Jarvis physical_examination_and_health_assessment_7th edition

UNIT 1: ASSESSMENT OF THE WHOLE PERSON 1 Evidence-Based Assessment, 1 2 Cultural Competence, 11 3 The Interview, 27 4 The Complete Health History, 49 5 Mental Status Assessment, 67 6 Substance Use Assessment, 89 7 Domestic and Family Violence Assessments, 103 UNIT 2: APPROACH TO THE CLINICAL SETTING 8 Assessment Techniques and Safety in the Clinical Setting, 115 9 General Survey, Measurement, Vital Signs, 127 10 Pain Assessment: The Fifth Vital Sign, 161 11 Nutritional Assessment, 181 UNIT 3: PHYSICAL EXAMINATION 12 Skin, Hair, and Nails, 199 13 Head, Face, and Neck, Including Regional Lymphatics, 251 14 Eyes, 281 15 Ears, 325 16 Nose, Mouth, and Throat, 353 17 Breasts and Regional Lymphatics, 385 18 Thorax and Lungs, 413 19 Heart and Neck Vessels, 459 20 Peripheral Vascular System and Lymphatic System, 509 21 Abdomen, 537 22 Musculoskeletal System, 577 23 Neurologic System, 633 24 Male Genitourinary System, 691 25 Anus, Rectum, and Prostate, 721 26 Female Genitourinary System, 737 UNIT 4: INTEGRATION: PUTTING IT ALL TOGETHER 27 The Complete Health Assessment: Adult, 775 28 The Complete Physical Assessment: Infant, Child, and Adolescent, 789 29 Bedside Assessment and Electronic Health Recording, 799 30 The Pregnant Woman, 807 31 Functional Assessment of the Older Adult, 831 Illustration Credits, 845This page intentionally left blank1 C H A P T E R 1  Evidence-Based Assessment C.D. is a 23-year-old Caucasian woman who works as a pediatric nurse at a children’s hospital. She comes to clinic today  for a scheduled physical examination to establish with a new  primary  care  provider  (Fig.  1-1).  On  arrival  the  examiner  collects  a  health  history  and  performs  a  complete  physical  examination.  The  preliminary  list  of  significant  findings  looks like this: •  Recent  graduate  of  a  BSN  program.  Strong  academic  record (A/B). Reports no difficulties in college. Past medical history: •  Diagnosed with type 1 diabetes at age 12 years. Became  stuporous  during  a  family  vacation.  Rushed  home;  admitted to ICU with decreased level of consciousness  (LOC)  and  heavy  labored  breathing;  blood  sugar  1200 mg/dL. Coma × 3 days; ICU stay for 5 days. Diabetic teaching during hospital stay with follow-up with  diabetic educator prn. •  Now uses insulin pump. Reports HbA1c 7%. •  Finger  fracture  and  ankle  sprains  during  childhood  (unable to remember exact dates). •  Bronchitis “a lot” as a child. •  Tympanostomy tubes at age 5 because of frequent ear  infections. No issues in adulthood. •  Diabetic seizures at ages 16 and 18 caused by hypoglycemia.  Family  gave  glucagon  injection.  Did  not  go  to  ED. •  Denies tobacco use. Reports having 1 glass of red wine  approximately 5-6 days in the past month. •  Current medications: Insulin, simvastatin, birth control  pills, fish oil, multivitamin, melatonin (for sleep). •  Birth  control  since  age  16  because  of  elevated  blood  sugar  during  menstruation.  Gynecologic  examinations  annually.  Last  Pap  test  6  months  ago;  told  was  “negative.” •  Family history: Mother and paternal grandfather with  hypertension; maternal grandfather transient ischemic  attack,  died  at  age  80  from  a  myocardial  infarction;  maternal  grandmother  died  at  age  49  of  cervical  and  ovarian cancer; paternal grandmother with arthritis in  the hands and knees; paternal grandfather with kidney  disease at age 76; sister with migraine headaches. •  BP 108/72 mm Hg right arm, sitting. HR 76 beats/min,  regular. Resp 14/min unlabored. •  Weight 180 lbs. Height 5ft 6 in. BMI 29 (overweight). •  Health  promotion:  Reports  consistently  wearing  sunscreen  when  outside  and  completing  skin  selfexamination every few months. Consistently monitors  blood glucose. Walks 2 miles at least 3 days per week  and  does  strength  training  exercises  2  days  per  week.  No  hypoglycemic  episodes  during  exercise.  Reports  weekly  pedicure  and  foot  check  to  monitor  for  skin  breakdown.  Biannual  dental  visits.  Performs  BSE  monthly. •  Relationships: Close relationship with family (mother,  father,  brother,  and  sister);  no  significant  other.  Feels  safe  in  home  environment  and  reports  having  close  female friends. •  Health perception: “Could probably lose some weight,”  but  otherwise  reports  “good”  health.  Primarily  concerned with blood sugar, which becomes labile with life  transitions. •  Expectations of provider: Establish an open and honest  relationship.  Listen  to  her  needs  and  facilitate  her  health goals. 1-12 UNIT 1 Assessment of the Whole Person professional observe by inspecting, percussing, palpating, and  auscultating during the physical examination). Together with  the  patient’s  record  and  laboratory  studies,  these  elements  form the database. From the database you make a clinical judgment or diagnosis about the individual’s health state, response to actual or  potential  health  problems,  and  life  processes.  Thus  the  purpose of assessment is to make a judgment or diagnosis. An organized assessment is the starting point of diagnostic  reasoning. Because all health care diagnoses, decisions, and  treatments are based on the data you gather during assessment,  it  is  paramount  that  your  assessment  be  factual  and  complete. Diagnostic Reasoning The step from data collection to diagnosis can be a difficult  one.  Most  novice  examiners  perform  well  in  gathering  the  data (given adequate practice) but then treat all the data as  being equally important. This makes decision making slow  and labored. Diagnostic reasoning  is  the  process  of  analyzing  health  data and drawing conclusions to identify diagnoses. Novice  examiners  most  often  use  a  diagnostic  process  involving  hypothesis  forming  and  deductive  reasoning.  This  hypothetico-deductive process has four major components:  (1) attending to initially available cues; (2) formulating diagnostic hypotheses; (3) gathering data relative to the tentative  hypotheses; and (4) evaluating each hypothesis with the new  data  collected,  thus  arriving  at  a  final  diagnosis. A  cue  is  a  piece  of  information,  a  sign  or  symptom,  or  a  piece  of  laboratory data. A hypothesis is a tentative explanation for a  cue or a set of cues that can be used as a basis for further  investigation. Once you complete data collection, develop a preliminary  list of significant signs and symptoms for all patient health  needs. This is less formal in structure than your final list of  diagnoses will be and is in no particular order. Cluster or group together the assessment data that appear  to  be  causal  or  associated.  For  example,  with  a  person  in  acute  pain,  associated  data  are  rapid  heart  rate,  increased  BP, and anxiety. Organizing the data into meaningful clusters  is  slow  at  first;  experienced  examiners  cluster  data  more  rapidly  because  they  recall  proven  results  of  earlier  patient  situations and recognize the same patterns in the new clinical  situation.10 Validate the data you collect to make sure they are accurate. As you validate your information, look for gaps in data  collection. Be sure to find the missing pieces, because identifying  missing  information  is  an  essential  critical-thinking  skill. How you validate your data depends on experience. If  you are unsure of the BP, validate it by repeating it yourself.  Eliminate any extraneous variables that could influence BP  results such as recent activity or anxiety over admission. If  you  have  less  experience  analyzing  breath  sounds  or  heart  murmurs, ask an expert to listen. Even with years of clinical  experience, some signs always require validation (e.g., a breast  lump). Physical examination: •  Normocephalic. Face symmetric. Denies pain on sinus  palpation. •  Vision tested annually. Has worn corrective lenses since  4th grade. PERRLA. •  Scarring bilateral tympanic membranes. Denies hearing  problems. Whispered words heard bilaterally. •  Gums  pink;  no  apparent  dental  caries  except  for  3  noticeable fillings. Reports no dental pain. •  Compound nevus on left inner elbow; patient reports  no  recent  changes  in  appearance.  No  other  skin  concerns. •  Breath  sounds  clear  and  equal  bilaterally.  Heart  S1S2,  neither  accentuated  nor  diminished.  No  murmur  or  extra heart sounds. •  CBE done with annual gynecologic visit. •  Abdomen is rounded. Bowel sounds present. Reports  BM daily. •  Extremities warm and = bilat. All pulses present, 2+ and  = bilat. No lymphadenopathy. Sensory modalities intact  in legs and feet. No lesions. The examiner analyzed and interpreted all the data; clustered  the information, sorting out which data to refer and which  to treat; and identified the diagnoses. It is interesting to note  how  many  significant  findings  are  derived  from  data  the  examiner collected. Not only physical data but also cognitive,  psychosocial, and behavioral data are significant for an analysis  of  C.D.’s  health  state.  The  findings  also  are  interesting  when considered from a life-cycle perspective (i.e., she is a  young adult who predictably is occupied with the developmental  tasks  of  emancipation  from  parents,  building  an  independent lifestyle, establishing a vocation, making friends,  forming an intimate bond with another, and establishing a  social  group).  C.D.  appears  to  be  meeting  the  appropriate  developmental tasks successfully. A body of clinical evidence has validated the use of the  particular assessment techniques in C.D.’s case. For example,  measuring the BP screens for hypertension and early intervention here wards off heart attack and stroke. Monitoring  blood sugar levels and HbA1c facilitates management of her  type 1 diabetes. Completing a skin assessment reveals a nevus  on her elbow that needs to be watched for any changes. Collecting health promotion data allows the examiner to personalize risk reduction and health promotion information while  reinforcing positive behaviors already in place. The physical  examination is not just a rote formality. Its parts are determined by the best clinical evidence available and documented  in the professional literature. ASSESSMENT—POINT OF ENTRY IN AN ONGOING PROCESS Assessment  is  the  collection  of  data  about  the  individual’s  health  state.  Throughout  this  text  you  will  be  studying  the  techniques of collecting and analyzing subjective data (i.e.,  what the person says about himself or herself during history  taking)  and  objective data  (i.e.,  what  you  as  the  health CHAPTER 1 Evidence-Based Assessment 3 guide  performance.  It  takes  time,  perhaps  2  to  3  years  in  similar  clinical  situations,  to  achieve  competency,  in  which  you see actions in the context of arching goals or daily plans  for  patients.  With  more  time  and  experience  the  proficient  nurse understands a patient situation as a whole rather than  as a list of tasks. At this level you can see long-term goals for  the patient. You project that today’s interventions apply to the  point at which you want the patient to be in the future. Finally  it seems that expert nurses vault over the steps and arrive at  a clinical judgment in one leap. The expert has an intuitive  grasp  of  a  clinical  situation  and  zeroes  in  on  the  accurate  solution.5 Critical Thinking and the Diagnostic Process The standards of practice in nursing, traditionally termed the  nursing process,  include  six  phases:  assessment,  diagnosis,  outcome identification, planning, implementation, and evaluation.3 This is an iterative process allowing practitioners to  move back and forth while caring for the needs of complex  patients (Fig. 1-2). Although  the  nursing  process  is  a  problem-solving  approach, the way in which we apply the process depends on  our level and years of experience. The novice has no experience  with  a  specified  patient  population  and  uses  rules  to  1-2 OUTCOME IDENTIFICATION • Identify expected outcomes • Individualize to the person • Culturally appropriate • Realistic and measurable • Include a timeline PLANNING • Establish priorities • Develop outcomes • Set timelines for outcomes • Identify interventions • Integrate evidence-based trends and research • Document plan of care THE INDIVIDUAL IMPLEMENTATION • Implement in a safe and timely manner • Use evidence-based interventions • Collaborate with colleagues • Use community resources • Coordinate care delivery • Provide health teaching and health promotion • Document implementation and any modification EVALUATION • Progress toward outcomes • Conduct systematic, ongoing, criterion-based evaluation • Include patient and significant others • Use ongoing assessment to revise diagnoses, outcomes, plan • Disseminate results to patient and family ASSESSMENT • Collect data: Review of the clinical record Health history Physical examination Functional assessment Risk assessment Review of the literature • Use evidence-based assessment techniques • Document relevant data DIAGNOSIS • Compare clinical findings with normal and abnormal variation and developmental events • Interpret data Identify clusters of clues Make hypotheses Test hypotheses Derive diagnoses • Validate diagnoses • Document diagnoses4 UNIT 1 Assessment of the Whole Person overlook  based  on  natural  assumptions.  Rates  of  incorrect  diagnoses are estimated to be as high as 10% to 15%, and one  of the primary causes of misdiagnosis is the clinician’s bias.12  An overweight young adult comes to your clinic for a scheduled  physical  examination.  Are  you  making  assumptions  about  her  lifestyle  and  eating  habits?  Make  sure  that  you  double-check the accuracy of your data (subjective and objective), identify normal and abnormal findings, and group like  findings together. For example, a man who has heart failure  may  exhibit  shortness  of  breath,  palpitations,  ankle edema,  and weight gain. Alone each of these may appear unrelated,  but together they are signs of an exacerbation of heart failure. Once  you  have  clustered  items  that  are  related,  you  are  ready to identify relevant information and anything that does  not fit. In the case of your heart failure patient, his complaints  of  a  headache  may  be  viewed  as  unrelated  to  the  primary  diagnosis, whereas abdominal pain and difficulty buttoning  his pants are related (presence of ascites). As you gather clinical cues and complete an assessment, also think about priority setting (Table 1-1). •  First-level priority problems are those that are emergent,  life  threatening,  and  immediate,  such  as  establishing  an  airway or supporting breathing. •  Second-level priority problems are those that are next in  urgency—those  requiring  your  prompt  intervention  to  forestall further deterioration (e.g., mental status change,  acute pain, acute urinary elimination problems, untreated  medical  problems,  abnormal  laboratory  values,  risks  of  infection, or risk to safety or security). •  Third-level priority problems are those that are important to the patient’s health but can be addressed after more  urgent  health  problems  are  addressed.  Interventions  to  treat these problems are more long term, and the response  to treatment is expected to take more time. •  Collaborative problems are those in which the approach  to  treatment  involves  multiple  disciplines.  Collaborative  problems  are  certain  physiologic  conditions  in  which  nurses  have  the  primary  responsibility  to  diagnose  the  onset  and  monitor  the  changes  in  status.8  For  example,  C.D.’s  data  regarding  diabetes  represent  a  collaborative  problem.  With  this  problem  the  sudden  imbalance  of  insulin and blood sugar has profound implications on the  central nervous and gastrointestinal (GI) systems. Her care  will be monitored by nurses, doctors, dietitians, and case  managers. Or another patient with an alcohol-use disorder  presents to the hospital for unrelated surgery and experiences sudden alcohol withdrawal symptoms. This causes  rebound effects on the central nervous and cardiovascular  systems that must be managed by a team of clinicians. Once  you  have  determined  problems,  you  must  identify  expected  outcomes  and  work  with  the  patient  to  facilitate  outcome achievement. Remember, your outcomes need to be  measurable.  Set  small  goals  that  can  be  accomplished  in  a  given time frame. For your heart failure patient your goal may  be to eliminate supplemental oxygen needs before discharge.  Include your patient in your outcome identification and his  or her input as appropriate. Functioning  at  the  level  of  expert  in  clinical  judgment  includes using intuition (i.e., knowledge received as a whole).  Intuition  is  characterized  by  immediate  recognition  of  patterns;  expert  practitioners  learn  to  attend  to  a  pattern  of  assessment  data  and  act  without  consciously  labeling  it.  Whereas the beginner operates more from a set of defined,  structured rules, the expert practitioner uses intuitive links,  has the ability to see salient issues in a patient situation, and  knows instant therapeutic responses.5 The expert has a storehouse  of  experience  concerning  which  interventions  have  been successful in the past. For example, compare the actions of the nonexpert and  the expert nurse in the following situation of a young man  with Pneumocystis jiroveci pneumonia: He was banging the side rails, making sounds, and pointing  to  his  endotracheal  tube.  He  was  diaphoretic,  gasping,  and  frantic.  The  nurse  put  her  hand  on  his  arm  and  tried  to  ascertain whether he had a sore throat from the tube. While  she  was  away  from  the  bedside  retrieving  an  analgesic,  the  expert nurse strolled by, hesitated, listened, went to the man’s  bedside,  reinflated  the  endotracheal  cuff,  and  accepted  the  patient’s  look  of  gratitude  because  he  was  able  to  breathe  again.  The  nonexpert  nurse  was  distressed  that  she  had  misread the situation. The expert reviewed the signs of a leaky  cuff with the nonexpert and pointed out that banging the side  rails  and  panic  help  differentiate  acute  respiratory  distress  from pain.15 The method of moving from novice to becoming an expert  practitioner is through the use of critical thinking. We all start  as novices, when we need the familiarity of clear-cut rules to  guide  actions.  Critical  thinking  is  the  means  by  which  we  learn to assess and modify, if indicated, before acting. We may  even be beginners more than once during our careers. As we  transition to different specialties, we must rebuild our database  of  experiences  to  become  experts  in  new  areas  of  practice. Critical thinking is required for sound diagnostic reasoning and clinical judgment. During your career you will need  to sort through vast amounts of data to make the sound judgments to manage patient care. These data will be dynamic,  unpredictable,  and  ever  changing.  There  will  not  be  any  one  protocol  you  can  memorize  that  will  apply  to  every  situation. Critical  thinking  is  recognized  as  an  important  component  of  nursing  education  at  all  levels.2,20  Case  studies  and  simulations frequently are used to encourage critical thinking  with students. As a student, be prepared to think outside the  box and think critically through patient-care situations. Critical thinking goes beyond knowing the pathophysiology of a  disease process and requires you to put important assessment  cues together to determine the most likely cause of a clinical  problem and develop a solution. Critical thinking is a multidimensional  thinking  process,  not  a  linear  approach  to  problem solving. Remember to approach problems in a nonjudgmental way  and to avoid making assumptions. Identify which information  you  are  taking  for  granted  or  information  you  may CHAPTER 1 Evidence-Based Assessment 5 EVIDENCE-BASED ASSESSMENT Does honey help burn wounds heal more quickly? Is St. John’s wort effective in relieving the symptoms of major depression? Does male circumcision reduce the risk of transmitting human immunodeficiency virus (HIV) in heterosexual men? Can magnesium sulfate reduce cerebral palsy risk in premature infants? Can infusing hearts with stem cells help heal tissue damage after a heart attack? Health  care  is  a  rapidly  changing  field.  The  amount  of  medical  and  nursing  information  available  today  has  skyrocketed.  Current  efforts  of  cost  containment  result  in  a  hospital population composed of people who have a higher  acuity  but  are  discharged  earlier  than  in  the  past.  Clinical  research studies are continuously pushing health care forward.  Keeping up with these advances and translating them into  practice are very challenging. Budget cuts, staff shortages, and  increasing  patient  acuity  mean  that  the  clinician  has  little  time to grab a lunch break, let alone browse the most recent  journal articles for advances in a clinical specialty. The conviction that all patients deserve to be treated with  the  most  current  and  best-practice  techniques  led  to  the  development  of  evidence-based practice (EBP).  In  1972  a  British  epidemiologist  and  early  proponent  of  EBP, Archie  Cochrane, identified a pressing need for systematic reviews  of randomized clinical trials. In a landmark case Dr. Cochrane  noted  multiple  clinical  trials  published  between  1972  and  1981 showing that the use of corticosteroids to treat women  in premature labor reduced the incidence of infant mortality.  A short course of corticosteroid stimulates fetal lung development, thus preventing respiratory distress syndrome, a serious  and  common  complication  of  premature  birth.  Yet  these  findings had not been implemented into daily practice, and  thousands of low-birth-weight premature infants were dying  needlessly. Following a systematic review of the evidence in  1989, obstetricians finally accepted the use of corticosteroid  treatment as standard practice for women in preterm labor.  Corticosteroid treatment has since been shown to reduce the  risk of infant mortality by 30% to 50%.9 EBP is more than the use of best-practice techniques to  treat patients. “EBP is a systematic approach to practice that  emphasizes the use of best evidence in combination with the  clinician’s experience, as well as the patient preferences and  values, to make decisions about care and treatment”16 (Fig.  1-3). This definition is comprehensive and holistic. Note how  clinical decision making depends on all four factors: the best  evidence  from  a  critical  review  of  research  literature;  the  patient’s own preferences; the clinician’s own experience and  expertise; and finally physical examination and assessment.  Assessment skills must be practiced with hands-on experience and refined to a high level. Although assessment skills are foundational to EBP, it is  important to question tradition when no compelling research  evidence  exists  to  support  it.  Some  time-honored  assessment techniques have been removed from the examination  repertoire because clinical evidence indicates that these techniques are not as accurate as once believed. For example, the  The  final  steps  to  the  critical-thinking  process  include  evaluation  and  planning.  You  must  continuously  evaluate  whether you are on the right track and correct any missteps  or misinterpretation of data. If you are not on the right path,  reassess, reanalyze, and revise. The final step is the development of a comprehensive plan that is kept up-to-date. Communicate the plan  to  the  multidisciplinary  team. Be aware  that this is a legal document and that accurate recording is  important  for  evaluation,  insurance  reimbursement,  and  research. TABLE 1-1 Identifying Immediate Priorities Principles of Setting Priorities 1. Make a complete list of current medications, medical problems, allergies, and reasons for seeking care. Refer to them frequently because they may affect how you set priorities. 2. Determine the relationships among the problems: If problem Y causes problem Z, problem Y takes priority over problem Z. Example: If pain is causing immobility, pain management is a high priority. Setting priorities is a dynamic, changing process; at times the order of priority changes, depending on the seriousness and relationship of the problems. Example: If abnormal laboratory values are at life-threatening levels, they become a higher priority; if the patient is having trouble breathing because of acute rib pain, managing the pain may be a higher priority than dealing with a rapid pulse (first-level priority, listed in the next section). Steps to Setting Priorities 1. Assign high priority to first-level priority problems (immediate priorities): Remember the “ABCs plus V”: • Airway problems • Breathing problems • Cardiac/circulation problems • Vital sign concerns (e.g., high fever) Exception: With cardiopulmonary resuscitation (CPR) for cardiac arrest, begin chest compressions immediately. Go to for the most current CPR guidelines. 2. Next attend to second-level priority problems: • Mental status change (e.g., confusion, decreased alertness) • Untreated medical problems requiring immediate attention (e.g., a person with diabetes who has not had insulin) • Acute pain • Acute urinary elimination problems • Abnormal laboratory values • Risks of infection, safety, or security (for the patient or for others) 3. Address third-level priority problems (later priorities): • Health problems that do not fit into the previous categories (e.g., problems with lack of knowledge, activity, rest, family coping) © 2014 Alfaro-LeFevre Workshop Handouts. www. AlfaroTeachS.6 UNIT 1 Assessment of the Whole Person Fostering a culture of EBP at the undergraduate and graduate levels is one way in which health care educators attempt  to make evidence-based care the “gold standard” of practice.  Students  of  medicine  and  nursing  are  now  taught  how  to  filter through the wealth of scientific data and critique their  findings.  They  are  learning  to  discern  which  interventions  would best serve their individual patients. Facilitating support  for  EBP  at  the  organizational  level  includes  time  to  go  to  the  library;  teaching  staff  to  conduct  electronic  searches;  journal club meetings; establishing nursing research committees;  linking  staff  with  university  researchers;  and  ensuring  that  adequate  research  journals  and  preprocessed  evidence  resources are available in the library.13 “We have come to a time when the credibility of the health professions will be judged by which of its practices are based on the best and latest evidence from sound scientific studies in combination with clinical expertise, astute assessment, and respect for patient values and preferences.”18 COLLECTING FOUR TYPES OF DATA Every examiner needs to establish four different types of databases, depending on the clinical situation: complete, focused  or problem-centered, follow-up, and emergency. Complete (Total Health) Database This  includes  a  complete  health  history  and  a  full  physical  examination.  It  describes  the  current  and  past  health  state  and forms a baseline against which all future changes can be  measured. It yields the first diagnoses. The complete database often is collected in a primary care  setting such as a pediatric or family practice clinic, independent or group private practice, college health service, women’s  health  care  agency,  visiting  nurse  agency,  or  community  health agency. When you work in these settings, you are the  first health professional to see the patient and have primary  responsibility  for  monitoring  the  person’s  health  care.  Collecting the complete database is an opportunity to build and  strengthen  your  relationship  with  the  patient.  For  the  well  person this database must describe the person’s health state;  perception  of  health;  strengths  or  assets  such  as  health  maintenance behaviors, individual coping patterns, support  systems, and current developmental tasks; and any risk factors  or  lifestyle  changes.  For  the  ill  person  the  database  also  includes a description of the person’s health problems, perception of illness, and response to the problems. For well and ill people, the complete database must screen  for pathology and determine the ways people respond to that  pathology  or  to  any  health  problem.  You  must  screen  for  pathology because you are the first, and often the only, health  professional  to  see  the  patient.  This  screening  is  important  to refer the patient to another professional, help the patient  make  decisions,  and  perform  appropriate  treatments.  But  this  database  also  notes  the  human  responses  to  health  problems. This factor is important because it provides additional  information  about  the  person  that  leads  to  nursing  diagnoses. traditional practice of auscultating bowel sounds was found  to  be  a  poor  indicator  of  returning  GI  motility  in  patients  having abdominal surgery.17 The research team first reviewed  earlier  studies  suggesting  that  early  postoperative  bowel  sounds  probably  do  not  represent  the  return  of  normal  GI  motility and therefore listening to the abdomen is not useful  in this situation. Research showed the primary markers for  returning  GI  motility  after  abdominal  surgery  to  be  the  return of flatus and the first postoperative bowel movement.  The  Madsen  team  instituted  a  new  practice  protocol  and  monitored  patient  outcomes  to  determine  whether  discontinuing the auscultation of bowel sounds was detrimental to  abdominal  surgery  patients.  Detrimental  outcomes  did  not  occur; the new practice guideline was shown to be safe for  patients’ recovery and a better allocation of staff time. Evidence  shows  that  other  assessment  skills  are  effective  for patient care. For example, clinicians should measure the  ankle brachial index (ABI), as described in Chapter 20 of this  text. Evidence is clear about the value of ABI as a screening  measure for peripheral artery disease. Despite the advantages to patients who receive care based  on EBP, it often takes up to 17 years for research findings to  be  implemented  into  practice.4  This  troubling  gap  has  led  researchers  to  examine  closely  the  barriers  to  EBP,  both  as  individual practitioners and as organizations. As individuals,  nurses  lack  research  skills  in  evaluating  quality  of  research  studies, are isolated from other colleagues knowledgeable in  research,  and  lack  confidence  to  implement  change.  Other  significant  barriers  are  the  organizational  characteristics  of  health care settings. Nurses lack time to go to the library to  read research; health care institutions have inadequate library  research  holdings;  and  organizational  support  for  EBP  is  lacking when nurses  wish to  implement  changes in patient  care.13 Evidence from research and evidence-based theories Physical examination and assessment of patient Clinical expertise Patient preferences and values Evidence-based clinical decision making 1-3CHAPTER 1 Evidence-Based Assessment 7 both within the person and from the external environment.  Thus the treatment of disease requires the services of numerous providers. Nursing includes many aspects of the holistic  model (i.e., the interaction of the mind and body, the oneness  and unity of the individual). Both the individual human and  the  external  environment  are  open  systems,  dynamic  and  continually  changing  and  adapting  to  one  another.  Each  person is responsible for his or her own personal health state  and is an active participant in health care. Health promotion  and disease prevention form the core of nursing practice. In  a  holistic  model  assessment  factors  are  expanded  to  include such things as lifestyle behaviors, culture and values,  family and social roles, self-care behaviors, job-related stress,  developmental tasks, and failures and frustrations of life. All  are significant to health. Health promotion and disease prevention  now  round  out our concept of health. Guidelines to prevention emphasize  the  link  between  health  and  personal  behavior.  The  report of the U.S. Preventive Services Task Force26 asserts that  the great majority of deaths among Americans younger than  65 years are preventable. Prevention can be achieved through  counseling from primary care providers designed to change  people’s unhealthy behaviors related to smoking, alcohol and  other drug use, lack of exercise, poor nutrition, injuries, and  sexually transmitted infections.14 Health promotion is a set  of positive acts that we can take. In this model the focus of  the health professional is on teaching and helping the consumer choose a healthier lifestyle. The frequency interval of assessment varies with the person’s  illness  and  wellness  needs.  Most  ill  people  seek  care  because of pain or some abnormal signs and symptoms they  have noticed, which prompts an assessment (i.e., gathering a  complete, a focused, or an emergency database). In addition,  risk assessment and preventive services can be delivered once  the presenting concerns are addressed (Fig. 1-4). But  for  the  well  person  opinions  are  inconsistent  about  assessment intervals. The term annual checkup is vague. What  does it constitute? Is it necessary or cost-effective? How can  primary-care clinicians deliver preventive services to people  with no signs and symptoms of illness? Periodic health checkups are an excellent opportunity to deliver preventive services  and update the complete database. Although periodic health  In acute hospital care the complete database also is gathered on admission to the hospital. In the hospital, data related  specifically to pathology may be collected by the admitting  physician. You collect additional information on the patient’s  perception of illness, functional ability or patterns of living,  activities  of  daily  living,  health  maintenance  behaviors,  response to health problems, coping patterns, interaction patterns, and health goals. Focused or Problem-Centered Database This is for a limited or short-term problem. Here you collect  a “mini” database, smaller in scope and more targeted than  the complete database. It concerns mainly one problem, one  cue complex, or one body system. It is used in all settings— hospital, primary care, or long-term care. For example, 2 days  after surgery a hospitalized person suddenly has a congested  cough,  shortness  of  breath,  and  fatigue.  The  history  and  examination focus primarily on the respiratory and cardiovascular systems. Or in an outpatient clinic a person presents  with a rash. The history follows the direction of this presenting concern such as whether the rash had an acute or chronic  onset; was associated with a fever, new food, pet, or medicine;  and was localized or generalized. Physical examination must  include a clear description of the rash. Follow-Up Database The status of any identified problems should be evaluated at  regular and appropriate intervals. What change has occurred?  Is the problem getting better or worse? Which coping strategies are used? This type of database is used in all settings to  follow up both short-term and chronic health problems. Emergency Database This is an urgent, rapid collection of crucial information and  often  is  compiled  concurrently  with  lifesaving  measures.  Diagnosis must be swift and sure. For example, a person is  brought  into  a  hospital  ED  with  suspected  substance  overdose.  The  first  history  questions  are, “What  did  you  take?”  “How much did you take?” and “When?” The person is questioned simultaneously while his or her airway, breathing, circulation,  level  of  consciousness,  and  disability  are  being  assessed. Clearly the emergency database requires more rapid  collection of data than the episodic database. Once the person  has been stabilized, a complete database can be compiled. EXPANDING THE CONCEPT OF HEALTH Assessment is the collection of data about a person’s health  state. A clear definition of health is important because this  determines  which  assessment  data  should  be  collected.  In  general the list of data that must be collected has lengthened  as our concept of health has broadened. Consideration of the whole person is the essence of holistic health. Holistic  health  views  the  mind,  body,  and spirit  as  interdependent  and  functioning  as  a  whole  within  the  environment.  Health  depends  on  all  these  factors  working  together. The basis of disease is multifaceted, originating from  1-4 (Yoder-Wise, 2014.)8 UNIT 1 Assessment of the Whole Person checkups could induce unnecessary costs and promote nonrecommended  services,  advocates  justify  well-person  visits  because  of  delivery  of  some  recommended  preventive  services and reduction of patient worry.7 The  Guide to Clinical Preventive Services  is  a  positive  approach  to  health  assessment  and  risk  reduction.26  The  Guide is updated annually and is accessible online or in print.  It presents evidence-based, gold standard recommendations  on screening, counseling, and preventive topics and includes  clinical considerations for each topic. These services include  screening  factors  to  gather  during  the  history,  age-specific  items  for  physical  examination  and  laboratory  procedures,  counseling topics, and immunizations. This approach moves  away  from  an  annual  physical  ritual  and  toward  a  rational  and varying periodicity based on factors specific to the patient.  Health education and counseling are highlighted as the means  to deliver health promotion and disease prevention. For example, the guide to examination for C.D. (23-yearold female, nonpregnant, not sexually active) would recommend the following services for preventive health care: 1.  Screening history for dietary intake, physical activity,  tobacco/alcohol/drug use, and sexual practices 2.  Physical examination  for  height  and  weight,  BP,  and  screening for cervical cancer and HIV 3.  Counseling  for  physical  activity  and  risk  prevention  (e.g., secondhand smoke, seatbelt use) 4.  Depression screening 5.  Healthy diet  counseling,  including  lipid  disorder  screening and obesity screening 6.  Chemoprophylaxis to include multivitamin with folic  acid (females capable of or planning pregnancy) C.D.  is  living  successfully  with  a  serious  chronic  condition.  Because she has diabetes, including periodic checks of hemoglobin A1c and a fasting glucose level is important. In addition,  you  should  ask  how  her  pump  is  functioning  and  whether she is having any difficulties with blood sugar control. CULTURE AND GENETICS In  a  holistic  model  of  health  care,  assessment  factors  must  include  culture.  An  introduction  to  cross-cultural  concepts  follows in Chapter 2. These concepts are developed throughout the text as they relate to specific chapters. Metaphors such as melting pot, mosaic, and salad bowl have  been used to describe the cultural diversity that characterizes  the United States. According to the U.S. Census Bureau, close  to  50%  of  the  population  of  the  United  States  will  consist  of people from diverse racial, ethnic, and cultural groups by  the year 2050. Emerging minority is a term that has been used  to classify the populations, including Blacks, Hispanics, and  Asian  Americans,  that  are  rapidly  becoming  a  combined  numeric majority.22 The population of the United States surpassed 311 million  people in the autumn of 2011; approximately 1 in 3 U.S. residents was part of a group other than single-race non-Hispanic  Whites  according  to  national  estimates  by  race,  Hispanic  origin, and age released by the Census Bureau. In 2043 the United States is expected to become a majorityminority nation. Although non-Hispanic Whites will remain  the  largest  single  group,  they  will  no  longer  constitute  a  numeric majority. By 2060 the U.S. Census Bureau projects  that  minorities  will  comprise  57%  of  the  population.  The  Hispanic and Asian populations are projected to more than  double  by  2060,  and  all  other  racial  groups  are  expected  to  increase as well. By 2060 nearly 33% of the population will be  Hispanic, 15% Blacks, 8.2% Asian, and 1.5% American Indians  or Alaska Natives. In 2050 the U.S. Census Bureau anticipates  that there will be more people over the age of 65 years than  under the age of 18 years for the first time in history.25 As the United States population is becoming more diverse,  the U.S. health care providers go abroad to work in a variety  of  health  care  settings  in  the  international  community.  Medical and nursing teams volunteer to provide free medical  and surgical care in developing countries (Fig. 1-5). International interchanges are increasing among health care providers,  making  attention  to  the  cultural  aspects  of  health  and  illness an even greater priority. During your professional career you may be expected to  assess short-term foreign visitors who travel for treatments,  international university faculty, students from abroad studying in U.S. high schools and universities, family members of  foreign  diplomats,  immigrants,  refugees,  members  of  more  than 106 different ethnic groups, and American Indians from  510 federally recognized tribes. A serious conceptual problem  exists  in  that  nurses  and  physicians  are  expected  to  know,  understand, and meet the health needs of people from culturally  diverse  backgrounds  with  minimal  preparation  in  cultural competence. Culture  has  been  included  in  each  chapter  of  this  book.  Understanding the basics of a variety of cultures is important  in health assessment. People from different cultures may interpret  symptoms  differently;  therefore  asking  the  right  questions is imperative for you to gather data that are accurate and  meaningful. Members of some cultural groups are demanding  culturally relevant health care that incorporates their specific  beliefs and practices. An increasing expectation exists among  1-5CHAPTER 1 Evidence-Based Assessment 9 members of certain cultural groups that health care providers  will respect their “cultural health rights,” an expectation that  may conflict with the unicultural Western biomedical worldview taught in U.S. educational programs that prepare nurses,  doctors, and other health care providers. Given the multicultural composition of the United States  and the projected increase in the number of individuals from  diverse  cultural  backgrounds  anticipated  in  the  future,  a  concern  for  the  cultural  beliefs  and  practices  of  people  is  increasingly important. BIBLIOGRAPHY 15.  Hanneman, S. K. (1996). Advancing nursing practice with a  unit-based clinical expert. Image, 28(4), 331-337. 16.  Leufer, T. C. (2009). Evidence-based practice: improving  patient outcomes. Nurs Stand, 23(32), 35-39. 17.  Madsen, D., Sebolt, T., Cullen, L., et al. (2005). Listening to  bowel sounds: an evidence-based practice project. Am J Nurs, 105(12), 40-50. 18.  Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare. (2nd ed.). Philadelphia:  Lippincott Williams & Wilkins. 19.  Melnyk, B. M., Fineout-Overhold, E., Stillwell, B., et al. (2009).  Evidence-based practice step by step: igniting the spirit of  inquiry. Am J Nurs, 109(11), 49-52. First in a 12-part series. 20.  National League for Nursing Accrediting Commission. (2006).  Accreditation manual and interpretive guidelines by program type for postsecondary and higher degree programs in nursing.  New York: Author. 21.  Robert, R. R., & Petersen, S. (2013). Critical thinking at the  bedside: providing safe passage to patients. Medsurg Nurs, 22(2):85-93. 22.  Spector, R. E. (2013). Cultural diversity in health and illness.  (8th ed.). Indianapolis, IN: Pearson. 23.  Throckmorton, T., & Windle, P. E. (2009). Evidence-based  case management practice. Part 1: the systemic review. Prof Case Manage, 14(2), 76-81. 24.  U.S. Bureau of the Census. (2014). Quickfacts. Washington,  DC: U.S. Government Printing Office. . 25.  U.S. Census Bureau. (2012). U.S. Census Bureau projections show a slower growing, older, more diverse nation a half century from now. Available at  releases/archives/population/. 26.  U.S. Preventive Services Task Force (USPSTF). (2012).   Guide to clinical preventive services. (2012). Available at  guidelines-recommendations/guide/guide-clinical-preventive  -. 1.  Alfaro-LeFevre, R. (2013). Critical thinking, clinical reasoning and clinical judgment. (5th ed.). St. Louis: Saunders. 2.  American Association of Colleges of Nursing. (2008).  Essentials of baccalaureate education for professional nursing practice. Available at  3.  American Nurses Association. (2010). Nursing scope and standards of performance and standards of clinical practice.  Washington, DC: American Nurses Publishing. 4.  Balas, E. A., & Boren, S. A. (2000). Managing clinical  knowledge for health care improvements. In Bemmel, J., &   A. T. McCray (Eds.). Yearbook of medical informatics 2000.  Stuttgart, Germany: Schattauer. 5.  Benner, P., Tanner, C. A., & Chesla, C. A. (1996). Expertise in nursing practice. New York: Springer. 6.  Benner, P., Tanner, C. A., & Chesla, C. A. (1997). Becoming an  expert nurse. Am J Nurs, 97(6), 16BBB-16DDD. 7.  Boulware, L. E., Marinopoulos, S., & Phillips, K. A. (2007).  Systematic review: the value of the periodic health evaluation.  Ann Intern Med, 146(4), 289-300. 8.  Carpenito-Moyet, L. J. (2012). Nursing diagnosis: application to clinical practice. (14th ed.). Philadelphia: Lippincott  Williams & Wilkins. 9.  Cochrane Collaboration. (2013). Available at  . 10.  Coderre, S., Mandin, H., Harasym, P. H., et al. (2003).  Diagnostic reasoning strategies and diagnostic success.   Med Educ, 37(8), 695-703. 11.  Crisp, N., & Chen, L. (2014). Global supply of health  professionals. N Engl J Med, 370(10), 950-957. 12.  Croskerry, P. (2013). From mindless to mindful practice— cognitive bias and clinical decision making. N Engl J Med, 368, . 13.  DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-based nursing: a guide to clinical practice. St. Louis: Mosby. 14.  Ezzati, M., & Riboli, E. (2013). Behavioral and dietary risk   factors for noncommunicable diseases. N Engl J Med, 369(10):954-964.This page intentionally left blank11 Cultural Competence A health profession role encompasses your relationships with people—your ability to listen to, empathize with, and understand people. How can you fulfill this role to the best of your ability? First be open to people who are different from you, have a curiosity about people, and begin the lifelong journey of becoming culturally competent (Fig. 2-1). The United States is becoming more diverse, not only through globalization and immigration, but also because of a wide range of subcultures and an increasing acceptance of lifestyle choices that may differ from the mainstream. For example, in 2011 approximately 4% of the U.S. adult population (or 9 million people) identified themselves as lesbian, gay, bisexual, or transgender (LGBT), and even larger numbers stated that they had same-sex experiences or were attracted to the same sex without necessarily identifying themselves as LGB.16 A key to understanding cultural diversity is self-awareness and knowledge of one’s own culture, which may be African American, Euro American, Chinese American, Dominican American, Mexican American, Southeast Asian–American, or any combination of self-identified ethnicities and races. Your cultural identification might include the subculture of nursing or health care professionals. You might identify yourself as a Midwesterner, a college student, an athlete, a member of the Polish community, or a Buddhist. These multiple and often changing cultural and subcultural identifications help define an individual and influence one’s beliefs about health and illness, coping mechanisms, and wellness behaviors. Over the course of your professional education, you will study physical examination and health promotion across the life span and learn to conduct numerous assessments such as a health history, a physical examination, a mental health assessment, a domestic violence assessment, a nutritional assessment, and a pain assessment. However, depending on the cultural and racial background of the person, the data you gather in the assessments may vary. Therefore a cultural assessment must be an integral component of a complete physical and health assessment. DEMOGRAPHIC PROFILE OF THE UNITED STATES The estimates of the U.S. population illustrate the increasing diversity in the population and explain the rationale for learning about the cultural aspects of health* and illness† from the point of view of the person seeking health care.46 The population of the United States exceeded 311 million people in 2011.44 Approximately 1 in every 6 to 7 people was an immigrant, and greater than one third of U.S. residents were part of a group other than single-race non-Hispanic White.27,44 The national minority, actually emerging majority, population totaled 37% of the total population.27 Among this emerging majority, the largest ethnic group is Hispanic, who make up 16.7% of the population and are the fastest-growing minority group. The largest racial minority group is African American or Black (12.2%), followed by Asians (4.8%), other races (4.7%), two or more races (2.8%), American Indians and Alaska natives (0.8%), and Native Hawaiians and other Pacific Islanders (0.2%).44 There are differences among the emerging majority groups when compared to non-Hispanic Whites. These demographic differences are age, poverty level, and household †Illness: “The loss of the person’s balance, both within one’s being (i.e., physical, mental, and/or spiritual) and in the outside world (i.e., natural, communal, and/or metaphysical).”41 *Health: “The balance of the person, both within one’s being (i.e., physical, mental, and/or spiritual) and in the outside world (i.e., natural, communal, and/or metaphysical), is a complex, interrelated phenomenon.”41 2-1 C H A P T E R 212 UNIT 1 Assessment of the Whole Person understanding of health care resources and how to navigate the health care system. They may not speak or understand English, and they may not be literate in the language of their country of origin. Therefore it is imperative that health care address the needs of this growing population. In 2011 the population in the United States included over 40 million foreign-born people, including legal and undocumented immigrants, representing 13% of the U.S. population and an increase of 9 million people since 2000.27,44 Although the number of foreign born is the greatest in U.S. history, the foreign born as a percent of the entire population does not reach the high point in American history (i.e., from 1890 to1920) when immigrants from Southern and Eastern Europe made up 15% of the population.36 The current wave of immigrants is predominantly from Latin America (50%) and Asia (27%). Mexico has by far the largest number of immigrants to the U.S. at 29% of the foreign-born population, followed by India at 4.6%, the Philippines at 4.5%, China at 4.1%, and Vietnam at 3.1%.36 The Immigration and Nationality Act of 1965 abolished quota systems that denied entrance into the United States to Latin Americans, Asians, and Africans, thus opening the way for the current wave of immigration. In 2011 there were also 11.1 million people who were foreign born and living in the United States without legal documents (unauthorized or undocumented immigrants), which decreased from 12 million in 2007. This is the result of a decrease or reversal of net immigration from Mexico, the origin of the largest number of unauthorized immigrants.34 The new wave of immigration and the numbers of unauthorized immigrants have engendered a great deal of controversy in the United States and have prompted new policy changes. The proposed Immigration Reform Bill would create a mechanism for the 11 million undocumented immigrants to achieve legal citizenship after proving that they can speak English, pass background checks, and pay t