Health Assessment in Nursing PDF

Health Assessment in Nursing **Janet R. Weber, RN, EdD Professor Director RN-BSN Program Department of Nursing Southeast Missouri State University Cape Girardeau,** **Missouri Jane H. Kelley, RN, PhD Adjunct Professor School of Nursing Indiana Wesleyan University Louisville, Kentucky (FIFTH EDITIO...

Health Assessment in Nursing **Janet R. Weber, RN, EdD Professor Director RN-BSN Program Department of Nursing Southeast Missouri State University Cape Girardeau,** **Missouri Jane H. Kelley, RN, PhD Adjunct Professor School of Nursing Indiana Wesleyan University Louisville, Kentucky (FIFTH EDITION)** **CHAPTER 1** **Introduction to Health Assessment in Nursing the American Nurses Association publication, nursing: Scope and Standards of Nursing Practice (American Nurses Association\[ANA\], 2010),** defines nursing as "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals, families, communities and populations." Emphasis is placed on "diagnosis and treatment of human responses" based on "accurate client assessments," including how effective nursing interventions are "to promote health and prevent illness and injury." Nursing: Scope and Standards of Practice states as Standard 1 that "The registered nurse collects comprehensive data pertinent to the patient's health or situation" (ANA, p. 21). To accomplish this pertinent and comprehensive data collection, the nurse: Collects data in a systematic and ongoing process Involves the patient, family, other health care providers, and environment, as appropriate, in holistic data collection Prioritizes data collection activities based on the patient's immediate condition, or anticipated needs of the patient or situation Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data Uses analytical models and problem-solving tools Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances Documents relevant data in a retrievable format (ANA, 2010, p. 21) Standard 2 states, "The registered nurse analyzes the assessment data to determine the diagnoses or issues. To accomplish this, the registered nurse: Derives the diagnosis or issues based on assessment data Validates the diagnoses or issues with the client, family, and other healthcare providers when possible and appropriate Documents diagnoses or issues in a manner that facilitates the determination of the expected outcomes and plan (ANA, 2010, p. 22). [The Nurse's Role in Health Assessment] The nurse's role in health assessment has changed significantly over the years (see Box 1-1, p. 3). In the 21st century, the nurse's role in assessment continues to expand, becoming more crucial than ever. The role of the nurse in assessment and diagnosis is more prevalent today than ever before in the history of nursing. Nurses from numerous countries are expanding their assessment and nursing diagnosis skills (Lunney, 2008; Baid, 2006). The rapidly evolving roles of nursing (e.g., forensic nursing) require extensive focused assessments and the development of related nursing diagnoses. Current focus on managed care and internal case management has had a dramatic impact on the assessment role of the nurse. The acute care nurse performs a focused assessment, and then incorporates assessment findings with a multidisciplinary team to develop a comprehensive plan of care (Fig. 1-1). Critical care outreach nurses need enhanced assessment skills to safely assess critically ill clients who are outside the structured intensive care environment (Coombs & Moorse, 2002). Ambulatory care nurses assess and screen clients to determine the need for physician referrals. Home health nurses make independent nursing diagnoses and referrals for collaborative problems as needed. Public health nurses assess the needs of communities, school nurses monitor the growth and health of children, and hospice nurses assess the needs of the terminally ill clients and their families. In all settings, the nurse increasingly documents and retrieves assessment data through sophisticated computerized information systems (Lee, Delaney, & Moorhead, 2007). Nursing health assessment courses with informatics content are becoming the norm in baccalaureate programs. In a report entitled "The Future of Nursing: Leading Change, Advancing Health," the Institute of Medicine (2010) has proposed an expansion of the roles and responsibilities of nurses in a way that will "bring nurses into the health care system as empowered, full partners with other health professionals, including physicians" (Eastman, 2010). As the scope and environment for nursing assessment diversify, nurses must be prepared to assess populations of clients not only across the continuum of health but also by way of telecommunication systems with online data retrieval and documentation capabilities. Picture the nurse assessing a client who has "poor circulation." While in the client's home, the nurse can refresh his or her knowledge of the differences between arterial and venous occlusions, using a "point-of-need" learning file accessed over the Internet. Also immediately available are the agency's policies, procedures, and care maps. Digital pictures of the client's legs can be forwarded to the off-site nurse practitioner or physician for analysis. These networks have already been prototyped and will allow nurses to transmit and receive information by video cameras attached to portable computers or television sets in the client's home. The nurse can then discuss and demonstrate assessments with other health care professionals as clearly and quickly as if they were in the same room. Assessment data and findings can be documented over the Internet or in computerized medical records, some small enough to fit into a laboratory coat pocket and many activated by the nurse's voice. The future will see increased specialization and diversity of assessment skills for nurses. While client acuity increases and technology advances, bedside nurses are challenged to make in-depth physiologic and psychosocial assessments while correlating clinical data from multiple technical monitoring devices. Bedside computers increasingly access individual client data as well as informational libraries and clinical resources (Ludwig-Beymer, Williams, & Stimac, 2012). The communication of health assessment and clinical data will span a myriad of electronic interactivities and research possibilities. Health care networks already comprise a large hospital or medical center with referrals from smaller community hospitals; subacute, rehabilitation, and extended-care units; HMOs; and home health services. These structures provide diverse settings and levels of care in which nurses will assess clients and facilitate their progress. New delivery systems such as "integrated clinical practice" for surgical care may require the nurse to assess and follow a client from the preoperative visit to a multidisciplinary outpatient clinic and even into the home by way of remote technology. There is tremendous growth of the nursing role in the managed care environment. The most marketable nurses will continue to be those with strong assessment and client teaching abilities as well as those who are technologically savvy. The following factors will continue to promote opportunities for nurses with advanced assessment skills: 1. Rising educational costs and focus on primary care that affect the numbers and availability of medical students 2. Increasing complexity of acute care 3. Growing aging population with complex comorbidities 4. Expanding health care needs of single parents 5. increasing impact of children and the homeless on communities 6. Intensifying mental health issues 7. Expanding health service networks 8. Increasing reimbursement for health promotion and preventive care services This future development of nursing languages relies on the ability of practicing nurses to collect and analyze relevant client data to develop valid nursing diagnoses (Moorhead, Johnson, Maas, & Swanson, 2008). **[BOX 1-1 EVOLUTION OF THE NURSE'S ROLE IN HEALTH ASSESSMENT]** Physical assessment has been an integral part of nursing since the days of Florence Nightingale**. LATE 1800s--EARLY 1900s** Nurses relied on their natural senses; the client's face and body would be observed for "changes in color, temperature, muscle strength, use of limbs, body output, and degrees of nutrition, and hydration" (Nightingale, 1992). Palpation was used to measure pulse rate and quality and to locate the fundus of the puerperal woman (Fitzsimmons & Gallagher, 1978). Examples of independent nursing practice using inspection, palpation, and auscultation have been recorded in nursing journals since 1901. Some examples reported in the American Journal of Nursing (1901--1938) include gastrointestinal palpation, testing eighth cranial nerve function, and examination of children in school systems. **1930--1949** The American Journal of Public Health documents routine client and home inspection by public health nurses in the 1930s. This role of case finding, prevention of communicable diseases, and routine use of assessment skills in poor inner-city areas was performed through the Frontier Nursing Service and the Red Cross (Fitzsimmons & Gallagher, 1978). **1950--1969.** Nurses were hired to conduct pre-employment health stories and physical examinations for major companies, such as New York Telephone, from 1953 through 1960 (Bews & Baillie, 1969; Cipolla & Collings, 1971). **1970--1989** The early 1970s prompted nurses to develop an active role in the provision of primary health services and expanded the professional nurse role in conducting health histories and physical and psychological assessments (Holzemer, Barkauskas, & Ohlson, 1980; Lysaught, 1970). Joint statements of the American Nurses Association and the American Academy of Pediatrics agreed that in-depth client assessments and on-the-spot diagnostic judgments would enhance the productivity of nurses and the health care of clients (Bullough, 1976; Fagin & Goodwin, 1972). Acute care nurses in the 1980s employed the "primary care" method of delivery of care. Each nurse was autonomous in making comprehensive initial assessments from which individualized plans of care were established. **1990--PRESENT** Over the last 20 years, the movement of health care from the acute care setting to the community and the proliferation of baccalaureate and graduate education solidified the nurses' role in holistic assessment. Downsizing, budget cuts, and restructuring were the priorities of the 1990s. In turn, there was a demand for documentation of client assessments by all health care providers to justify health care services. In the 1990s, critical pathways or care maps guided the client's progression, with each stage based on specific protocols that the nurse was responsible for assessing and validating. Advanced practice nurses have been increasingly used in the hospital as clinical nurse specialists and in the community as nurse practitioners. While state legislators and the American Medical Association struggled with issues of reimbursement and prescriptive services by nurses, government and societal recognition of the need for greater cost accountability in the health care industry launched the advent of diagnosis-related groups (DRGs) and promotion of health care coverage plans such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs). **Assessment: Step One of the Nursing Process** Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the process: diagnosis, planning, implementation, and evaluation (Table 1-1). Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ongoing and continuous throughout all phases of the nursing process. Health assessment is more than just gathering information about the health status of the client. It is analyzing and synthesizing that data, making judgments about the effectiveness of nursing interventions, and evaluating client care outcomes (AACN, 2008). The nursing process should be thought of as circular, not linear (Fig. 1-2, p. 4). **[TABLE 1-1 Phases of the Nursing Process ]** **Phase I Assessment** Collecting subjective and objective data. **Phase II Diagnosis** Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral). **Phase III Planning** Determining outcome criteria and developing a plan. **Phase IV Implementation** Carrying out the plan V Evaluation Assessing whether outcome criteria have been met and revising the plan as necessary. **[FOCUS OF HEALTH ASSESSMENT IN NURSING]** The purpose of a nursing health assessment is to collect holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. Thus the nurse performs holistic data collection. In addition, the nurse assesses how clients interact within their family and community, and how the clients' health status affects the family and community. For example, a diabetic client may not be able to eat the same foods that the rest of the family enjoys. If this client develops complications of diabetes and has an amputation, the client may not be able to carry out the family responsibility of maintaining the yard. The nurse also assesses how family and community affect the individual client's health status. A supportive creative family may find alternative ways of cooking tasteful foods that are healthy for the entire family. **[FRAMEWORK FOR HEALTH ASSESSMENT IN NURSIG]** History of Present Health Concern Personal Health History Family History Lifestyle and Health Practices **[TYPES OF HEALTH ASSESSMENT ]** The four basic types of assessment are: Initial comprehensive assessment Ongoing or partial assessment Focused or problem-oriented assessment Emergency assessment Each assessment type varies according to the amount and type of data collected 1**.Initial Comprehensive Assessment-** An initial comprehensive assessment involves collection of subjective data about the client's perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client's overall function) as well as objective data gathered during a step-by-step physical examination. The nurse typically collects subjective data and objective data in many settings (hospital, community, clinic, or home). 2**. Ongoing or Partial Assessment-** An ongoing or partial assessment of the client consists of data collection that occurs after the comprehensive database is established. This consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data. **3. Focused or Problem-Oriented Assessment-** A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem. For example, if your client, John P., tells you that he has pain you would ask him questions about the character and location of pain, onset, relieving and aggravating factors, and associated symptoms. **4. Emergency Assessment-**is a very rapid assessment performed in life-threatening situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment. An example of an emergency assessment is the evaluation of the client's airway, breathing, and circulation (known as the ABCs) when cardiac arrest is suspected. The major and only concern during this type of assessment is to determine the status of the client's life sustaining physical functions. **[STEPS OF HEALTH ASSESSMENT]** The assessment phase of the nursing process has four major steps: **1. Collection of subjective data**=Subjective data are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Biographical information (name, age, religion, occupation) History of present health concern: Physical symptoms related to each body part or system (e.g., eyes and ears, abdomen) Personal health history Family history Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity, relationships, cultural beliefs or practices, family structure and function, community environment). **2. Collection of objective data =**The examiner directly observes objective data (Fig. 1-8). These data include: Physical characteristics (e.g., skin color, posture) Body functions (e.g., heart rate, respiratory rate) Appearance (e.g., dress and hygiene) Behavior (e.g., mood, affect) Measurements (e.g., blood pressure, temperature, height, weight) Results of laboratory testing (e.g., platelet count, x-ray findings) This type of data is obtained by general observation and by using the four physical examination techniques: inspection, palpation, percussion, and auscultation. **3. Validation of data=**Validation of assessment data is a crucial part of assessment that often occurs along with collection of subjective and objective data. It serves to ensure that the assessment process is not ended before all relevant data have been collected, and helps to prevent documentation of inaccurate data. **4. Documentation of data=**Documentation of assessment data is an important step of assessment because it forms the database for the entire nursing process and provides data for all other members of the health care team. Thorough and accurate documentation is vital to ensure that valid conclusions are made when the data are analyzed in the second step of the nursing process. (FOR VALIDATION ONLY) =Although there are four steps, they tend to overlap and you may perform two or three steps concurrently. For example, you may ask your client, Jane Q., if she has dry skin while you are inspecting the condition of the skin. If she answers "no," but you notice that the skin on her hands is very dry, validation with the client may be performed at this point. **[PREPARING FOR THE ASSESSMENT]** Before actually meeting the client and beginning the nursing health assessment, there are several things you should do to prepare. It is helpful to review the client's medical record, if available (Fig. 1-6). Knowing the client's basic biographical data (age, sex, religion, educational level, and occupation) is useful. **[TABLE 1-2 Comparing Subjective and Objective Data]** +-----------------------+-----------------------+-----------------------+ | | **SUBJECTIVE** | **OBJECTIVE** | +=======================+=======================+=======================+ | Description Source | Description Data | Data directly or | | | elicited and verified | indirectly observed | | Methods used to | by the client | through measurement | | obtain data | | Sources Client | | | Client record | Observations and | | Skills needed to | | physical assessment | | obtain data | Other health care | findings of the nurse | | | professionals | or other health care | | Examples | | professionals | | | Client interview | Documentation of | | | | assessments made in | | | Interview and | client record | | | therapeutic--communic | Observations made by | | | ation | the client's family | | | Skills | or significant | | | | others. | | | Caring ability and | | | | empathy | Observations and | | | | physical assessment | | | Listening skills | | | | | Inspection | | | "I have a headache." | | | | | Palpation | | | "It frightens me." | | | | | Percussion | | | "I am not hungry." | | | | | Auscultation | | | | | | | | Respirations 16 per | | | | minute BP 180/100, | | | | apical pulse 80 and | | | | irregular. X-ray film | | | | reveals fractured | | | | pelvis | +-----------------------+-----------------------+-----------------------+ **Analysis of Assessment Data/ Nursing Diagnosis: Step Two of the Nursing Process** Analysis of data (often called nursing diagnosis) is the second phase of the nursing process. Analysis of the collected data goes hand in hand with the rationale for performing a nursing assessment. The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment data. Indeed, nurses often begin to analyze the data in their minds while performing assessment. To achieve the goal or anticipated outcome of the assessment, the nurse makes sure that the data collected are as accurate and thorough as possible. A nursing diagnosis is defined by the North American Nursing Diagnosis Association (NANDA, 2012--2014) as "a clinical judgment about individuals, family or community responses to actual and potential health problems and life processes. **[PROCESS OF DATA ANALYSIS]** To arrive at nursing diagnoses, collaborative problems, or referral, you must go through the steps of data analysis. This process requires diagnostic reasoning skills, often called critical thinking. The process can be divided into seven major steps: 1. Identify abnormal data and strengths. 2. Cluster the data. 3. Draw inferences and identify problems. 4. Propose possible nursing diagnoses. 5. Check for defining characteristics of those diagnoses. 6. Confirm or rule out nursing diagnoses. 7. Document conclusions **[Factors Affecting Health Assessment]** The client's culture, family, and the community where the person lives may all affect his or her health status. The person's family, community, and even spirituality are also affected by the individual's health status, even if only in subtle ways. Remember, though, that you must be aware of any perceived notions you have about the client's cultural, spiritual, community, or family context. **CHAPTER 2** **COLLECTING SUBJECTIVE DATA: The Interview and health history** Interviewing Obtaining a valid nursing health history requires professional, interpersonal, and interviewing skills. The nursing interview is a communication process that has two focuses: 1. Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information (Fig. 2-1). 2. Gathering information on the client's developmental, psychological, physiologic, sociocultural, and spiritual statuses to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nurse--client collaboration. **Collecting subjective data is an integral part of interviewing the client to obtain a nursing health history. Subjective data consist of:** 1.SENSATIONS OF SYMPTOMS 2.FEELINGS 3.PERCEPTIONS 4.DESIRES 5.PREFERENCES 6\. BELIEFS 7.IDEAS 8.VALUES 9.PERSONAL [**PHASES OF THE INTERVIEW** ] **The nursing interview has three basic phases:** 1. **Preintroductory Phase**-The nurse reviews the medical record before meeting with the client (Fig. 2-2). This information may assist the nurse with conducting the interview by knowing some of the client's biographical information that is already documented. 2. **Introductory Phase** -After introducing himself to the client, the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential. 3. **Working Phase During this phase**-, the nurse elicits the client's comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level. The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client. 4. **Working Phase**- During this phase the nurse elicits the client's comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level. The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client 5. **Summary and Closing Phase**- During the summary and closing, the nurse summarizes information obtained during the working phase and validates problems and goals with the client (see Chapter 4). She also identifies and discusses possible plans to resolve the problem (nursing diagnoses and collaborative problems) with the client (see Chapter 5). Finally, the nurse makes sure to ask if anything else concerns the client and if there are any further questions. 1. **Nonverbal Communication**-Nonverbal communication is as important as verbal communication. Your appearance, demeanor, posture, facial expressions, and attitude strongly influence how the client perceives the questions you ask. - Appearance-ensure that your appearance is professional. Wear comfortable, neat clothes and a laboratory coat or a uniform. Ensure your name tag including credentials is clear. - Demeanor- When you enter a room to interview a client, display poise. Focus on the client and the Upcoming interview and assessment do not enter the room laughing loudly, yelling to a coworker, or muttering under your breath. This appears unprofessional to the client and will have an effect on the entire interview process. - Facial expression- Facial expressions are often an overlooked aspect of communication because facial expression often shows what you are truly thinking. - Attitude- Attitude One of the most important nonverbal skills to develop as a health care professional is a nonjudgmental attitude. All clients should be accepted, regardless of beliefs, ethnicity, life style and health care practices. - Silence- Silence Another nonverbal technique to use during the interview process is silence. Period of silence allow you and the client to reflect and organize thought which facilitate more accurate reporting and data collection. - Listening- is the most important skill to learn and develop fully in order to collect complete and valid data from your client. To listen effectively, you need to maintain good eye contact, smile or display an open, appropriate facial expression, maintain an open body position (Open arm and hands and lean forward). **NONVERBAL COMMUNICATION TO AVOID** 1.**Excessive or Insufficient Eye Contact**-Contact Avoid extremes in eye contact. Some clients feel very uncomfortable with too much eye contact; others believe that you are hiding something from them if you do not look them in the eye. Therefore, it is best to use a moderate amount of eye contact. 2.**Distraction and Distance** - Avoid being occupied with something else while you are asking questions during the interview. This behavior makes the client believe that the interview may be unimportant to you. Avoid appearing mentally distant as well. Also try to avoid physical distance exceeding 2 to 3 feet during the interview. Rapport and trust are established when the client senses your focus and concern are solely on the client and the client's health. 3**. Standing**- Avoid standing while the client is seated during the interview. Standing puts you and the client at different levels. You may be perceived as the superior, making the client feel inferior. Care of the client's health should be an equal partnership between the health care provider and the client. 2.**Verbal Communication** Effective verbal communication is essential to a client interview. The goal of the interview process is to elicit as much data about the client's health status as possible. - Open-Ended Questions- are used to elicit the client's feelings and perceptions. They typically begin with the words "how" or "what." An example of this type of question is: "How have you been feeling lately?" These types of questions are important because they require more than a one-word response from the client and, therefore, encourage description. Asking open-ended questions may help to reveal significant data about the client's health status. - Closed-Ended Questions- to obtain facts and to focus on specific information. The client can respond with one or two words. The questions typically begin with the words "when" or "did." An example of this type of question is: "When did your headache start?" Closed-ended questions are useful in keeping the interview on course. They can also be used to clarify or obtain more accurate information about issues disclosed in response to open-ended questions. For example, in response to the open-ended question "How have you been feeling lately?" the client says, "Well, I've been feeling really sick to my stomach and I don't feel like eating because of it." You may be able to follow up and learn more about the client's symptom with a closed-ended question such as "When did the nausea start?" - Laundry List - Another way to ask questions is to provide the client with a list of words to choose from in describing symptoms, conditions, or feelings. This laundry list approach helps you to obtain specific answers and reduces the likelihood of the client perceiving or providing an expected answer. For example, "Is the pain Severe, dull, sharp, mild, cutting or piercing? d0es the pain occurs once every year, day, month, or hour?" Repeat choices as necessary. - Rephrasing - information the client has provided is an effective way to communicate during the interview. This technique helps you to clarify information the client has stated. - Well-Placed Phrases- The nurse can encourage client verbalization by using well-placed phrases. For example, if the client is in the middle of explaining a symptom or feeling and believes that you are not paying attention, you may fail to get all the necessary information. Listen closely to the client during his or her description and use phrases such as "um-hum," "yes," or "I agree" to encourage the client to continue. - Inferring - information from what the client tells you and what you observe in the client's behavior may elicit more data or verify existing data, be careful not to lead the client to answers that are not true. - Providing Information - Another important thing to do throughout the interview is to provide the client with information as questions and concerns arise. Make sure that you answer every question as thoroughly as you can. If you do not know the answer, explain that you will find out for the client. **VERBAL COMMUNICATION TO AVOID** Biased or Leading Questions 1\. **Avoid using biased or leading questions.** These cause the client to provide answers that may not be true. The way you phrase a question may actually lead the client to think you want her to answer in a certain way. For example, if you ask "You don't feel bad, do you?" the client may conclude that you do not think she should feel bad and will answer "no" even if this is not true. 2\. **Rushing Through the Interview-** Avoid rushing the client. If you ask questions on top of questions, several things may occur. First, the client may answer "no" to a series of closed-ended questions when he or she would have answered "yes" to one of the questions if it was asked individually. This may occur because the client did not hear the individual question clearly or because the answers to most were "no" and the client forgot about the "yes" answer in the midst of the others. With this type of interview technique, the client may believe that his individual situation is of little concern to the nurse. Taking time with clients shows that you are concerned about their health and helps them to open up 3.**Reading the Questions-** Avoid reading questions from the history form. This deflects attention from the client and results in an impersonal interview process. As a result, the client may feel ill at ease opening up to formatted question. **SPECIAL CONSIDEARTION DURING THE INTERVIEW** 1.**Gerontologic variation in communication-** Age affects and commonly slows all body systems to varying degrees. However, normal aspects of aging do not necessarily equate with a health problem, so it is important not to approach an interview with an elderly client assuming that there is a health problem. Older clients have the potential to be as healthy as younger clients. When interviewing an older client, you must first assess hearing acuity, loss. 2\. **Cultural Variations in Communication Ethnic/cultural variations in communication and self-**disclosure styles may significantly affect the information obtain, be aware of possible variations in your communication style and the client's. If misunderstanding or difficulty in communication style and the clients. 3\. **Emotional Variations in Communication-** Not every client you encounter will be calm, friendly, and eager to participate in the interview process. Clients' emotions vary for a number of reasons. They may be scared or anxious about their health or about disclosing personal information, angry that they are sick or about having to have an examination, depressed about their health or other life events, or they may have an ulterior motive for having an assessment performed. [**Complete Health History** ] The health history is an excellent way to begin the assessment process because it lays the groundwork for identifying nursing problems and provides a focus for the physical examination. The importance of the health history lies in its ability to provide information that will assist the examiner in identifying areas of strength and limitation in the individual's lifestyle and current health status. **[INTERACTING WITH CLIENTS WITH VARIOUS EMOTIONAL STATES]** **WHEN INTERACTING WITH AN ANXIOUS CLIENT** - Provide the client with simple, organized information in a structured format. - Explain who you are, along with your role and purpose. - Ask simple, concise questions. - Avoid becoming anxious like the client. - Do not hurry, and decrease any external stimuli. **WHEN INTERACTING WITH AN ANGRY CLIENT** - Approach this client in a calm, reassuring, in-control manner. - Allow him to ventilate feelings. However, if the client is out of control, do not argue with or touch the client. UÊ Obtain help from other health care professionals as needed. - Avoid arguing and facilitate personal space so that the client does not feel threatened or cornered. **WHEN INTERACTING WITH A DEPRESSED CLIENT** - Express interest in and understanding of the client and respond in a neutral manner. - Do not try to communicate in an upbeat, encouraging manner. This will not help the depressed client. **WHEN INTERACTING WITH A MANIPULATIVE CLIENT** - Provide structure and set limits. - Differentiate between manipulation and a reasonable request - If you are not sure whether you are being manipulated, obtain an objective opinion from other nursing colleagues. **WHEN INTERACTING WITH A SEDUCTIVE CLIENT** - Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors. - Encourage client to use more appropriate methods of coping in relating to others. **WHEN DISCUSSING SENSITIVE ISSUES** (E.G., SEXUALITY, DYING, SPIRITUALITY) - First, be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then recognize that these factors may affect the client's health and may need to be discussed with someone. - Ask simple questions in a nonjudgmental manner. UÊ Allow time for ventilation of client's feelings as needed. - If you do not feel comfortable or competent discussing personal, sensitive topics, you may make referrals as appropriate, for example, to a pastoral counselor for spiritual concerns or other specialists as needed. **[BIOGRAPHIC DATA]** Usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information---the client or significant others. The client's birth date, Social Security number, medical record number, or similar identifying data may be included in biographic data section. The process of determining the client's culture, ethnicity, and subculture begins with collecting data about date and place of birth; nationality or ethnicity; marital status; religious or spiritual practices; and primary and secondary languages spoken, written, and read. This information helps the nurse to examine special needs and beliefs that may affect the client or family health care. **[ASSESSMENT TOOL 2-1 Nursing Health History Format Summary (Used for Client Care Plan)]** **Biographical Data** - Name - Address - Phone - Gender - Provider of history (patient or other) - Birth date - Place of birth - Race or ethnic background - Primary and secondary languages (spoken and read) - Marital Status - Religious or Spiritual Practices - Educational Level - Occupation - Significant others or support persons (availability) **Reasons for Seeking Health** **Care** - Reason for seeking health care (major health problem or concern) - Feelings about seeking health care (fears and past experiences) **History of Present Health Concern Using COLDSPA** - Character (How does it feel, look, smell, sound, etc.?) - Onset (When did it begin; is it better, worse, or the same since it began?) - Location (Where is it? Does it radiate?) Duration (How long does it last? Does it recur?) - Severity (How bad is it on a scale of 1 \[barely noticeable\] to 10 \[worst pain ever experienced\]?) - Pattern (What makes it better? What makes it worse?) - Associated factors (What other symptoms do you have with it? Will you be able to continue doing your work or other activities \[leisure or exercise\]?) **Past Health History** - Problems at birth - Childhood illnesses - Immunizations to date - Adult illnesses (physical, emotional, mental) - Surgeries - Accidents - Prolonged pain or pain patterns - Allergies - Physical, emotional, social, or spiritual weaknesses - Physical, emotional, social, or spiritual strengths **Family Health History** - Age of parents (Living? Deceased date?) - Parents' illnesses and longevity - Grandparents' illnesses and longevity - Aunts' and uncles' age and illnesses and longevity - Children's ages and illnesses or handicaps and longevity **[Review of Systems for Current Health Problems]** - Skin, hair, and nails: Color, temperature, condition, rashes, lesions, excessive sweating, hair loss, dandruff - Head and neck: Headache, stiffness, difficulty swallowing, enlarged lymph nodes, sore throat - Ears: Pain, ringing, buzzing, drainage, difficulty hearing, exposure to loud noises, dizziness, drainage - Eyes: Pain, infections, impaired vision, redness, tearing, halos, blurring, black spots, flashes, double vision - Mouth, throat, nose, and sinuses: Mouth pain, sore throat, lesions, hoarseness, nasal obstruction, sneezing, coughing, snoring, nosebleeds - Thorax and lungs: Pain, difficulty breathing, shortness of breath with activities, orthopnea, cough, sputum, hemoptysis, respiratory infections - Breasts and regional lymphatics: Pain, lumps, discharge from nipples, dimpling or changes in breast size, swollen and tender lymph nodes in axilla - Heart and neck vessels: Chest pain or pressure, palpitations, edema, last blood pressure, last electrocardiogram (ECG) - Peripheral vascular: Leg or feet pain, swelling of feet or legs, sores on feet or legs, color of feet and legs - Abdomen: Pain, indigestion, difficulty swallowing, nausea and vomiting. Gas, jaundice, hernias - Male genitalia: Painful urination, frequency or difficulty starting or maintaining urinary system, blood in urine, sexual problems, penile lesions, penile pain, scrotal swelling, difficulty with erection or ejaculation, exposure to STIs - Female genitalia: Pelvic pain, voiding pain, sexual pain, voiding problems (dribbling, incontinence) age of menarche or menopause (date of last menstrual period), pregnancies and types of problems, abortions, STIs, HRT, birth control methods - Anus, rectum, and prostate: Pain, with defecation, hemorrhoids, bowel habits, constipation, diarrhea, blood in stool - Musculoskeletal: Pain, swelling, red, stiff joints, strength of extremities, abilities to care for self and work - Neurologic: Mood, behavior, depression, anger, headaches, concussions, loss of strength or sensation, coordination, difficulty with speech, memory problems, strange thoughts or actions, difficulty reading or learning **Lifestyle and Health Practices** - Description of a typical day (AM to PM) - Nutrition and weight management - 24-hour dietary intake (foods and fluids) - Who purchases and prepares meals - Activities on a typical day - Exercise habits and pattern - s Sleep and rest habits and patterns - Use of medications and other substances (caffeine, nicotine, alcohol, recreational drugs) - Self-concept - Self-care responsibilities Social activities for fun and relaxation Social activities contributing to society - Relationships with family, significant others, and pets - Values, religious affiliation, spirituality - Past, current, and future plans for education - Type of work, level of job satisfaction, work stressors - Finances - Stressors in life, coping strategies used Residency, type of environment, neighborhood, environ mental risks. **BOX 2-4 COMPONENTS OF THE COLDSPA SYMPTOM ANALYSIS MNEMONIC** +-----------------------------------+-----------------------------------+ | MNEUMONIC | QUESTION | +===================================+===================================+ | Character | Describe the sign or symptom | | | (feeling, appearance, sound, | | | smell or taste if applicable | | | | | | "What does the pain feel like?" | +-----------------------------------+-----------------------------------+ | Onset | When did it begin? | | | | | | " When did this pain start" | +-----------------------------------+-----------------------------------+ | Location | Where it is? Does it radiate? | | | Does it occur anywhere else? | | | "Where does it hurt the most? | | | Does it radiate or go to any | | | other part of your body? | +-----------------------------------+-----------------------------------+ | Duration | How long does it last? Does it | | | recur? How long does the pain | | | last? Does it come and go or is | | | it constant? | +-----------------------------------+-----------------------------------+ | Severity | How bad is it? How much does it | | | bother you? | | | | | | "How intense is the pain? Rate it | | | on a scale of 1 to 10" | +-----------------------------------+-----------------------------------+ | Pattern | What makes it better or worse? | | | "What makes your back pain worse | | | or better? Are there any | | | treatment you've tried that | | | relieve the pain?" | +-----------------------------------+-----------------------------------+ | Associated factors/ how it | What other symptoms occur with | | affects the client | it? How does it affect you? "What | | | do you think caused it to start? | | | Do you have any other problems | | | that seem related your back pain? | | | How does this pain affect your | | | life and daily activities? | +-----------------------------------+-----------------------------------+ **[LIFE STYLE AND HEALTH PRACTICES PROFILE]** This is a very important section of the health history because it deals with the client's human responses, which include nutritional habits, activity and exercise patterns, sleep and rest patterns, self-concept and self-care activities, social and community activities, relationships, values and beliefs system, education and work, stress level and coping style, and environment. **Overview of how the client sees his usual pattern of daily activities** 1. **Nutrition and Weight management**- Ask the client to recall what consists of an average 24-hour intake with emphasis on what foods are eaten and in what amounts. Also ask about snacks, fluid intake, and other substances consumed. The client's fluid intake should be compared with the general recommendation of six to eight glasses of water or non-caffeinated fluids daily. It is also important to ask about the client's bowel and bladder habits at this time. - What do you usually eat during atypical day? please tell me the kinds of foods you prefer, how often you eat throughout the day, and how much you eat." S - do YOU EAT OUT AT RESTAURANTS FREQUENTLY? - do you EAT ONLY WHEN hungry? do YOU EAT BECAUSE OF Boredom, habit, anxiety, depression? - Who buy and prepares the food you eat? - Where do you eat your meals? - How much and what type of fluids do you drink? **Activity Level and Exercise** Next, assess how active the client is during an average week either at work or at home. Inquire about regular exercise. Explain to the client that regular exercise reduces the risk of heart disease, strengthens heart and lungs, reduces stress, and manages weight. **EXAMPLE QUESTION**: What is your daily pattern of activity? Do you follow a regular exercise plan? What type exercise do you do? Are there any reasons why you cannot follow a moderately strenuous exercise program? What do you do for leisure and recreation? Do your leisure and recreational activities include exercise? **Sleep and Rest/Sleep Pattern** Inquire whether the client feels he is getting enough sleep and rest. Sample question: Tell me about your sleeping pattern? Do you have trouble falling asleep or staying asleep? How much sleep do you get each night? Do you feel rested when you awaken? Do you nap during the day? How often and for how long? What do you do to help you fall asleep? **Self-Concept and Self-Care Responsibilities** This includes assessment of how the client views herself and investigation of all behaviors that a person does to promote her health. Example include: Sexual responsibility, basic hygiene practices, regulatory of health care checkups (dental, visual, medical, breast/testicular self-examination and accident prevention and hazard protection. **Sample question include**: - what DO YOU SEE AS YOUR TALENTs OR SPECIAL ABILITIES? - how DO YOU FEEL ABOUT YOUR SELF? About YOUR APPEARANCE? - Can YOU TELL ME WHAT ACTIVITIES YOU DO TO KEEP YOURSELF safe, healthy, or to prevent disease?" - do YOU PRACTICE SAFE SEX? - how DO YOU KEEP YOUR HOME SAFE? - Do YOU DRIVE SAFELY? - how Often DO YOU HAVE MEDICAL CHECK Ups or SCREENINGS? - How often do you see the dentist or have your eyes (Vision) examined? **Social Activities** QUESTIONS ABOUT SOCIAL ACTIVITIES HELP THE NURSE TO DISCOVER what outlets the client has for support and relaxation: - What do you do for fun and relaxation? - With whom do you socialize most frequently? - Are you involved in any community activities? - How do you feel about your community? - Do you think that you have enough time to socialize? - What do you see as your contribution to society? **Relationship** Ask clients to describe the composition of the family into which they were born and about past and current relationships with these family members. In this way, you can assess problems and potential support from the client's family of origin. In addition, similar information should be sought about the client's current family. Sample questions include: - Who is (are) the most important person(s) in your life? Describe your relationship with that person. - What was it like growing up in your family? - What is your relationship like with your spouse? - What is your relationship like with your children? - Describe any relationship you have with significant others? - Do you get along with your in-laws? - Are you close to your extended family? - Do you have any pets? - What is your role in your family? It is an important role? - Are you satisfied with your current sexual relationships? Have there been any recent changes? **Values and Belief System** Assess the client values, religious, and spiritual beliefs. Some clients may not be comfortable discussing values or beliefs. Sample questions include: - what IS MOST IMPORTANT TO YOU IN LIFE? - what DO YOU HOPE TO ACCOMPLISH IN YOUR LIFE? - Do you have a religious affiliation? Is this important to you? - Is a relationship with god (or another) higher power an important part of your life? - What gives you strength and hope? **Stress Levels and Coping Styles** To investigate the amount of stress clients perceive they are under and how they cope with it, ask that address what events cause stress for the client and how they usually respond. Sample question include: - What type of things make you angry? - How would you describe your stress level? - How do you manage anger and stress? - What do you see as the greatest stressors in your life? - Where do you usually turn for help in a time of crisis? **CHAPTER 3** **COLLECTING OBJECTIVE DATA:** 1. THE PHYSICAL EXAMINATION - PREPARING THE PHYSICAL SETTING The physical examination may take place in a variety of settings such as a hospital room, outpatient clinic, physician's office, school health office, employee health office, or a client's home. It is important that the nurse strive to ensure that the examination setting meets the following conditions: Comfortable, warm room temperature: Provide a warm blanket if the room temperature cannot be adjusted. Private area free of interruptions from others: Close the door or pull the curtains if possible. Quiet area free of distractions: Turn off the radio, television, or other noisy equipment. **Equipment Needed for Physical Examinations** for All Examinations: - Gloves/Gowns-To protect examiner in any part of the examination when the examiner may have contact with blood, body fluids, secretions, excretions, and contaminated items or when disease-causing agents could be transmitted to or from the client. 2. For Vital Signs Examination - Sphygmomanometer to measure diastolic and systolic blood pressure. Stethoscope to auscultate blood sounds when measuring blood pressure. - Thermometer (oral, rectal, tympanic) to measure body temperature - Watch with second hand to time heart Pain rating scale to determine perceived rate, pulse rate - Pain rating scale to determine perceived rate, pulse rate pain level. 3. For Nutritional Status Examination - Skinfold calipers to measure skinfold thickness of subcutaneous tissue - Flexible tape measure to measure mid-arm circumference. - Skin marking pen to mark measurement. - Platform scale with height attachment to measure height and weight 4. For Skin, Hair, and Nail Examination - Examination light Penlight - Mirror for client's self-examination of skin - Metric ruler to measure size of skin lesions - Magnifying glass to enlarge visibility of lesion - Wood's light to test for fungus 5. For Head and Neck Examination - Stethoscope to auscultate the thyroid - Small cup of water to help client swallow during examination of the thyroid gland 6. For Eye Examination - Penlight to test pupillary constriction - Snellen E chart to test distant vision - Newspaper to test near vision - Opaque card to test for strabismus - Ophthalmoscope to view the red reflex and to examine the retina of the eye 7. For Ear Examination - Tuning fork to test for bone and conduction of sound - Otoscope to view the ear canal and tympanic membrane 8. For Mouth, Throat, Nose, and Sinus Examination - Penlight to provide light to view the mouth and throat and to trans illuminate the sinuses - 4 × 4-inch small gauze pad to grasp tongue to examine mouth - Tongue depressor to depress tongue to view throat, check looseness of teeth, view cheeks, and check strength of tongue - Otoscope with wide-tip attachment to view the internal nose 9. For Thoracic and Lung Examination - Stethoscope (diaphragm) to auscultate breath sounds - Metric ruler and skin marking pen to measure diaphragmatic excursion - Stethoscope (bell and diaphragm) to auscultate heart sounds - Two metric rulers to measure jugular venous pressure - Sphygmomanometer and stethoscope to measure blood pressure measure vascular sounds - Flexible metric measuring tape to of extremities for edema - Tuning fork to detect vibratory sensation - Doppler ultrasound device and conductivity gel to detect pressure and weak pulses - not easily heard with a stethoscope. 10. For Abdominal Examination - Stethoscope to detect bowel sounds - Flexible metric measuring tape and skin marking pen to measure size and mark the area of percussion of organs - Two small pillows to place under knees and head to promote relaxation of abdomen 11. For Musculoskeletal Examination - Flexible metric measuring tape to measure size of extremities - Goniometer to measure degree of flexion and extension of joints 12. For Neurologic Examination - Cotton-tipped applicators to put salt or sugar on tongue to test taste - Newspaper to test for near vision - Ophthalmoscope - Flexible metric measuring tape - Objects to feel, such as a coin or key to test for stereognosis (ability to recognize objects by touch) - Reflex (percussion) hammer to test deep tendon reflexes 13. For Neurologic Examination (continued) - Cotton ball and paper clip to test for light, sharp, and dull touch and two-point discrimination - Substances to smell and taste to test for smell and taste perception - Snellen E chart - Penlight - Tongue depressor to test for rise of uvula and gag reflex - Tuning fork to test for vibratory sensation 14. For Male Genitalia and Rectum Examination - Gloves and water-soluble lubricant to promote comfort for client - Penlight for scrotal illumination - Specimen card for occult blood - Liquid Pap medium - pH paper - Feminine napkins **[PREPARING ONESELF]** **BOX 3-1 CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) AND HEALTH CARE INFECTION CONTROL PRACTICES ADVISORY COMMITTEE (HICPAC) ISOLATION PRECAUTION GUIDELINES**1. **STANDARD PRECAUTIONS** - Assume that every person is potentially infected or colonized with an organism that could be transmitted in the health care setting, and apply the following infection control practices during the delivery of health care. - **Hand Hygiene** - Perform hand hygiene Before having direct contact with patients After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient) If hands will be moving from a contaminated body site to a clean body site during patient care After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient After removing gloves - Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., - Clostridium difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores. - Do not wear artificial fingernails or extenders if duties include direct contact with patients at high risk for infection and associated adverse outcomes (e.g., those in intensive care units \[ICUs\] or operating rooms). - **[Personal Protective Equipment (PPE)]** Observe the following principles of use: Wear PPE (gloves, gown, mouth/nose/eye protection) when the nature of the anticipated patient interaction indicates that contact with blood or body fluids may occur. Prevent contamination of clothing and skin during the process of removing PPE. Before leaving the patient's room or cubicle, remove and discard PPE. - **[Gloves]** Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur. Wear gloves with fit and durability appropriate to the task. Wear disposable medical examination gloves for providing direct patient care Wear disposable medical examination gloves or reusable utility gloves for cleaning the environment or medical equipment. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens. Change gloves during patient care if the hands will move from a contaminated body site (e.g., perineal area) to a clean body site (e.g., face). - **Gowns** Wear a gown that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient care activities when contact with blood, body fluids, secretions, or excretions is anticipated. Wear a gown for direct patient contact if the patient has uncontained secretions or excretions. Remove gown and perform hand hygiene before leaving the patient's environment. Do not reuse gowns, even for repeated contacts with the same patient. Routine donning of gowns upon entrance into a high-risk unit (e.g., ICU, neonatal intensive care unit \[NICU\], or hematopoietic stem cell transplant \[HSCT\] unit) is not indicated. - **Mouth, Nose, Eye Protection/GOOGLE** - Use PPE to protect the mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed. - During aerosol-generating procedures (e.g., bronchoscopy, suctioning of the respiratory tract \[if not using in-line suction catheters\], endotracheal intubation) in patients who are not suspected of being infected with an agent for which respiratory protection is otherwise recommended (e.g., Mycobacterium tuberculosis, severe acute respiratory syndrome \[SARS\], or hemorrhagic fever viruses), wear one of the following: a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles (in addition to gloves and gown). (Safe Injection Practices) The following recommendations apply to the use of needles, cannulas that replace needles, and, where applicable, intravenous delivery systems: Use aseptic technique to avoid contamination of sterile injection equipment. Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulas, and syringes are sterile, single use items; they should not be reused for another patient or used to access a medication or solution that might be intended for a subsequent patient. Use fluid infusion and administration sets (i.e., intravenous bags, tubing, and connectors) for one patient only, and dispose appropriately after use. Consider a syringe or needle/ cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set. Use single-dose vials for parenteral medications whenever possible. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable. Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients **[PHYSICAL EXAMINATION TECHNIQUES]** **Four basic techniques** must be mastered before you can perform a thorough and complete assessment of the client. 1. **INSPECTION**I-involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings. This technique is used from the moment that you meet the client and continues throughout the examination. **Use the following guidelines as you practice the technique of inspection:** Make sure the room is a comfortable temperature. A too cold or too-hot room can alter the normal behavior of the client and the appearance of the client's skin. Use good lighting, preferably sunlight. Fluorescent lights can alter the true color of the skin. In addition, abnormalities may be overlooked with dim lighting. Look and observe before touching. Touch can alter appearance and distract you from a complete, focused observation. Completely expose the body part you are inspecting while draping the rest of the client as appropriate. Note the following characteristics while inspecting the client: color, patterns, size, location, consistency, symmetry, movement, behavior, odors, or sounds. Compare the appearance of symmetric body parts (e.g., eyes, ears, arms, hands) or both sides of any individual body part. 2. **PALPATION** -consists of using parts of the hand to touch and feel for the following characteristics: Texture (rough/smooth) Temperature (warm/cold) Moisture (dry/wet) Mobility (fixed/movable/still/vibrating) Consistency (soft/hard/fluid filled) Strength of pulses (strong/weak/thready/bounding) Size (small/medium/large) Shape (well defined/irregular) Degree of tenderness [**The Four types of palpation follow**: ] ** Light palpation**: To perform light palpation (Fig. 3-1), place your dominant hand lightly on the surface of the structure. There should be very little or no depression (less than 1 cm). Feel the surface structure using a circular motion. Use this technique to feel for pulses, tenderness, surface skin texture, temperature, and moisture. **Moderate palpation**: Depress the skin surface 1 to 2 cm (0.5 to 0.75 inch) with your dominant hand, and use a circular motion to feel for easily palpable body organs and masses. Note the size, consistency, and mobility of structures you palpate. ** Deep palpation**: Place your dominant hand on the skin surface and your nondominant hand on top of your dominant hand to apply pressure (Fig. 3-2). This should result in a surface depression between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle. **Bimanual palpation**: Use two hands, placing one on each side of the body part (e.g., uterus, breasts, spleen) being palpated (Fig. 3-3). Use one hand to apply pressure and the other hand to feel the structure. Note the size, shape, consistency, and mobility of the structures you palpate. 3. **Percussion-** Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures. 2**.Blunt**- is used to detect tenderness over organs (e.g., kidneys) by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface using one or two fingertips to elicit possible tenderness (e.g., tenderness over the sinuses). 3\. **Indirect or mediate percussion** (Fig. 3-6) is the most commonly used method of percussion. The tapping done with this type of percussion produces a sound or tone that varies with the density of underlying structures. **The following techniques help to develop proficiency in the technique of indirect percussion:** Place the middle finger of your nondominant hand on the body part you are going to percuss. Keep your other fingers off the body part being percussed because they will damp the tone you elicit. Use the pad of your middle finger of the other hand (ensure that this fingernail is short) to strike the middle finger of your nondominant hand that is placed on the body part. Withdraw your finger immediately to avoid damping the tone. Deliver two quick taps and listen carefully to the tone. Use quick, sharp taps by quickly flexing your wrist, not your forearm. 4. **Auscultation-** is a type of assessment technique that requires the use of a stethoscope to listen for heart sounds, movement of blood through the cardiovascular system, movement of the bowel, and movement of air through the respiratory tract. A stethoscope is used because these body sounds are not audible to the human ear. The sounds detected using auscultation are classified according to the intensity (loud or soft), pitch (high or low), duration (length), and quality (musical, crackling, raspy) of the sound. **To Use a stethoscope, follow these Guidelines:** 1\. Place the earpieces into the outer ear canal. They should fit snugly but comfortably to promote effective sound transmission. The earpieces are connected to binaural (metal tubing), which connect to rubber or plastic tubing. The rubber or plastic tubing should be flexible and no more than 12 inches long to prevent the sound from diminishing. 2\. Angle the binaural down toward your nose. This will ensure that sounds are transmitted to your eardrums. 3\. Use the diaphragm of the stethoscope to detect high-pitched sounds. The diaphragm should be at least 1.5 inches wide for adults and smaller for children. Hold the diaphragm firmly against the body part being auscultated. 4\. Use the bell of the stethoscope to detect low-pitched sounds. The bell should be at least 1 inch wide. Hold the bell lightly against the body part being auscultated. **Do's and Don'ts** Warm the diaphragm or bell of the stethoscope before placing it on the client's skin. Explain what you are listening for and answer any questions the client has. This will help to alleviate anxiety. Do not apply too much pressure when using the bell---too much pressure will cause the bell to work like the diaphragm. Avoid listening through clothing, which may obscure or alter sounds. **[DIFFERRENT POSITIONING OF THE CLIENT]** 1. **SITTING POSITION-** The client should sit upright on the side of the examination table. In the home or office setting, the client can sit on the edge of a chair or bed. This position is good for evaluating the head, neck, lungs, chest, back, breasts, axillae, heart, vital signs, and upper extremities. This position is also useful because it permits full expansion of the lungs and it allows the examiner to assess symmetry of upper body parts. 2. **SUPINE POSITION-** Ask the client to lie down with the legs together on the examination table (or bed if in a home setting). A small pillow may be placed under the head to promote comfort. If the client has trouble breathing, the head of the bed may need to be raised. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. 3. **DORSAL RECUMBENT POSITION-** The client lies down on the examination table or bed with the knees bent, the legs separated, and the feet flat on the table or bed. This position may be more comfortable than the supine position for clients with pain in the back or abdomen. Areas that may be assessed with the client in this position include head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses. The abdomen should not be assessed because the abdominal muscles are contracted in this position 4. **SIMS' POSITION** -The client lies on the right or left side with the lower arm placed behind the body and the upper arm flexed at the shoulder and elbow. The lower leg is slightly flexed at the knee while the upper leg is flexed at a sharper angle and pulled forward. This position is useful for assessing the rectal and vaginal areas. The client may need some assistance getting into this position. Clients with joint problems and elderly clients may have some difficulty assuming and maintaining this position. 5. **STANDING POSITION-** The client stands still in a normal, comfortable, resting posture. This position allows the examiner to assess posture, balance, and gait. This position is also used for examining the male genitalia. 6. **PRONE POSITION-** The client lies down on the abdomen with the head to the side. The prone position is used primarily to assess the hip joint. The back can also be assessed with the client in this position. Clients with cardiac and respiratory problems cannot tolerate this position. 7. **KNEE--CHEST POSITION** -The client kneels on the examination table with the weight of the body supported by the chest and knees. A 90-degree angle should exist between the body and the hips. The arms are placed above the head, with the head turned to one side. A small pillow may be used to provide comfort. The knee--chest position is useful for examining the rectum. This position may be embarrassing and uncomfortable for the client; therefore, the client should be kept in the position for as limited a time as possible. Elderly clients and clients with respiratory and cardiac problems may be unable to tolerate this position. 8. **LITHOTOMY POSITION** -The client lies on the back with the hips at the edge of the examination table and the feet supported by stirrups. The lithotomy position is used to examine the female genitalia, reproductive tracts, and the rectum. The client may require assistance getting into this position. It is an exposed position, and clients may feel embarrassed. In addition, elderly clients may not be able to assume this position for very long or at all. Therefore, it is best to keep the client well draped during the examination and to perform the examination as quickly as possible. **CHAPTER 4** **[VALIDATING AND DOCUMENTING DATA]** PURPOSE OF VALIDATION-is the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate. The steps of validation include deciding whether the data require validation, determining ways to validate the data, and identifying areas for which data are missing. Failure to validate data may result in premature closure of the assessment or collection of inaccurate data. **[METHODS OF VALIDATION]** There are several ways to validate your data: 1. CHECK YOUR OWN DATA THROUGH A REPEAT ASSESSMENT &OR example, take the client's temperature again with a different thermometer. 2\. Clarify the data with the client by asking additional question. For example, if a client is holding his abdomen the nurse may assume he is having abdominal pain, when actually the client is very upset about his diagnosis and feeling nauseated. 3\. verify THE DATA WITH ANOTHER HEALTH CARE PROFESSIONAL. Example ask a more experienced nurse to listen to the abnormal heart sounds you think you have just heard. 4\. compare YOUR OBJECTIVE WITH YOURSUBJECTIVE finding's to uncover discrepancies. For example, if the client states that she "never gets any time in the sun," yet has dark, wrinkled, suntanned skin, you need to validate the client's perception of never getting any time in t **CHAPTER 2** **[UNIT 2-ASSESSING MENTAL STATUS AND SUBSTANCE ABUSE]** \* Mental status refers to a client's level of cognitive functioning (thinking, knowledge, problem solving) and emotional functioning (feelings, mood, behaviors, stability). One cannot be totally healthy without "mental health." Mental health is an essential part of one's total health and is more than just the absence of mental disabilities or disorders. \* The World Health ORGANIZATIO HEALTH IS A STATE OF Complete physical, mental and social well-being and not merely the absence of disease or infirmity." WHO further defines mental health as "a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stress of life, can work productively and is able to make a contribution to his/her community. **[FACTORS AFFECTING MENTAL HEALTH]** There are several factors that may influence the client's mental health or put him or her at risk for impaired mental health. These include: 1.Economic and social factors such as Rapid changes, stressful work conditions and isolation. 2\. unhealthy LIFESTYLE CHOICES SUCH AS SEDENTARY LIFESTYLE OR substance abuse. 3\. exposure to violence such as being victim of child abuse 4\. Personality factors 5\. Spiritual factors- Assessing spirituality and Religious practices 6\. Cultural factors- Assessing culture 7\. Changes or impairments in the structure and function the neurologic system. Example, Cerebral abnormalities often disturb the client's intellectual ability, communication ability, or emotional behavior. (Chapter 25, Assessing neurologic system) 8\. Psychosocial development level and issues (Chapter 7, Assessing developmental level across the lifespan. **MENTAL DISORDER DEFINES AS FOLLOWS** A. A behavioral or psychological syndrome or pattern that occurs in an individual B. That reflects an underlying psychobiologic dysfunction C. The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) D.-UST NOT BE MERELY AN EXPECTABLE RESPONSE TO COMMON stressors and losses (e.g., the loss of a loved one) or a culturally sanctioned response to a particular event (e.g., trance states in religious rituals) E. That is not primarily a result of social deviance or conflicts with society. with society Mental disorders may affect other body systems when society. \*Mental Disorder may affect other body system when prompt assessment and intervention is delayed. For Example: clients with depression may lose their appetite and over time may develop nutritional deficiencies that affect the gastrointestinal system as well as other body system. **[EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION: DEMENTIA AND ALZHEIMER'S DISEASE]** **INTRODUCTION** According to Healthy People 2020, dementia is not a disease but a set of symptoms associated with the **loss of cognitive functioning---thinking, remembering, and reasoning---to such an extent that it interferes with a person's daily life.** The cognitive changes occur because of brain diseases or trauma, and can have a rapid or a gradual onset. Memory loss is a common symptom of dementia, although memory loss by itself does not mean a person has dementia. General symptoms of dementia include (Alzheimer's Association, 2009): 1. Memory loss that disrupts daily life 2. Challenges in planning or solving problems 3. Difficulty completing familiar tasks at home, at work, or at leisure 4. Confusion with time or place 5. Trouble understanding visual images or spatial relationship 6. New problems with words in speaking or writing 7. Misplacing things and losing the ability to retrace steps 8. Decreased or poor judgment 9. Withdrawal from work or social activities 10. Changes in mood or personality **[Alzheimer's disease]**, the most common cause of dementia of the elderly, results from gradual destruction of brain nerve cells and a shrinking brain. Symptoms resemble general dementia symptoms but include loss of recent memory, depression, anxiety, personality changes, unpredictable quirks or behaviors, and problems with language, calculation, and abstract thinking (Alzheimer's Association, 2001--2011). Alzheimer's disease is the 6th leading cause of death among adults aged 18 years and older. It has been predicted that about 33% of women and 20% of men over 65 years of age will develop dementia (Yaffe, 2007. **Signs of Alzheimer's Typical Age-Related Changes** Poor judgment and decision making Making a bad decision once in a while Inability to manage a budget Missing a monthly payment Losing track of the date or the season Forgetting which day it is and remembering later Difficulty having a conversation Sometimes forgetting which word to use Misplacing things and being unable to retrace steps to find them Losing things from time to time **[RISK ASSESSMENT]** **Assess for the Following Risk Factors** Nonmodifiable risk factors include: 1. Increasing age 2. Genetic predisposition and family history 3. Latino or African American descent due to higher vascular disease rates 1. Diseases that predispose a client to vascular complications (such as diabetes, high blood pressure, and high cholesterol) (Alzheimer's Association, 2011) 2. Head trauma UÊ Smoking 3. Hormone therapy, starting therapy later in life (starting therapy at menopause may be protective; but risk increases when started later in life \[Whitmer et al., 2011\]). 4. Dysrhythmias and depression (Byers et al., 2001) 5. Not maintaining healthy aging behaviors, including keeping weight within recommended guidelines, avoiding tobacco use and excess alcohol intake, staying socially connected, and exercising both body and mind. **[CLIENT EDUCATION]** **Teach Clients** 1. Engage in mentally challenging activities (e.g., card and board games \[which also fulfill a social function when done with others\], jigsaw puzzles, reading, crossword puzzles, Sudoku, brain teasers, and activities that require both physical and mental exertion such as yard work, cooking, and playing with pets \["Mentally Challenging Activities & Delaying Dementia," 2011\]). 2. Maintain healthy aging behaviors, including maintain healthy weight, avoid tobacco use and excess alcohol intake, stay socially connected, and exercise both body and mind. 3. Avoid activities that have a risk of head trauma. 4. Ask a physician about initiating hormonal therapy, beginning the therapy at menopause rather than later in life. 5. Maintain heart healthy diet and exercise program. **INTRODUCTION** As defined in the Healthy People 2020 report, substance abuse is "a set of related conditions associated with the consumption of mind- and behavior-altering substances that have negative behavioral and health outcomes." The National Institute on Drug Abuse (NIDA) report lists the 10 most abused drugs in the United States and in the world: tobacco, alcohol, marijuana, prescription drugs, methamphetamine, MDMA (Ecstasy); crack cocaine, heroin, steroids, and inhalants (Belew, 2011). **Two groups of individuals are of particular interest in substance abuse study**: 1. **Adolescents,** who---in addition to alcohol, marijuana, and other illegal substances---are using an increasing amount of prescription drugs, especially from their parents' medicine cabinets, in the belief that these are less harmful than street drugs; 2. **and military personnel** serving in Iraq and Afghanistan, who are under great strain from combat environments, which often causes mental and family problems, and even leads to cases of suicide. Approximately 22 million Americans suffering from a drug or alcohol problem; almost 95% were unaware of their problem. The effects of substance abuse on individuals, families, and communities are substantial and cumulative. According to Healthy People 2020, these problems include: teenage pregnancy, HIV/AIDS, other STIs, domestic violence, child abuse, motor vehicle accidents, interpersonal violence of fights, crime, homicide, and suicide. **RISK ASSESSMENT** The NIDA (2003) cautions that having risk factors for substance abuse does not mean that a person will ultimately abuse drugs. Many factors affect the person's risk, both to increase the chances for abuse and to reduce the changes through protective factors. The NIDA cautions the health care professional doing the risk assessment to remember that most people who are at risk do not start using drugs or become addicted. **The importance of a particular risk is associated with age and development. The NIDA suggests assessing for the following risk factors**: 1. A history of early aggressive behavior 2. Lack of parental supervision 3. A history of substance abuse 4. Drug availability 5. Poverty **In Addition, the NIDA Recommends Assessing for Protective Factors** 1. Self-control 2. Parental monitoring 3. Academic competence 4. Anti--drug use policies at school 5. Strong neighborhood attachment **CLIENT EDUCATION** Teach Clients Teaching should be adjusted according to the developmental level of the client (NIDA, 2003; UN Office on Drugs & Crime, 2004). **Teach the Family** 1. Be aware of early aggressive behavior and seek professional assistance from behavioral counselors, if necessary. 2. Provide support and supervision to young children and adolescents, including developing a close relationship by learning to listen versus criticizing, becoming involved in the child's/adolescent's activities. 3. Discuss substance abuse issues with the young person. 4. Avoid allowing easy access to family members' prescription drugs. 5. Avoid serving as a role model for substance abuse (seek professional help or group help for personal addictions). 6. Seek help for young people who abuse substances (prescription drugs, alcohol, other addictive drugs, including marijuana). 7. Help to establish a strong community attachment base (both family, community, and school) as support for the young person. 8. Note slipping academic performance as a risk for substance abuse and follow up on this or other behavioral or mood changes. 9. Monitor young person's behaviors for signs of substance abuse. **Teach Young Clients** 1. To reach out to parents and friends who are not substance abusers if tempted to experiment or if dependence becomes noticeable to you or to your friends 2. That drugs can alter the way a person behaves and feels 3. To express your feelings constructively and show respect for the feelings of others 4. To seek ways to increase personal confidence and self-esteem 5. To value your body and recognize your individuality 6. About the physical and emotional effects of alcohol and other substances on the body and personality 7. About the physical and emotional differences between people and how to accept them UÊ Responsible attitudes towards medicines and health professionals 8. Ways that substances can get into the body 9. A responsible attitude towards the social use of alcohol (where laws allow it) 10. Critical responses to the advertising of medicines and other health supplements 11. To recognize situations in which choices can be made and identify the consequences of your choices 12. To follow simple safety instructions and know when and how to get help from adults and others, such as police or ambulance services **[PHYSICAL ASSESSMENT:]** 1.Assess for the level of consciousness-when assessing the Mental status of an older client, be sure first to check vision and hearing before assuming that the client has a mental problem. 2\. Observe the client's level of consciousness. Ask the client his or her name, address, and phone number. Ask the client to identify where you currently are (e.g., hospital, clinic), the day, and the approximate time of day. (Client is not alert to person, place, day or time; Does not respond appropriately). (If the client does not respond appropriately, call the client's name and note the response. If the client does not respond, call the name louder. If necessary, shake the client gently. If the client still does not respond, apply a painful stimulus**.) CLINICAL TIP** When assessing level of consciousness, always begin with the least noxious stimulus: verbal, tactile, to painful. 3\. Use the Glasgow Coma Scale (GCS) for clients who are at high risk for rapid deterioration of the nervous system (see Assessment Tool 6-2, p. 94) GCS score of less than 14 indicates some impairment in the level of consciousness. A score of 3, the lowest possible score, indicates deep coma 4\. Observe posture, gait, and body movements. (Slumped posture may reflect feelings of powerlessness or hopelessness characteristic of depression or organic brain disease. Bizarre body movements and behavior may be noted in schizophrenia or may be a side effect of drug therapy or other activity. Tense or anxious clients may elevate their shoulders toward their ears and hold the entire body stiffly.) 5\. Observe behavior and affect. (Uncooperative, bizarre behavior may be seen in the angry, mentally ill, or violent client. Anxious clients are often fidgety and restless. Some degree of anxiety is often seen in ill clients. Apathy or crying may be seen with depression. Incongruent behavior may be seen in clients who are in denial of problems or illness. Prolonged, euphoric laughing is typical of mania.) 6\. Observe dress and grooming. (Unusually meticulous grooming and finicky mannerisms may be seen in obsessive-compulsive disorder. Poor hygiene and inappropriate dress may be seen with organic brain syndrome. Bizarre dress may be seen in schizophrenia or manic disorders. Extreme unilateral neglect may result from a lesion due to a cerebral vascular accident (CVA).) CLINICAL TIP Be careful not to make premature judgments regarding the client's dress. Styles and clothing fads (e.g., torn jeans, oversized clothing, baggy pants), developmental level, and socioeconomic level impact an individual's mode of dress. CULTURAL CONSIDERATIONS Culture may influence a person's dress (e.g., Indian women may wear saris; Hasidic Jewish men wear black suits and black skull caps). (Uncoordinated clothing, extremely light clothing, or extremely warm clothing for the weather conditions may be seen on mentally ill, grieving, depressed, or poor clients. This may also be noted in clients with heat or cold intolerances.) OLDER ADULT CONSIDERATIONS Some older adults may wear excess clothing because of slowed metabolism and loss of subcutaneous fat, resulting in cold intolerance. (Extremely loose clothing held up by pins or a belt may suggest recent weight loss. Clients wearing long sleeves in warm weather may be protecting themselves from the sun or covering up needle marks secondary to drug abuse. Soiled clothing may indicate homelessness, vision deficits in older adults, or mental illness.) 6. Observe hygiene. Base assessment on the normal level of hygiene for the client's developmental and socioeconomic level and cultural background. (A dirty, unshaven, unkempt appearance with a foul body odor may reflect depression, drug abuse, or low socioeconomic level (i.e., homeless client). Poor hygiene may be seen in dementia or other conditions that indicate a self-care deficit. If others care for the client, poor hygiene may reflect neglect by caregiver or caregiver role strain). CULTURAL CONSIDERATIONS Asians and Native Americans have fewer sweat glands and, therefore, less obvious body odor than most Caucasians and black Africans, who have more sweat glands. Additionally, some cultures do not use deodorant products (see Chapter 11 for more information) (Breath odors from smoking or from drinking alcoholic beverages may be noted.) 7. Observe facial expressions. Note particularly eye contact and affect. (Reduced eye contact is seen in depression or apathy. Extreme facial expressions of happiness, anger, or fright may be seen in anxious clients). (Drooping or gross asymmetry occurs with neurologic disorder or injury (e.g., Bell's palsy or stroke). 8. Observe speech. Observe and listen to tone, clarity, and pace of speech. (depression or Parkinson's disease. Loud, rapid speech may occur in manic phases of bipolar disorder. Disorganized speech, consistent (nonstop) speech, or long periods of silence may indicate mental illness or a neurologic disorder (e.g., dysarthria, dysphasia, speech defect, garbled speech. 9. If the client has difficulty with speech, perform additional tests: 1. Ask the client to name object in the room 2. Ask the client to read from printed material appropriate for his or her educational level. 3. Ask the client to write a sentence. (Client cannot name objects correctly, read print correctly, or write a basic correct sentence. Deficits in this area require further neurologic assessment to identify any dysfunction of higher cortical levels.) 10. Observe mood, feelings, and expressions. Ask client "How are you feeling today?" and "What are your plans for the future?" (Flat affect, euphoria, anxiety, fear, ambivalence, irritability, depression, and/or rage are all examples of altered mood expressions) CLINICAL TIP Moods and feelings often vary from sadness to joy to anger, depending on the situation and circumstance. 11. Observe thought processes and perceptions. Observe thought processes for clarity, content, and perception by inquiring about client's thoughts and perceptions expressed. Use statements such as "Tell me more about what you just said" or "Tell me what your understanding is of the current situation or your health."( Abnormal processes include persistent repetition of ideas, illogical thoughts, interruption of ideas, invention of words, or repetition of phrases, as in schizophrenia; rapid flight of ideas, repetition of ideas, and use of rhymes and punning, as in manic phases of bipolar disorder; continuous, irrational fears, and avoidance of an object or situation, as in phobias; delusion, extreme apprehension; compulsions, obsessions, and illusions are also abnormal (see the glossary for definitions). 12. Identify possibly destructive or suicidal tendencies in client's thought processes and perceptions by asking, "How do you feel about the future?" or "Have you ever had thoughts of hurting yourself or doing away with yourself?" or "How do others feel about you?" (Clients who are suicidal may share past attempts of suicide, give plan for suicide, verbalize worthlessness about self, joke about death frequently. Clients who are depressed or feel hopeless are at higher risk for suicide. Clients who have depression early in life have a twofold increased risk for dementia (Byers et al., 2012). Clients undergoing hemodialysis often have depression and suicidal ideation) 13. Use Assessment Guide 6-1, the SAD PERSO NS Suicide Risk Assessment (p. 83), to determine the risk factors the client may have that may put him or her at risk for suicide. (Evaluate any risk factors on the SAD PERSONS. Suicide is the 10th leading cause of death in the United States for all ages and is four times more prevalent in men. Firearms accounted for 17,352 deaths, suffocation 8,161 deaths, and poisoning 6,358 deaths (Centers for Disease Control and Prevention, 2012). **[Assessing for cognitive Abilities ]** 1**.Assess orientation**. Ask for the client's name and names of family members (person), the time such as hour, day, date, or season (time), and where the client lives or is now (place) (Figure 6-4). (Reduced degree of orientation may be seen with organic brain disorders or psychiatric illness such as withdrawal from chronic alcohol use or schizophrenia**)** **2.** **Assess concentration**. Note the client's ability to focus and stay attentive to you during the interview and examination. Give the client directions such as "Please pick up the pencil with your left hand, place it in your right hand, then hand it to me." (Distraction and inability to focus on task at hand are noted in anxiety, fatigue, attention deficit disorders, and impaired states due to alcohol or drug intoxication) OLDER ADULT CONSIDERATIONS Some older clients may like to reminisce and tend to wander somewhat from the topic at hand. 3\. Assess recent memory. Ask the client "What did you have to eat today?" or "What is the weather like today?" (Inability to recall recent events is seen in delirium, dementia, depression, and anxiety.) OLDER ADULT CONSIDERATIONS Some older clients may exhibit hesitation with short-term memory. 4\. Assess remote memory. Ask the client: "When did you get your first job?" or "When is your birthday?" Information on past health history also gives clues as to the client's ability to recall remote events. (Inability to recall past events is seen in cerebral cortex disorders.) 5\. Assess use of memory to learn new information. Ask the client to repeat four unrelated words. The words should not rhyme and they cannot have the same meaning (e.g., rose, hammer, automobile, brown). Have the client repeat these words in 5 minutes, again in 10 minutes, and again in 30 minutes. (Inability to recall words after a delayed period is seen in anxiety, depression, or Alzheimer's disease. See Box 6-3 (p. 89) for seven early warning signs of Alzheimer's disease.) OLDER ADULT CONSIDERATIONS Clients older than 80 should recall two to four words after 5 minutes and possibly after 10 and 30 minutes with hints that prompt recall. 6\. Assess abstract reasoning. Ask the client to compare objects. For example, "How are an apple and orange the same? How are they different? (Inability to compare and contrast objects correctly or interpret proverbs correctly is seen in schizophrenia, mental retardation, delirium, and dementia.) **7.** Assess judgment. Ask the client, "What do you do if you have pain?" or "What would you do if you were driving and a police car was behind you with its lights and siren turned on?" (Impaired judgment may be seen in organic brain syndrome, emotional disturbances, mental retardation, or schizophrenia) 8\. Assess visual, perceptual and constructional ability. Ask the client to draw the face of a clock or copy simple figures (Fig. 6-5) Inability to draw the face of a clock or copy simple figures correctly is seen with mental retardation, dementia, or parietal lobe dysfunction of the cerebral cortex. 9\. Use the SLUMS Dementia/Alzheimer's Test Exam (Assessment Tool 6-3, p. 95) if time is limited and a quick measure is needed to evaluate cognitive function. 10\. If further assessment is needed to distinguish delirium from other types of cognitive impairment, use The Confusion Assessment Method (CAM; see Assessment Tool 6-4, p. 96). CLINICAL TIP The SLUMS and CAM test level of orientation, memory, speech, and cognitive functions but not mood, feelings, expressions, thought processes, or perceptions.