Other ___________________________
10. Nutrition
• Assesses teeth, asks pertinent questions regarding nausea
• Other ___________________________
• Obtains weight.
11. Endocrine
• Assess if client is stressed or has sensory overload
• Other ___________________________
12. Self-Concept (how client feels about self):
• May have already assessed this in the process, has gotten clues from client, or
may utilize therapeutic communication relating to feelings.
13. Medications/Treatment
• List medications client is currently taking and any types of treatments.
1.
2.
3.
4.
5.
6.
14. Role Function – Erikson’s Developmental Stage
• Identify client’s chronological age vs. Erikson’s Developmental Stage.
Determine individuals living, working and psychosocial environment.
15. Communication – Interviewing Skills
• Client teaching regarding importance of TCBD, movement, leg exercises, any
other area you have determined the client has a knowledge/defect.
• Ask client if he/she has any questions.

Signatures
Student _______________________________
Faculty ________________________________
Comments
____________________________________________________________________
_______________________________________________________________________
_
_______________________________________________________________________
_
_______________________________________________________________________
_
_______________________________________________________________________
_
_______________________________________________________________________
_
_______________________________________________________________________
_
• After completing the observed Biopsychosocial Assessment Practicum

complete a Narrative Charting Documentation of the entire assessment
process.
• Following your Narrative Charting Documentation Assignment, complete a
Nursing Care Plan identifying a minimum of 3 Nursing Diagnosis
• Lastly complete a Nursing Concept Map.

NOTE: This must be completed and turned into or emailed to clinical instructor within
24 hours after Practicum.

Module 10 – Nursing Care of Adults with Altered Functioning

Study Guide 10.2
Practice Test Questions
1. During your assessment of Mr. Jones’ urinary output, you note there is
400cc urinary output on your shift. Which of the following is closest to
normal, 24-hour urinary output?
a. 30cc – 50cc
b. 300cc – 500cc
c. 1500cc – 3000cc
d. 500cc – 1000cc
2. Mr. Jones, age 57, had a colon resection this morning. You are assessing
bowel sounds in all four quadrants. From the following, identify what
you would most likely identify in your assessment.
a. High-pitched bubbling
b. Intermittent gurgling
c. Absent bowel sounds
d. Passing gas rectally
3. Which of the following data would be considered as “objective?”

a. Client reports abdominal discomfort
b. Bowel sounds absent in right upper quadrant
c. Physician reports history of abdominal pain.
d. Client states medication is causing constipation
4. During the client’s assessment, the nurse questions client about time,
place, person. This is to find out the client’s:
a. Native language
b. Educational level
c. Orientation
d. Sensory function
5. Which of the following nursing strategies is MOST appropriate for the

assessment of a client’s mobility?
a. Watching client bathe and dress
b. Listening to client describe activities
c. Scheduling a physical therapy session
d. Reading what nurses charted on previous shift

6. Mr. Ream has difficulty breathing when lying in a supine position and
must assume an upright or sitting position in order to breath more
effectively and comfortably. Mr. Ream’s condition correctly would be
termed:
a. Acapnia
b. Dyspnea
c. Orthopnea
d. Hypercapnia
7. When auscultating for breath sounds, the nurse should instruct the client
to:
a. Inhale slowly and exhale rapidly
b. Take deep breaths through the mouth and hold them
c. Take a deep breath in through the mouth and exhale slowly through
the mouth
d. Take several quick, deep breaths in and out through the mouth
8. For which of the following clients would you take an oral temperature?
a. A client receiving oxygen therapy
b. An unconscious client
c. A postoperative client who had an abdominal hysterectomy
d. A postoperative client who had nasal surgery and packing
9. Mr. Bolton has been on strict bed rest for three days following surgery.
This will be the first time ambulating. You take his BP and it is 100/80.
Upon standing, he states he feels like he is “going to faint and (gets) weak
in the knees.” You assist him back to bed and repeat taking his BP. It is
now 90/64. This is an example of
a. Postoperative hemorrhage
b. Orthostatic hypotension
c. Hypotension
d. Pulse pressure difference
10. For which of the following reasons is the thumb not used in palpating the
pulse?
a. The thumb is not as sensitive to touch as the index finger.
b. The pulse may be obliterated by the pressure exerted by the thumb.
c. The person taking the pulse most likely feels his own pulse in his
thumb.
d. It is awkward to take the pulse with the thumb.
11. The Glasgow Coma Scale was completed during the client’s assessment.
The client’s score was 15. The nurse would expect the client to be:
a. Unresponsive

b. Aphasic
c. Conscious
d. Elderly
12. Ms. Harris is retaining fluid. The BEST tool for assessment is:
a. Assessing skin turgor
b. Daily weights
c. Monitoring I & O
d. Monitoring neuromuscular tone
13. Mrs. Anderson, age 45, has been admitted to your unit and has an IV
infusing. Any abnormal behaviors, relating to fluid and electrolytes, may
first be notes as:
a. Polyuria
b. Dependent edema
c. Diaphoresis
d. Altered mental status
14. Mr. Weaver has just returned to the unit after undergoing eye surgery
with a local anesthetic and has bandages on both eyes. When his lunch
tray is delivered your assessment of the situation tells you to:
a. Open all containers and leave, letting him be as independent as
possible.
b. Feed him, allowing sufficient time for tasting, chewing, and
swallowing.
c. Cut his meat into bite-sized pieces and tell him the position of the food
according to the hours of a clock.
d. Keep him on a liquid diet until the bandages are removed.

ANSWER KEY:
1. c
2. c
3. b
4. c
5. a
6. c
7. c
8. c
9. b
10. c
11. c
12. b
13. d

Fundamentals Modules 1-10 Study Guides

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Fundamentals Modules 1-10 Study Guides

Uploaded by

Copyright:

Available Formats

Foundations of Nursing

1 1 Module 1 – Introduction to the Role of a Student Nurse and Introduction to Wellness

The Visual /Verbal Learning Style

The Visual/Verbal Learning Style

Learning Strategies for the Visual/Verbal Learning Style

The Visual/Non-Verbal Learning Style

Learning Strategies of the Visual/Non-Verbal Learner

• When learning mathematical or technical information, make charts to organize the

The Tactile/Kinesthetic Learning Style

Strategies for the Tactile/Kinesthetic Learner

The Auditory/Verbal Learning Style

Strategies for the Auditory/Verbal Learner

Overriding Areas of Care: Critical Elements

Critical Elements: The instructor should be realistic in evaluating violations of asepsis.

Examples of clear violation:

Examples of clear violation:

Examples of clear violation:

4. Caring: Is defined as a pattern of behavior that pervades the nurse-client interaction as

Critical Elements: Establishes communication with the client by introducing self;

Examples of clear violation:

 The student does not respond to the client’s verbal expressions

Many consider the following four concepts to be central to nursing.

A Conceptual Framework is a group of related ideas, statements, or concepts. Freud’s structure

1. Nursing is the diagnosis and treatment of human responses to actual or potential

Persons refer to individual open systems with physiological, psychological, social,

Health is a dynamic state of equilibrium maintained by lines of defense and exists on a

Nursing as defined in Nursing’s Social Policy Statement is “the prevention of illness,

Education is a dynamic and synergistic process of sharing information between

Teaching/Learning is defined as the right and responsibility of nurse educators to utilize

Study Guide 1.8

1. Demonstrate knowledge to function as a patient advocate.

3. Demonstrate knowledge to implement critical thinking utilizing the nursing process in

Current Conditions or Diseases Treatments and Medications

Current Conditions or Diseases Common in Your

Family Ethnic Group

Health care provider: _________________________________________

Record of Medical Tests and Exams

Date Test/Exam/Vaccination Recommended Frequency

What’s your Medicine Cabinet IQ?

Scoring: Add up the number of questions you answered correctly.

Medicine Cabinet Check-up

Equipment Over-the-Counter Medications

Getting the Most Out of Your Medical Care

• List five things you should observe about symptoms.

• What four general categories of symptoms require professional assistance?

Selecting and Evaluating a Physician

Physician’s Name: __________________________________________________

Evaluating Health Insurance

What is the yearly premium for the policy? _____________________________________

Is preauthorization required for any services? ______________ Which services? ____________

Are restrictions placed on your choice of physician? ___________________________________

Would your current physician be covered by the plan? __________________________________

Is there a grace period for non-payment of premiums or other fees? _______________________

Under what circumstances can the policy be cancelled? _________________________________

Study Guide 1.11

Mortgage or Loan Less Than $10,000………………………………………………………. 17

Total all circled points Total Score: _______

• The nature of a person is described as a biopsychosocial being in constant

• A positive response to a changing environment is commonly known as the process of

• Human responses may be effective or ineffective.

occur. In other words, it is a response which is considered within the normal

Posttraumatic Stress Disorder

Is preauthorization required for any services? __ Which services?