11/8/21, 2:45 PM Nurse's Touch Video Interaction Family in a Stressful Situation
https://scorm.atitesting.com/courses/FCAEA235-130E-47FC-A14E-88DF7D4186A1/1/launchpage.html 1/1
%SimulationName% Video Transcript
DR. KOVAC: How are you feeling, Mrs. Travis? MRS. TRAVIS: I guess as expected. DR. KOVAC: Mr. Travis,
your wife did very well during the surgery. It took a little longer than we expected. MR. TRAVIS: I was worried.
DR. KOVAC: We found a small tumor in her stomach. Because of the size, the surgery was more complicated
than we anticipated. We were successful in removing the entire tumor. However, I'm concerned about the
appearance of this tumor, and we noted some areas on her liver and her pancreas that were abnormal. We
obtained many biopsies, and we should have the results soon. I would like to admit her to the hospital and
observe her overnight. MR. TRAVIS: This can't be happening.
11/8/21, 2:41 PM Nurse's Touch Video Interaction Family in a Stressful Situation
https://scorm.atitesting.com/courses/FCAEA235-130E-47FC-A14E-88DF7D4186A1/1/launchpage.html 1/1
%SimulationName% Video Transcript
ESCORT: May I help you, Mr. Travis? MR. TRAVIS: I’m so worried. I know I come up here every five minutes
or so. ESCORT: Can I get you a bottle of water or something? MR. TRAVIS: No, thanks. I'm fine. Has anyone
called for me yet? ESCORT: Uh, no, there have been no calls yet, but it has been a while. I can check again on
your wife if you would like. MR. TRAVIS: Yes, that would be great. Thank you. ESCORT: I was just going to
call back. Do you have an update for Mr. Travis about how his wife is doing? He hasn’t been able to sit still the
entire time that she’s been in surgery. If you don’t have something to tell him, I’m going to just tell him that
everything is going to be just fine. MR. TRAVIS: Heather, do you know something about my wife? Why is it
taking so long?
11/8/21, 2:39 PM Nurse's Touch Video Interaction Family in a Stressful Situation
https://scorm.atitesting.com/courses/FCAEA235-130E-47FC-A14E-88DF7D4186A1/1/launchpage.html 1/1
%SimulationName% Video Transcript
HEATHER: Mrs. Travis, you pushed your call light. Is there something we can do for you? MRS. TRAVIS: My
husband went to the waiting room to get more coffee. I've never seen him so nervous. Do you know how soon
they'll come and get me for surgery? HEATHER: We can check on that. Right, Rose? ROSE: Yes, we can check
on that. MRS. TRAVIS: Thank you. My husband’s so nervous, he’s making me nervous. I’m having a hard time
relaxing. I don’t know what to do to help him calm down so that I can relax.
11/8/21, 2:37 PM Nurse's Touch Video Interaction Family in a Stressful Situation
https://scorm.atitesting.com/courses/FCAEA235-130E-47FC-A14E-88DF7D4186A1/1/launchpage.html 1/1
%SimulationName% Video Transcript
HEATHER: Mr. Travis, is there anything I can do for you? I see you looking out into the hallway often. Were
you looking for someone? MR. TRAVIS: Yeah, I'm just watc ...
Delivering Results Through Person-Centred Care: Kaiser Permanente Patient Car...NHSScotlandEvent
This session provides a living example of how care at the practice, team, organisation and system levels have been transformed through person-centred approaches using ‘Caring Science’ impacting on quality variables across the whole organisation.
This document describes the PROSPEC study which aimed to create a computerized patient-centered intervention to facilitate discussions between patients and physicians about prostate cancer screening. The study involved interviews with community members and physicians to develop an evidence-based ontology and computer program. Analysis found that after using the intervention, patients were more likely to initiate discussion about screening compared to before. The presenter learned about the research process and plans continued study of how race influences patient-physician communication.
Dr. Hooshang Saberi is a neurosurgeon in Iran who led the first team in Iran to successfully transplant Schwann cells to repair spinal cord injuries. The team has now treated over 60 patients, with about a 60% success rate of improved neurological function. Dr. Saberi was interested in this research due to seeing patients suffering from spinal cord injuries. He conducted animal studies to test the hypothesis that Schwann cells could promote repair in the spinal cord like they do in the peripheral nervous system. This technique uses only Schwann cells for transplantation and represents a unique approach compared to research in other countries.
1) An anesthesiologist plays a critical role in surgery beyond just putting the patient to sleep - they must continuously monitor the patient's vital signs and be prepared to respond if complications arise.
2) It takes extensive education and clinical training to become a physician anesthesiologist. Using them provides patients the highest level of care and safety during their procedure.
3) Research shows that having a physician anesthesiologist present reduces the risk of death from surgical complications.
Mis houston,chicago,nyc how to survive minimally invasive surgery Marisa Tapia
This document provides guidance for perioperative nurses on preparing for and assisting with minimally invasive surgeries. It emphasizes the importance of preoperative planning, teaching, and briefing to set the stage for success. Key aspects of planning include scheduling cases appropriately, providing realistic time estimates, and keeping preference cards updated. Preoperative teaching involves giving patients instructions, addressing questions, and providing checklists and reliable online resources. Briefings before and after surgery allow the team to communicate, clarify roles, and debrief on how to improve. Effective teamwork relies on leadership, assertive communication, and maintaining situational awareness.
The document defines and describes the nursing process, which is a problem-solving approach used by nurses to address patient health needs. It has 6 main components: assessment, diagnosis, planning, implementation, evaluation, and outcome identification. Assessment involves collecting a health history and doing a physical exam. A nursing diagnosis identifies actual or potential patient problems that nurses can address through independent nursing action. The nursing diagnosis is developed based on assessment data and identifies the problem and its etiology.
Priscilla Pringle Health Academy Portfolioppringle4
Priscilla Pringle describes her rotations as a student at Via Christi Hospital. During her first two weeks, she toured the hospitals and learned about procedures and safety protocols. She then completed rotations in various departments, including rehabilitation services, medical intensive care, pediatrics, labor and delivery, radiology, and the operating room. She found pediatrics and the operating room to be her favorite rotations. Priscilla is considering careers as a registered nurse, physical therapy assistant, pediatrician, or physician's assistant.
The document provides information for a simulation scenario involving a patient presenting with acute upper GI bleeding. A 60-year-old Chinese male accompanied by his wife presents to a free community clinic complaining of nausea, abdominal discomfort, and dark stools for several days. Initial assessment reveals elevated vital signs and abdominal tenderness. The patient then vomits bright red blood twice, becoming pale and weak with declining vital signs. Learners are expected to recognize signs of acute GI bleeding, provide supportive care, and arrange emergency transport. Debriefing questions assess learners' critical thinking and nursing care for this type of scenario.
Delivering Results Through Person-Centred Care: Kaiser Permanente Patient Car...NHSScotlandEvent
This session provides a living example of how care at the practice, team, organisation and system levels have been transformed through person-centred approaches using ‘Caring Science’ impacting on quality variables across the whole organisation.
This document describes the PROSPEC study which aimed to create a computerized patient-centered intervention to facilitate discussions between patients and physicians about prostate cancer screening. The study involved interviews with community members and physicians to develop an evidence-based ontology and computer program. Analysis found that after using the intervention, patients were more likely to initiate discussion about screening compared to before. The presenter learned about the research process and plans continued study of how race influences patient-physician communication.
Dr. Hooshang Saberi is a neurosurgeon in Iran who led the first team in Iran to successfully transplant Schwann cells to repair spinal cord injuries. The team has now treated over 60 patients, with about a 60% success rate of improved neurological function. Dr. Saberi was interested in this research due to seeing patients suffering from spinal cord injuries. He conducted animal studies to test the hypothesis that Schwann cells could promote repair in the spinal cord like they do in the peripheral nervous system. This technique uses only Schwann cells for transplantation and represents a unique approach compared to research in other countries.
1) An anesthesiologist plays a critical role in surgery beyond just putting the patient to sleep - they must continuously monitor the patient's vital signs and be prepared to respond if complications arise.
2) It takes extensive education and clinical training to become a physician anesthesiologist. Using them provides patients the highest level of care and safety during their procedure.
3) Research shows that having a physician anesthesiologist present reduces the risk of death from surgical complications.
Mis houston,chicago,nyc how to survive minimally invasive surgery Marisa Tapia
This document provides guidance for perioperative nurses on preparing for and assisting with minimally invasive surgeries. It emphasizes the importance of preoperative planning, teaching, and briefing to set the stage for success. Key aspects of planning include scheduling cases appropriately, providing realistic time estimates, and keeping preference cards updated. Preoperative teaching involves giving patients instructions, addressing questions, and providing checklists and reliable online resources. Briefings before and after surgery allow the team to communicate, clarify roles, and debrief on how to improve. Effective teamwork relies on leadership, assertive communication, and maintaining situational awareness.
The document defines and describes the nursing process, which is a problem-solving approach used by nurses to address patient health needs. It has 6 main components: assessment, diagnosis, planning, implementation, evaluation, and outcome identification. Assessment involves collecting a health history and doing a physical exam. A nursing diagnosis identifies actual or potential patient problems that nurses can address through independent nursing action. The nursing diagnosis is developed based on assessment data and identifies the problem and its etiology.
Priscilla Pringle Health Academy Portfolioppringle4
Priscilla Pringle describes her rotations as a student at Via Christi Hospital. During her first two weeks, she toured the hospitals and learned about procedures and safety protocols. She then completed rotations in various departments, including rehabilitation services, medical intensive care, pediatrics, labor and delivery, radiology, and the operating room. She found pediatrics and the operating room to be her favorite rotations. Priscilla is considering careers as a registered nurse, physical therapy assistant, pediatrician, or physician's assistant.
The document provides information for a simulation scenario involving a patient presenting with acute upper GI bleeding. A 60-year-old Chinese male accompanied by his wife presents to a free community clinic complaining of nausea, abdominal discomfort, and dark stools for several days. Initial assessment reveals elevated vital signs and abdominal tenderness. The patient then vomits bright red blood twice, becoming pale and weak with declining vital signs. Learners are expected to recognize signs of acute GI bleeding, provide supportive care, and arrange emergency transport. Debriefing questions assess learners' critical thinking and nursing care for this type of scenario.
The document summarizes Grace Lewis' experiences in the St. Gianna Catholic Health Academy program over 14 weeks. She rotated through various medical units including the SICU, radiology, the lab, NICU, general surgery, labor and delivery, the cardiac unit, physical therapy, the ER, respiratory therapy, the OR, and PICU. Her favorite rotations were NICU, radiology, respiratory therapy, and the OR. Through this experience, Grace explored various medical careers and developed a strong interest in becoming a neonatal nurse or neonatologist.
1) The document outlines a talk on improving remote rheumatology consultations. It discusses building a workflow process, conducting a virtual musculoskeletal exam, identifying clues from limited physical exams, and guiding patients.
2) Case examples are presented to demonstrate elements of a remote exam. The document also discusses targeting improvements such as research, advocacy, and collaboration that medical students can engage in.
3) In closing, the document emphasizes that telemedicine should enhance but not replace in-person care, and some patients may still require face-to-face exams.
Brooke Poelstra plans to attend Kansas State University to major in Biology and pursue pre-med. She then wants to become an OB/GYN. She has experience in the health field through her high school's health academy. Brooke is interested in several medical careers including OB/GYN, medical examiner, physical therapist, plastic surgeon, respiratory therapist, and pediatrician. She documents her rotations in various hospital departments through blogs.
Brooke Poelstra plans to attend Kansas State University to study biology and pursue pre-med, with the goal of becoming an OB/GYN. She has experience in St. Gianni Health Academy and has done rotations in various hospital units including OR, labor and delivery, MICU, and rehab services. Brooke wrote blogs reflecting on her experiences in these rotations and plans to continue gaining experience in healthcare.
Medical documentation is your proof that you provided good care. It should tell a story, communicate with the healthcare team, explain your medical decision-making, and be able to be used and referenced for medical billing and research. Tips and tricks on how to get this right.
Perfecting the art of medical hypnosis as an alternative to traditional anesthesia, learnings from Sodexo's International Leaders' Survey, addressing the challenges and opportunities created by the multi-generational workforce in hospitals, improving transport services to increase efficiency, news around the world.
1) A 35-year-old man was in a serious car accident and was taken to the trauma center in critical condition. Scans showed brain injury and herniation.
2) The patient meets criteria for organ donation due to his brain injury and clinical condition. The nurse calls the organ procurement organization.
3) The organ procurement organization evaluates the patient and determines he is medically suitable for organ donation. The nurse continues providing care and supporting the family while donation is considered.
Joe a well respected RN with many years of experience, worked in.docxvrickens
"Joe" a well respected RN with many years of experience, worked in the intensive care unit. One afternoon a patient was brought to the unit immediately post heart surgery. Joe assumed his care, and began his assessment. Shortly after the patient's arrival, the surgeon came in to see that patient.
The surgeon decided that he needed to replace a blocked central line, although the patient did have two patent peripheral IVs. Joe assisted the surgeon with the line placement, then called for radiology to come up and confirm line placement, as per protocol. Just as Joe heard the radiology tech coming, the patient developed asystole. Joe and the surgeon instituted ACLS protocol. When the surgeon called for a medication to be pushed, Joe went to push it via the patent peripheral IV, as placement of the central line had not been confirmed. The surgeon yelled 'No! In the central line! Push it in the central line!' Joe responded, 'The central line placement has not been confirmed, so it has to go through the peripheral." At this point, the surgeon yelled, "I want it through the central line, and you have to do what I say, because I'm the physician!" Joe yelled back that he was not going to risk his license just because a physician refused to follow protocol. He told the surgeon that he would push it through the peripheral line. The surgeon was livid, but made no attempt to push the med himself, so Joe pushed it through the peripheral line. The patient was then revived.
Joe and the surgeon continued to argue after the patient was resuscitated, to the point where other staff feared a fist fight would ensue. The house manager, an RN, was called in. Joe explained the situation to her. The surgeon said "I told him he was a nurse and he had to do what I told him to do. He's not going to lose his license or get fired as long as he does what I tell him to do. But he won't listen."
The house manager responded. "Well, the hospital policy does say that central lines cannot be used until placement has been confirmed by radiology." The surgeon went berserk, yelling at everyone. The house manager then said "well, if you want, we can change that policy so if a physician says it's ok, the line can be used without confirmation."
What do you think of the house manager's response to the situation?
What, if anything, do you think Joe should have done differently?
How would you have responded?
What do you suggest should be done about this proposed change in the policy?
Contents lists available at ScienceDirect
International Journal of Nursing Studies
journal homepage: www.elsevier.com/locate/ijns
Effect of non-nutritive sucking and sucrose alone and in combination for
repeated procedural pain in preterm infants: A randomized controlled trial
Haixia Gaoa,⁎, Mei Lib, Honglian Gaoc, Guihua Xua, Fang Lib, Jing Zhoub, Yunsu Zoub,
Honghua Jiangb
a School of Nursing, Nanjing University of Chinese Medicine, Nanjing, China
b Children’s Hospital of Nanjing Medical U ...
This document provides information about the emergency department ultrasound service at a hospital, including:
- The ultrasound team consists of 4 consultants, 1 fellow currently training, and 1 registrar currently working to complete competency in procedures like EFAST and AAA scanning.
- An emergency physician with fellow/registrar is rostered daily from 0800-1800 for ultrasound, with a limited service possibly available after hours.
- The service performs full diagnostic scans, focused scans to assess things like shock or sepsis, and ultrasound-guided procedures. Areas like musculoskeletal ultrasound require a private referral.
- The advantages of the emergency department sonographers include timely access and assistance with patient management decisions. Registrars are encouraged to
OSCE Pediatrics Observed Stations Dr.D.Y.Patil Medical College CMEDr Padmesh Vadakepat
The document provides information about the structure and tips for the Observed Structured Clinical Examination (OSCE) assessment. It outlines the various stations one may encounter, including observed clinical examinations, procedures, history taking, counseling, and rest stations. It emphasizes arriving prepared with the proper equipment, reading questions carefully, focusing on key details, and maintaining a calm demeanor throughout. Clinical examples and common mistakes made by students are discussed to help optimize performance.
This document provides a certification preparation test for hemodialysis technicians and nurses. It contains a disclaimer stating that passing this test does not guarantee passing any official certification and that candidates are responsible for their own study and preparation. The test then begins with multiple choice questions about topics like the roles and responsibilities of physicians, nurses, administrators, and other staff in a dialysis facility according to regulations.
The document discusses the experience of a nurse working in an emergency department for eight years. It describes "frequent flyers" as patients who come in multiple times a month for various complaints. The nurse realizes she had developed an unfair bias against these patients for using emergency resources for non-medical reasons. After reading a book on crucial conversations, the nurse is determined to change attitudes towards frequent flyers and advocate more effectively for all patients.
The document provides guidance on taking a patient's medical history. It discusses the importance of obtaining an accurate history and outlines the general approach and structure for conducting a history, including introducing oneself, ensuring confidentiality, listening to the patient, and asking open-ended questions. It then covers how to record specific components of the history, such as the chief complaint, history of present illness, past medical history, drug history, family history, and social history.
NCIHC's latest Home for Trainers 90-minute webinar on partnering with providers to ensure successful encounters. Webinar intended for interpreter trainers. 1.5 CEUs.
Ms Susan Moug's keynote speech 'The Promotion of Physical Activity - Everyone's Responsibility' at the SCPN's 'Be Active Against Cancer' conference, Tuesday 4th February 2014.
Trevor Alexander completed a summer internship at Cohesion Phenomics where he gained hands-on experience in genetic testing and analysis. Cohesion Phenomics performs complex genetic testing to help physicians diagnose heritable disorders. Trevor learned laboratory techniques like DNA isolation, PCR, sequencing, and analysis. He began by observing the laboratory processes and then performed tasks under supervision. By the end of the internship, Trevor was able to independently complete the full genetic testing and analysis process. His final project involved analyzing a rare mutation in a patient sample to determine clinical significance. The internship provided valuable experience that will help Trevor in pursuing future education and career opportunities in biology and laboratory science.
This document describes the emergency department ultrasound service at James Wheeler Hospital. It includes:
1) There are 5 ED consultants with ultrasound qualifications who provide the service from 0800-1800 Monday to Friday, with limited availability after hours. One US fellow is also undergoing training.
2) The service provides full diagnostic scans, focused bedside scans to assist with diagnosis and management, and ultrasound-guided procedures. Common scans include EFAST, AAA, lung/heart/sepsis assessments.
3) The advantages of ED sonographers include timely access, clinical experience to tailor exams, and assistance with procedures and patient management. For appropriate scans, clinical questions and patient preparation are requested. Training opportunities in basic ultrasound
11Getting Started with PhoneGapWHAT’S IN THIS CHAPTERSantosConleyha
11
Getting Started with PhoneGap
WHAT’S IN THIS CHAPTER?
! History of PhoneGap
! Di! erences between HTML5 and PhoneGap
! Getting a development environment set up
! Implementing the Derby App
PhoneGap is an open source set of tools created by Nitobi
Solution
s (now part of Adobe)
that enables you to create mobile applications for multiple devices by utilizing the same code.
PhoneGap is a hybrid mobile application framework that allows the use of HTML, CSS,
and JavaScript to write applications that are based on the open standards of the web. These
applications also have access to the native functionality of the device. PhoneGap has been
downloaded more than 600,000 times, and more than 1,000 apps built with PhoneGap are
available in the respective app stores, which makes PhoneGap a viable solution for creating
cross-platform mobile apps.
HISTORY OF PHONEGAP
PhoneGap was started at the San Francisco iPhone Dev Camp in August 2008. iOS was shaping
up to become a popular mobile platform, but the learning curve for Objective-C was more work
than many developers wanted to take on. PhoneGap originally started as a headless browser
implementation for the iPhone. Because of the popularity of HTML/CSS/JavaScript, it was a
goal that this project use technologies with which many developers where already familiar.
Based on the growing popularity of the framework, in October 2008 Nitobi added support
for Android and BlackBerry. PhoneGap was awarded the People’s Choice award at the Web2.0
Expo Launch Pad in 2009, which was the start of developers recognizing PhoneGap as a
valuable mobile development tool. PhoneGap version 0.7.2 was released in April 2009, and
was the fi rst version for which the Android and iPhone APIs were equivalent.
c11.indd 309c11.indd 309 28/07/12 6:08 PM28/07/12 6:08 PM
310 " CHAPTER 11 GETTING STARTED WITH PHONEGAP
In September 2009 Apple approved the use of the PhoneGap platform to build apps for the iPhone
store. Apple required that all PhoneGap apps be built using at least version 0.8.0 of the PhoneGap
software. In July 2011, PhoneGap released version 1.0.0.
WHY USE PHONEGAP?
PhoneGap enables you to leverage your current HTML, CSS, and JavaScript skill sets to create a mobile
application. This can greatly speed up development time. When you develop for multiple platforms
using PhoneGap, you can reuse the majority of the code you have written for the mobile project, further
reducing development costs. It isn’t necessary to learn Java, C#, and Objective-C to create an applica-
tion with PhoneGap that can target iPhone, Android, BlackBerry, and Windows Phone 7.
If you fi nd native functionality missing from PhoneGap, you can extend the functionality of the
PhoneGap platform using native code. With the PhoneGap add-in structure, you can create an add-in
using the native language of the device and a JavaScript API that will call the native plug-in you
created. Cross-platfo ...
11Proposal Part One - Part 1 Influence of Internet on TourismSantosConleyha
11
Proposal Part One - Part 1: Influence of Internet on Tourism Industry
Research Proposal: Influence of Internet on Tourism Industry
Introduction
The tourism industry has been among the best-valued sectors within the nation to generate massive revenue for the government. Besides, the industry is considered among the earliest since it started several decades ago. For an extended period, the industry uses Integrated Marketing Communications to promote their various products and services to the entire world. The introduction of technology in the industry leads to improvements in the sectors. Most individuals without extensive information on the tourism industry can access the data in their comfort zones. It implies that IT and internet technology play a significant role in ensuring effective strategy due to its existence globally.
Most European countries have tried to promote and implement internet technology in ensuring satisfactory delivery of products and services (Kayumovich, 2020). Since it has a custom within the tourism and hotel industry to provide intangible products and services, including but not limited to services alongside comfort, the internet has been an effective method of delivering its messages to the targeted customers. Also, through internet technology, the industry has achieved more customers in the global market, including the European market. The promotion of branding within the European tourism industry has been effective due to the introduction and implementation of internet technology. Thus, the internet is believed to significantly influence the tourism industry in various sectors, including but limited to infrastructure, travel, alongside the marketing sector. Before introducing the internet alongside the IT, travelling of customers was dangerous and unpleasant since travellers had constraint understanding of locations they were visiting.
As a result, the existing vacationers of time had limited knowledge of the cultures and terrain alongside the climate change and patterns necessary to stimulate the travelling issues. Therefore, tourism sectors, including but not limited to tour companies, travel agencies and other like hotels, had developed strategies necessary to promote booking and reservation processes (David-Negre et al. 2018). However, several decades ago, popular sites were visited by tourists. It implies that the tourism sectors within the local or remote area faced challenges of securing sufficient clients as people were could not define the destination. Also, shortage of information on a particular region leads to reduced travelling by visitors. The research involved the utilization of relevant literature review on the subject matter to provide factual information. Therefore, the report offers adequate information on the influence of the internet on the tourism industry. This research would give me the stage to show my finding and view and also propose how the internet can be leveraged to an extend i ...
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The document summarizes Grace Lewis' experiences in the St. Gianna Catholic Health Academy program over 14 weeks. She rotated through various medical units including the SICU, radiology, the lab, NICU, general surgery, labor and delivery, the cardiac unit, physical therapy, the ER, respiratory therapy, the OR, and PICU. Her favorite rotations were NICU, radiology, respiratory therapy, and the OR. Through this experience, Grace explored various medical careers and developed a strong interest in becoming a neonatal nurse or neonatologist.
1) The document outlines a talk on improving remote rheumatology consultations. It discusses building a workflow process, conducting a virtual musculoskeletal exam, identifying clues from limited physical exams, and guiding patients.
2) Case examples are presented to demonstrate elements of a remote exam. The document also discusses targeting improvements such as research, advocacy, and collaboration that medical students can engage in.
3) In closing, the document emphasizes that telemedicine should enhance but not replace in-person care, and some patients may still require face-to-face exams.
Brooke Poelstra plans to attend Kansas State University to major in Biology and pursue pre-med. She then wants to become an OB/GYN. She has experience in the health field through her high school's health academy. Brooke is interested in several medical careers including OB/GYN, medical examiner, physical therapist, plastic surgeon, respiratory therapist, and pediatrician. She documents her rotations in various hospital departments through blogs.
Brooke Poelstra plans to attend Kansas State University to study biology and pursue pre-med, with the goal of becoming an OB/GYN. She has experience in St. Gianni Health Academy and has done rotations in various hospital units including OR, labor and delivery, MICU, and rehab services. Brooke wrote blogs reflecting on her experiences in these rotations and plans to continue gaining experience in healthcare.
Medical documentation is your proof that you provided good care. It should tell a story, communicate with the healthcare team, explain your medical decision-making, and be able to be used and referenced for medical billing and research. Tips and tricks on how to get this right.
Perfecting the art of medical hypnosis as an alternative to traditional anesthesia, learnings from Sodexo's International Leaders' Survey, addressing the challenges and opportunities created by the multi-generational workforce in hospitals, improving transport services to increase efficiency, news around the world.
1) A 35-year-old man was in a serious car accident and was taken to the trauma center in critical condition. Scans showed brain injury and herniation.
2) The patient meets criteria for organ donation due to his brain injury and clinical condition. The nurse calls the organ procurement organization.
3) The organ procurement organization evaluates the patient and determines he is medically suitable for organ donation. The nurse continues providing care and supporting the family while donation is considered.
Joe a well respected RN with many years of experience, worked in.docxvrickens
"Joe" a well respected RN with many years of experience, worked in the intensive care unit. One afternoon a patient was brought to the unit immediately post heart surgery. Joe assumed his care, and began his assessment. Shortly after the patient's arrival, the surgeon came in to see that patient.
The surgeon decided that he needed to replace a blocked central line, although the patient did have two patent peripheral IVs. Joe assisted the surgeon with the line placement, then called for radiology to come up and confirm line placement, as per protocol. Just as Joe heard the radiology tech coming, the patient developed asystole. Joe and the surgeon instituted ACLS protocol. When the surgeon called for a medication to be pushed, Joe went to push it via the patent peripheral IV, as placement of the central line had not been confirmed. The surgeon yelled 'No! In the central line! Push it in the central line!' Joe responded, 'The central line placement has not been confirmed, so it has to go through the peripheral." At this point, the surgeon yelled, "I want it through the central line, and you have to do what I say, because I'm the physician!" Joe yelled back that he was not going to risk his license just because a physician refused to follow protocol. He told the surgeon that he would push it through the peripheral line. The surgeon was livid, but made no attempt to push the med himself, so Joe pushed it through the peripheral line. The patient was then revived.
Joe and the surgeon continued to argue after the patient was resuscitated, to the point where other staff feared a fist fight would ensue. The house manager, an RN, was called in. Joe explained the situation to her. The surgeon said "I told him he was a nurse and he had to do what I told him to do. He's not going to lose his license or get fired as long as he does what I tell him to do. But he won't listen."
The house manager responded. "Well, the hospital policy does say that central lines cannot be used until placement has been confirmed by radiology." The surgeon went berserk, yelling at everyone. The house manager then said "well, if you want, we can change that policy so if a physician says it's ok, the line can be used without confirmation."
What do you think of the house manager's response to the situation?
What, if anything, do you think Joe should have done differently?
How would you have responded?
What do you suggest should be done about this proposed change in the policy?
Contents lists available at ScienceDirect
International Journal of Nursing Studies
journal homepage: www.elsevier.com/locate/ijns
Effect of non-nutritive sucking and sucrose alone and in combination for
repeated procedural pain in preterm infants: A randomized controlled trial
Haixia Gaoa,⁎, Mei Lib, Honglian Gaoc, Guihua Xua, Fang Lib, Jing Zhoub, Yunsu Zoub,
Honghua Jiangb
a School of Nursing, Nanjing University of Chinese Medicine, Nanjing, China
b Children’s Hospital of Nanjing Medical U ...
This document provides information about the emergency department ultrasound service at a hospital, including:
- The ultrasound team consists of 4 consultants, 1 fellow currently training, and 1 registrar currently working to complete competency in procedures like EFAST and AAA scanning.
- An emergency physician with fellow/registrar is rostered daily from 0800-1800 for ultrasound, with a limited service possibly available after hours.
- The service performs full diagnostic scans, focused scans to assess things like shock or sepsis, and ultrasound-guided procedures. Areas like musculoskeletal ultrasound require a private referral.
- The advantages of the emergency department sonographers include timely access and assistance with patient management decisions. Registrars are encouraged to
OSCE Pediatrics Observed Stations Dr.D.Y.Patil Medical College CMEDr Padmesh Vadakepat
The document provides information about the structure and tips for the Observed Structured Clinical Examination (OSCE) assessment. It outlines the various stations one may encounter, including observed clinical examinations, procedures, history taking, counseling, and rest stations. It emphasizes arriving prepared with the proper equipment, reading questions carefully, focusing on key details, and maintaining a calm demeanor throughout. Clinical examples and common mistakes made by students are discussed to help optimize performance.
This document provides a certification preparation test for hemodialysis technicians and nurses. It contains a disclaimer stating that passing this test does not guarantee passing any official certification and that candidates are responsible for their own study and preparation. The test then begins with multiple choice questions about topics like the roles and responsibilities of physicians, nurses, administrators, and other staff in a dialysis facility according to regulations.
The document discusses the experience of a nurse working in an emergency department for eight years. It describes "frequent flyers" as patients who come in multiple times a month for various complaints. The nurse realizes she had developed an unfair bias against these patients for using emergency resources for non-medical reasons. After reading a book on crucial conversations, the nurse is determined to change attitudes towards frequent flyers and advocate more effectively for all patients.
The document provides guidance on taking a patient's medical history. It discusses the importance of obtaining an accurate history and outlines the general approach and structure for conducting a history, including introducing oneself, ensuring confidentiality, listening to the patient, and asking open-ended questions. It then covers how to record specific components of the history, such as the chief complaint, history of present illness, past medical history, drug history, family history, and social history.
NCIHC's latest Home for Trainers 90-minute webinar on partnering with providers to ensure successful encounters. Webinar intended for interpreter trainers. 1.5 CEUs.
Ms Susan Moug's keynote speech 'The Promotion of Physical Activity - Everyone's Responsibility' at the SCPN's 'Be Active Against Cancer' conference, Tuesday 4th February 2014.
Trevor Alexander completed a summer internship at Cohesion Phenomics where he gained hands-on experience in genetic testing and analysis. Cohesion Phenomics performs complex genetic testing to help physicians diagnose heritable disorders. Trevor learned laboratory techniques like DNA isolation, PCR, sequencing, and analysis. He began by observing the laboratory processes and then performed tasks under supervision. By the end of the internship, Trevor was able to independently complete the full genetic testing and analysis process. His final project involved analyzing a rare mutation in a patient sample to determine clinical significance. The internship provided valuable experience that will help Trevor in pursuing future education and career opportunities in biology and laboratory science.
This document describes the emergency department ultrasound service at James Wheeler Hospital. It includes:
1) There are 5 ED consultants with ultrasound qualifications who provide the service from 0800-1800 Monday to Friday, with limited availability after hours. One US fellow is also undergoing training.
2) The service provides full diagnostic scans, focused bedside scans to assist with diagnosis and management, and ultrasound-guided procedures. Common scans include EFAST, AAA, lung/heart/sepsis assessments.
3) The advantages of ED sonographers include timely access, clinical experience to tailor exams, and assistance with procedures and patient management. For appropriate scans, clinical questions and patient preparation are requested. Training opportunities in basic ultrasound
Similar to 11821, 245 PM Nurses Touch Video Interaction Family in a S (20)
11Getting Started with PhoneGapWHAT’S IN THIS CHAPTERSantosConleyha
11
Getting Started with PhoneGap
WHAT’S IN THIS CHAPTER?
! History of PhoneGap
! Di! erences between HTML5 and PhoneGap
! Getting a development environment set up
! Implementing the Derby App
PhoneGap is an open source set of tools created by Nitobi
Solution
s (now part of Adobe)
that enables you to create mobile applications for multiple devices by utilizing the same code.
PhoneGap is a hybrid mobile application framework that allows the use of HTML, CSS,
and JavaScript to write applications that are based on the open standards of the web. These
applications also have access to the native functionality of the device. PhoneGap has been
downloaded more than 600,000 times, and more than 1,000 apps built with PhoneGap are
available in the respective app stores, which makes PhoneGap a viable solution for creating
cross-platform mobile apps.
HISTORY OF PHONEGAP
PhoneGap was started at the San Francisco iPhone Dev Camp in August 2008. iOS was shaping
up to become a popular mobile platform, but the learning curve for Objective-C was more work
than many developers wanted to take on. PhoneGap originally started as a headless browser
implementation for the iPhone. Because of the popularity of HTML/CSS/JavaScript, it was a
goal that this project use technologies with which many developers where already familiar.
Based on the growing popularity of the framework, in October 2008 Nitobi added support
for Android and BlackBerry. PhoneGap was awarded the People’s Choice award at the Web2.0
Expo Launch Pad in 2009, which was the start of developers recognizing PhoneGap as a
valuable mobile development tool. PhoneGap version 0.7.2 was released in April 2009, and
was the fi rst version for which the Android and iPhone APIs were equivalent.
c11.indd 309c11.indd 309 28/07/12 6:08 PM28/07/12 6:08 PM
310 " CHAPTER 11 GETTING STARTED WITH PHONEGAP
In September 2009 Apple approved the use of the PhoneGap platform to build apps for the iPhone
store. Apple required that all PhoneGap apps be built using at least version 0.8.0 of the PhoneGap
software. In July 2011, PhoneGap released version 1.0.0.
WHY USE PHONEGAP?
PhoneGap enables you to leverage your current HTML, CSS, and JavaScript skill sets to create a mobile
application. This can greatly speed up development time. When you develop for multiple platforms
using PhoneGap, you can reuse the majority of the code you have written for the mobile project, further
reducing development costs. It isn’t necessary to learn Java, C#, and Objective-C to create an applica-
tion with PhoneGap that can target iPhone, Android, BlackBerry, and Windows Phone 7.
If you fi nd native functionality missing from PhoneGap, you can extend the functionality of the
PhoneGap platform using native code. With the PhoneGap add-in structure, you can create an add-in
using the native language of the device and a JavaScript API that will call the native plug-in you
created. Cross-platfo ...
11Proposal Part One - Part 1 Influence of Internet on TourismSantosConleyha
11
Proposal Part One - Part 1: Influence of Internet on Tourism Industry
Research Proposal: Influence of Internet on Tourism Industry
Introduction
The tourism industry has been among the best-valued sectors within the nation to generate massive revenue for the government. Besides, the industry is considered among the earliest since it started several decades ago. For an extended period, the industry uses Integrated Marketing Communications to promote their various products and services to the entire world. The introduction of technology in the industry leads to improvements in the sectors. Most individuals without extensive information on the tourism industry can access the data in their comfort zones. It implies that IT and internet technology play a significant role in ensuring effective strategy due to its existence globally.
Most European countries have tried to promote and implement internet technology in ensuring satisfactory delivery of products and services (Kayumovich, 2020). Since it has a custom within the tourism and hotel industry to provide intangible products and services, including but not limited to services alongside comfort, the internet has been an effective method of delivering its messages to the targeted customers. Also, through internet technology, the industry has achieved more customers in the global market, including the European market. The promotion of branding within the European tourism industry has been effective due to the introduction and implementation of internet technology. Thus, the internet is believed to significantly influence the tourism industry in various sectors, including but limited to infrastructure, travel, alongside the marketing sector. Before introducing the internet alongside the IT, travelling of customers was dangerous and unpleasant since travellers had constraint understanding of locations they were visiting.
As a result, the existing vacationers of time had limited knowledge of the cultures and terrain alongside the climate change and patterns necessary to stimulate the travelling issues. Therefore, tourism sectors, including but not limited to tour companies, travel agencies and other like hotels, had developed strategies necessary to promote booking and reservation processes (David-Negre et al. 2018). However, several decades ago, popular sites were visited by tourists. It implies that the tourism sectors within the local or remote area faced challenges of securing sufficient clients as people were could not define the destination. Also, shortage of information on a particular region leads to reduced travelling by visitors. The research involved the utilization of relevant literature review on the subject matter to provide factual information. Therefore, the report offers adequate information on the influence of the internet on the tourism industry. This research would give me the stage to show my finding and view and also propose how the internet can be leveraged to an extend i ...
11Social Inclusion of Deaf with Hearing CongreSantosConleyha
11
Social Inclusion of Deaf with Hearing Congregants within a Ministerial Setting Comment by Stumme, Clifford James (College Applied Studies & Acad Succ): As you review this sample student paper, please keep in mind that there are some flaws in this paper (as with any piece of writing). However, it is one of the best INDS 400 research proposals received to date, so it is an excellent reference point.
Sample Student Comment by Stumme, Clifford James (College Applied Studies & Acad Succ) [2]: Also, remember that what you are looking at is an example of the overall research proposal, not just the literature review. If you are working on your literature review, refer to the portion marked “literature review” and remember that within that literature review portion, there is a unique introduction, body paragraphs, and conclusion. The first paragraph is the introduction for the proposal as a whole, which is different from the kind of introduction you should write for the literature review itself. Also remember that while this research proposal has an abstract, you do not need one for the literature review.
Liberty University
INDS 400: Knowledge Synthesis for Professional and Personal Development
January 3, 2020
Abstract Comment by Stumme, Clifford James (College Applied Studies & Acad Succ) [2]: Notice how the abstract gives a brief overview of the elements of the research proposal without arguing or getting ahead of itself by predicting results.
Culture can influence how people interact and the level of inclusion of different cultures in a particular setting.While numerous studies have been conducted examining deaf studies and deaf culture, there is a curious lack of research that has specifically considered the level of inclusion of deaf people in evangelical hearing churches. This research proposal includes an interdisciplinary including a literature review that examines a handful of studies on interactions among deaf and hearing populations to consider challenges of hearing and deaf integration. Examining these diverse perspectives, including Catholic ministry, disability ministry and deaf culture, provides a fresh interdisciplinary perspective to approach the challenges of deaf inclusion in ministerial settings. It was found through this literature review that a gap in scholarly research exists in this area. As further research would be necessary to address this gap, the goal of this research proposal is to conduct a qualitative study for further research by petitioning deaf perspective through online interviews utilizing the social media platform of Facebook. Although a low budget would be necessary, the implications of this research would provide a platform to open community conversation to address challenges and provide ideas on integration of deaf and hearing congregants in evangelical hearing churches. Examining deaf perspectives may provide additional information for fellowship, growth and exposure to the Gospel for deaf congr ...
11Managing Economies of Scale in a Supply Chain Cycle InventoSantosConleyha
This document summarizes key concepts about managing economies of scale in supply chain cycle inventory. It discusses how using larger lot sizes can help exploit fixed ordering costs but also leads to higher average inventory levels. The economic order quantity (EOQ) model is presented as a way to determine the optimal lot size that minimizes total inventory costs. The document also covers how aggregating demand across multiple products or customers can further reduce costs.
11Mental Health Among College StudentsTomia WillinSantosConleyha
11
Mental Health Among College Students
Tomia Willingham
Sophia Learning
Eng 215
March 14, 2021
Introduction
Going to college can be demanding for many people. In addition to managing academic insistence, many students have to cope with their families' complex separation tasks. At the same time, some of them continue to deal with a lot of many family duties. Mental health experts and advocates contend that it is an epidemic that colleges need to investigate further. Depression, anxiety disorders are some of the significant mental health issues that affect college students. The effects of suicidal ideas on university students' academic achievement have not been explored, yet mental health conditions are associated with academic achievement (De Luca et al., 2016). A novel coronavirus has worsened the situation of mental health. Even before the onset of this virus, there was concern from mental health policymakers in America because of the rising mental health challenges. They claimed a need for additional aid for struggling university students and the capability for these institutions to provide it. Regrettably, many university students with mental health conditions do not seek and receive the necessary treatment. The primary reasons for not pursuing help include thinking that the challenge will get better with time, stigma from their peers and no time to seek the treatment because of a busy schedule (Corrigan et al. 2016). Without this treatment, college students experiencing medical conditions most of the time get lower grades, drop out of college, immerse themselves into substance abuse, or become unemployed. Because these mental health conditions are invisible, they can only be seen through academic performance or social behavior change. Should universities strike a balance between mental health conditions and academics? This review will conclude that the mental health condition of university students and scholars should be balanced. Comment by Dr. Helen Doss: You need to answer this question and present the answer as the thesis at the end of this paragraph. Comment by Dr. Helen Doss: This is not a review essay—it is an argumentative or persuasive essay. Comment by Dr. Helen Doss: What does this mean—should be balanced? By what? For what? And, by whom? Comment by Dr. Helen Doss: This paragraph is too long. See: https://www.umgc.edu/current-students/learning-resources/writing-center/writing-resources/parts-of-an-essay/paragraph-structure.cfm
Effects of not Balancing Mental Health and Academics
There are consequences of not balancing mental health and academics in higher learning institutions, mainly if they do not receive any treatment. For example, if depression goes untreated, it raises the chances of risky behavior like substance abuse. The condition affects how students sleep, eat, and it also affects how students think. Also, students cannot concentrate in class, and they cannot make rational decisions. By lack of concent ...
11From Introductions to ConclusionsDrafting an EssayIn this chapSantosConleyha
11From Introductions to ConclusionsDrafting an Essay
In this chapter, we describe strategies for crafting introductions that set up your argument. We then describe the characteristics of well-formulated paragraphs that will help you build your argument. Finally, we provide you with some strategies for writing conclusions that reinforce what is new about your argument, what is at stake, and what readers should do with the knowledge you convey
DRAFTING INTRODUCTIONS
The introduction is where you set up your argument. It’s where you identify a widely held assumption, challenge that assumption, and state your thesis. Writers use a number of strategies to set up their arguments. In this section we look at five of them:
· Moving from a general topic to a specific thesis (inverted-triangle introduction)
· Introducing the topic with a story (narrative introduction)
· Beginning with a question (interrogative introduction)
· Capturing readers’ attention with something unexpected (paradoxical introduction)
· Identifying a gap in knowledge (minding-the-gap introduction)
Remember that an introduction need not be limited to a single paragraph. It may take several paragraphs to effectively set up your argument.
Keep in mind that you have to make these strategies your own. That is, we can suggest models, but you must make them work for your own argument. You must imagine your readers and what will engage them. What tone do you want to take? Playful? Serious? Formal? Urgent? The attitude you want to convey will depend on your purpose, your argument, and the needs of your audience.◼ The Inverted-Triangle Introduction
An inverted-triangle introduction, like an upside-down triangle, is broad at the top and pointed at the base. It begins with a general statement of the topic and then narrows its focus, ending with the point of the paragraph (and the triangle), the writer’s thesis. We can see this strategy at work in the following introduction from a student’s essay. The student writer (1) begins with a broad description of the problem she will address, (2) then focuses on a set of widely held but troublesome assumptions, and (3) finally, presents her thesis in response to what she sees as a pervasive problem.
The paragraph reads, “In today’s world, many believe that education’s sole purpose is to communicate information for students to store and draw on as necessary. By storing this information, students hope to perform well on tests. Good test scores assure good grades. Good grades eventually lead to acceptances into good colleges, which ultimately guarantee good jobs. Many teachers and students, convinced that education exists as a tool to secure good jobs, rely on the banking system. In her essay “Teaching to Transgress,” bell hooks defines the banking system as an “approach to learning that is rooted in the notion that all students need to do is consume information fed to them by a professor and be able to memorize and store it” (185). Through the banking s ...
11Groupthink John SmithCampbellsville UnivSantosConleyha
1
1
Groupthink
John Smith
Campbellsville University
BA611 – Organizational Theory
Dr. Jane Corbett
January 17, 2021
Definition
Groupthink is a pattern of thought characterized by self-deception, forced manufacture of consent, and conformity to group values and ethics.
Summary
Valine (2018) discussed how powerful an effect groupthink can have on community and peers. It followed two case studies about JPMorgan Chase and Wells Fargo, which explains how many sources and credentials the author has used. The focus of the article is that circumstances have occurred inside these companies which were able to affect the entire economy as well. Groupthink is usually followed by irrational thinking and decision making which completely ignores alternatives and constantly goes for the primary decision. The large difference between group and groupthink is that the group consists of members of various backgrounds and experiences, while groupthink usually has members of similar ones. Further, there is no way for groupthink to recover from bad decisions mainly because all members have a similar understanding and point of the view towards a certain topic. The illusion of invulnerability is the main characteristic related to groupthink, where teammates ignore the danger, take extreme risks, and act highly optimistic.
Discussion
Groupthink is characterized by incorrect decisions that groups make mainly due to mental efficiency, reality testing, and moral judgment. Many conditions can cause groupthink to occur, and the most frequent ones are collective rationalization, belief in inherent morality, stereotyped views of out-groups, direct pressure on dissenters, and self-censorship.
The collective rationalization explains how different warnings are against the group thinking, so and where those opinions can create a misunderstanding. Belief in inherent morality points out that members ignore the ethical and moral consequences of decisions because they believe the correctness of their cause. The stereotyped views of out-groups are the characters to create a negative feeling about opposition outside the group environment. The direct pressure on dissenters is where team leaders discuss all members that have different opinions and philosophies than the group’s commitments and agreement. Lastly, the self-censorship is where teammates keep their thoughts and opinions without expressing them to others.
The case study about the London Whale explains how JPMC, one of the largest banks in the world, has lost 6.5 billion dollars due to bad and poor investment decisions. Everything occurred in April and May of 2012, where larger trading loss happened in Chase’s Investment Office throughout the London branch. The main transaction that affected Morgan Chase was credit default swaps (CDS) and it was shown that famous trader Bruno Iksil has gathered significant CDS position in the market at that time. Following this case, the internal control has risen o ...
11Sun Coast Remediation Research Objectives, Research QueSantosConleyha
11
Sun Coast Remediation: Research Objectives, Research Questions, and Hypotheses
4
Sun Coast Remediation
Unique R. Simpkins
Southern Columbia University
Course Name Here
Instructor Name
11-2-2021
Research Objectives, Research Questions, and Hypotheses
Based on the information amassed by the former health and safety director, the organization needs to pursue safety-related programs or initiatives to ensure employees' health. It is an appropriate approach to help the firm and the employees achieve goals and inhibit costs arising from injuries and illnesses while on duty. The completion of this task will provide managers with practicable insights on the approach to enhance safety and protect the firm from losses. This task accounts for the objectives, questions, and hypotheses of the research based on the provided statement of the problem.
RO1: Explore the correlation between the size of the Particulate Matter (PM) and the health of the employee.
RQ1: Is there a correlation between the size of the Particulate Matter (PM) and the health of the employee?
Ho1: There is no statistically significant evidence connecting the size of the Particulate Matter (PM) and the health of the employee.
Ha1: There is statistically significant evidence connecting the size of the Particulate Matter (PM) and the health of the employee.
RO2: Establish whether safety training is feasible in decreasing the lost-time hours.
RQ2: Is safety training feasible in decreasing the lost-time hours?
Ho2: There is no statistically significant evidence linking safety training and reduction in lost-time hours.
Ha2: There is statistically significant evidence linking safety training and reduction in lost-time hours.
RO3: Establish the effectiveness of predicting the decibels (dB) levels before the employee placement on determining the on-site risk.
RQ3: Is predicting the decibels (dB) levels before the employee placement on determining the on site risk effective?
Ho3: There is no statistically significant relationship between predicting the decibels (dB) levels before the employee placement and effective determination of the on-site risk.
Ha3: There is a statistically significant relationship between predicting the decibels (dB) levels before the employee placement and effective determination of the on-site risk.
RO4: Establish whether the revised training program is more practicable than the initially adopted initiative.
RQ4: Is the revised training program is more practicable than the previously adopted initiative?
Ho4: There is no statistically significant proof that the new training program is more feasible than the old program.
Ha4: There is statistically significant proof that the new training program is more feasible than the old program.
RO5: Determine the blood lead levels variation before and after exposure at the end of the remediation service.
RQ5: Do the blood lead levels before and after exposure at the end of the remediation service va ...
11Me Talk Pretty One Day # By David Sedaris From his bSantosConleyha
11
Me Talk Pretty One Day # By David Sedaris
From his book Me Talk Pretty One Day
At the age of forty-one, I am returning to school and have to think of myself as
what my French textbook calls Ba true debutant.D After paying my tuition, I was issued
a student ID, which allows me a discounted entry fee at movie theaters, puppet shows,
and Festyland, a far-flung amusement park that advertises with billboards picturing a
cartoon stegosaurus sitting in a canoe and eating what appears to be a ham sandwich.
IFve moved to Paris with hopes of learning the language. My school is an easy
ten-minute walk from my apartment, and on the first day of class I arrived early,
watching as the returning students greeted one another in the school lobby. Vacations
were recounted, and questions were raised concerning mutual friends with names like
Kang and Vlatnya. Regardless of their nationalities, everyone spoke what sounded to
me like excellent French. Some accents were better than others, but the students
exhibited an ease and confidence that I found intimidating. As an added discomfort,
they were all young, attractive, and well-dressed, causing me to feel not unlike Pa Kettle
trapped backstage after a fashion show.
The first day of class was nerve-racking because I knew IFd be expected to
perform. ThatFs the way they do it here # itFs everybody into the language pool, sink or
swim. The teacher marched in, deeply tanned from a recent vacation, and proceeded to
rattle off a series of administrative announcements. IFve spent quite a few summers in
Normandy, and I took a monthlong French class before leaving New York. IFm not
completely in the dark, yet I understood only half of what this woman was saying.
BIf you have not meimslsxp or lgpdmurct by this time, then you should not be in
this room. Has everyone apzkiubjxow? Everyone? Good, we shall begin.D She spread
out her lesson plan and sighed, saying, BAll right, then, who knows the alphabet?D
It was startling because (a) I hadnFt been asked that question in a while and (b) I
realized, while laughing, that I myself did not know the alphabet. TheyFre the same
letters, but in France theyFre pronounced differently. I know the shape of the alphabet
but had no idea what it actually sounded like.
BAhh.D The teacher went to the board and sketched the letter a. BDo we have
anyone in the room whose first name commences with an ahh?D
12
Two Polish Annas raised their hands, and the teachers instructed them to present
themselves by stating their names, nationalities, occupations, and a brief list of things
they liked and disliked in this world. The first Anna hailed from an industrial town
outside of Warsaw and had front teeth the size of tombstones. She worked as a
seamstress, enjoyed quiet times with friends, and hated the mosquito.
BOh, really,D the teacher said. BHow very interesting. I thought that everyone
loved the mosquito, but here, in front of all the world, you claim to ...
11Program analysis using different perspectivesSantosConleyha
11
Program analysis using different perspectives
Student's Name
Institution
Course
Professor
Date
TABLE OF CONTENTS
Introduction……………………………………………………………………………………
Program Description/ Analysis of a Classical Liberal perspective…………………………
Program Description/ Analysis of a Radical perspective……………………………………
Program Description/ Analysis of a Conservative perspective……………………………..
Program Description/ Analysis of a Mordern Liberal perspective...………………………
Comparisons of four perspectives……………………………………………………………
Assessment and modifications of the perspectives………………………………………….
Conclusion……………………………………………………………………………………..
Introduction
Program analysis using different perspectives
In a political economy, policies and programs are essential tools that assist in understanding the ongoing struggle for equality and social justice. Although both have an underlying difference, they serve an almost similar purpose. Essentially, understanding the goal of any program or policy can be achieved by analyzing the contending perspectives (Harvey, 2020). This involves the intentional bringing of different perspectives in contrast. They help examine core economic problems or concepts from an orthodox perspective, and others criticize it from a heterodox perspective. The perspectives are essential since both the heterodox and orthodox positions can be examined and reach a consensus.
In the United States, there has been a rise in spending on prescription drugs, which has led to the introduction of a Build Better Program. One proposal is driving down the cost of prescription drugs by allowing Medicare to negotiate with drugmakers over price; starting in 2025-ten drugs (plus insulin) would be on the table the first year, growing to 20 by 2028 (The White House, 2021). Although members of Congress have accepted the proposal, there is a need to analyze it using the different contending perspectives. This paper explores the proposal using the Classical Liberal, The radical, the Conservative Perspective, and the Modern Liberal Perspective. Individuals have the right to pursue their happiness, and proponents of the different political economy perspectives should work hand-in-hand to promote human development within society.
Analysis by Perspective
The Classical Liberal
The political philosophy and ideology belonging to liberalism emphasize securing citizens' freedom by limiting government power. Today, the proponents hold various thoughts and Perspectives, one being Neo-Austrian economics (Clark, 2016). Essentially, the program's main aim is to reduce the overall cost of prescription drugs. From the Perspective of Neo-Austrians, humans are self-interested. They can act autonomously by utilizing their capacity to discover an efficient means of satisfying their desires and basic needs (Harvey, 2020). Also, the government is created by the people to protect their natural rights. At the same time, justice requires safeguarding the people's rights established by the c ...
11Factors that Affect the Teaching and Learning ProcessSantosConleyha
11
Factors that Affect the Teaching and Learning Process
Lua Shanks
Dr. Thompson
Valley State University
10-6-2021
Factors that Affect the Teaching and Learning Process
Contextual Factors
The efficacious teaching and learning processes are important in generating the desired academic outcomes for students. Such processes entail the transformation and transfer of knowledge from the educators to students. It requires a combination of different elements within the procedure, in which an instructor determines and establishes the learning goals and objectives, and designs teaching resources. Thereafter, teachers implement the learning strategy that they will utilize to impart intellectual content into students. However, learning is a cardinal factor that an educator musty take into account while overseeing the process of knowledge acquisition and retention. Many factors play an important role in shaping the process of teaching and learning. Contextual factors, for instance, are associated with a particular context and characteristic that is distinct to a specific group, community, society, and individual. Such factors may take the form of a child’s educational, community, as well as classroom settings.
Community, District, and School Factors
Armstrong School District is a major public learning institution that occupies a geographical area of approximately 437 square miles. Located in Pennsylvania, it forms one of the 500 public school districts in the state, and hosts teachers and students from diverse racial, ethnic, and ethnic backgrounds. As a consequence, the institution partners with families, community leaders, and teachers to improve students’’ capacity to acquire knowledge ahead of their graduation. The community refers to the urban or rural environment in which both the teachers and learners operate. These may include the teacher and students’ ethnic, racial political or social affiliations that affect learning or knowledge acquisition. Additionally, parents and community members play an integral role in ensuring the quality of education in schools. They for, example, collaborate with teachers and school administrators to develop the most effective ways of improving their students’ learning outcomes. Indeed, community involvement in schooling issues is potentially a rich area for innovation that has immense benefits that far exceeds its limitations. Considering that governments are constrained in offering quality education due to contextual issues such as remoteness, bureaucracy, corruption, and inefficient management, community factors are pivotal in bridging the gap between government initiatives and community needs. This helps to adjust the child’s familial obligations to family interests, thereby shifting towards ways of mobilizing a sense of community by strengthening trust and relationships between community members, parents, governments, as well as teachers and school leaders. Other important community factors that af ...
11
Criminal Justice: Racial discrimination
Student’s Name:
Institutional Affiliation:
Instructor’s Name:
Course Code:
Due Date:
Racial discrimination
Abstract
When there is justice in society, every person feels satisfied with the way legal actions are carried out in the community. Unfortunately, there are several instances of racial discrimination in the United States. Most of the racial discrimination in the United States ate directed towards black people. Although everyone is required to have equal treatment in the United States, achieving zero discrimination has always been difficult.
Understanding racial discrimination in the USA is vital as it makes it easy for one to identify ways to eliminate the criminal injustices resulting from racial discrimination. This will be essential since it will help to eliminate racial discrimination in the criminal justice system.
Introduction
When there is justice in society, every person feels satisfied with the way legal actions are carried out in society. The criminal justice community is when people are not discriminated against based on their skin color. Laws applicable are carried out uniformly such that every person is treated equally. When the laws are applied equally to every individual, it increases the trust in the criminal justice system. However, when there are biases in applying the laws, the criminal justice system becomes compromised. According to Kovera (2019), there are many disparities in the criminal justice system as black people are discriminated against by police officers based on their race. As a result, black people suffer more as compared to white people when they violate similar laws.
There is a lot of disparity in the criminal justice system of the United States. Many people suffer as a result of racial discrimination in the United States. People are discriminated against a lot in the administration of the policies. According to Donnel (2017), there is racial inequality in how criminal justice is carried out in policymaking. The criminal justice system discriminates against people based on their race. For example, police officers harass black people for minor mistakes which white people are left to walk freely even after making similar mistakes. Black people suffer because of the color of their skin.
Hypothesis/Problem Statement/Purpose Statement
Racial discrimination affects the outcomes of the criminal justice system adversely. How does racial discrimination affect the judicial criminal justice system? The study aims to identify ways in which criminal justice racial discrimination is practiced in the United States. It will also provide insights on the racial discrimination cases, which are helpful in the development of policies that can be helpful in the elimination of racial discrimination in society hence promoting equality among the citizens.
Literature Review and Definitions included in the research
According to Hinton, Henderson, and Reed (2018), there is mu ...
11Communication Plan for Manufacturing PlantStudSantosConleyha
11
Communication Plan for Manufacturing Plant
Student’s Name
Institutional Affiliation
Instructor
Course
Date
Communication Plan of a Manufacturing Plant
Background
In manufacturing companies, organization employees are at the centre of an organization. Most of them are at the front lines with the ability to change strategy into results. At the culmination of the day, the plant employees have the responsibility of ensuring that the operations are conducted smoothly, a product reaches consumers timely, and quality products are manufacture with the appropriate specifications. However, despite the primary role they play, manufacturing plants are disjointed (Adejimola, 2008). That disengagement is embodied with a hefty price which is paying a negative role in the performance of manufacturing plants just as they are being challenged to increase their efficiency and effectiveness to the company compared to previous years. To realize rapid growth around the globe, the manufacturing industry is attempting to standardize operations and continuously leverage operations. Such kind of effort needs a company to possess highly invested employees (Obiekwe, O& Eke, 2019). For this reason, natural communication naturally is primary on the path to more highly engaged and motivated employees. However, it can sometimes be challenging to plant employees due to natural challenges that accompany workplace. Some may not frequently be on Smartphone’s or emails, or they may be having various shifts to manage, and the environment may be less conducive, which makes it challenging for them to have one-on-one conversations.
Policies for Oral, Written, and Non-Verbal Communications
Interpersonal communication in a manufacturing plant is the way employees or people communication with others. It may involve a group of p-people, another person or the members of the public. In some instances, it may encompass non-verbal, written or non-verbal communication. In the manufacturing industry, when an individual is communicating with others, they need to consider the person they are talking to, the type of information they want to deliver and the most appropriate and relevant form of communication change. In some instances, such issues may be determined by the information an individual wants to communication (Obiekwe, O& Eke, 2019). At all times, it is required that the staff members remain polite, respectful to both the clients and one another. At no time should they sear, raise their voice, speak in a way belittling another.
Cultural awareness is also another essential element when communicating in a cultural plant. All individuals working in the plant need to recognize that individuals emerge from varying backgrounds and cultures, and they also accompany various attitudes, different values and beliefs (Obiekwe, O& Eke, 2019). All staffs in the plant need to exercise non-judgmental communication remain respectful and are tolerant of the differences prevalence ...
11CapitalKarl MarxPART I. COMMODITIES AND MONEYCHAPTER I. SantosConleyha
11
Capital
Karl Marx
PART I. COMMODITIES AND MONEY
CHAPTER I. COMMODITIES
Section 1. The two factors of a commodity: use-value and value (the substance of value and the magnitude of value)
The wealth of those societies in which the capitalist mode of production prevails, presents itself as “an immense accumulation of commodities,”1 its unit being a single commodity. Our investigation must therefore begin with the analysis of a commodity.
A commodity is, in the first place, an object outside us, a thing that by its properties satisfies human wants of some sort or another. The nature of such wants, whether, for instance, they spring from the stomach or from fancy, makes no difference.2 Neither are we here concerned to know how the object satisfies these wants, whether directly as means of subsistence, or indirectly as means of production.
Every useful thing, as iron, paper, &c., may be looked at from the two points of view of quality and quantity. It is an assemblage of many properties, and may therefore be of use in various ways. To discover the various uses of things is the work of history.3 So also is the establishment of socially-recognised standards of measure for the quantities of these useful objects. The diversity of these measures has its origin partly in the diverse nature of the objects to be measured, partly in convention.
The utility of a thing makes it a use-value.4 But this utility is not a thing of air. Being limited by the physical properties of the commodity, it has no existence apart from that commodity. A commodity, such as iron, corn, or a diamond, is therefore, so far as it is a material thing, a use-value, something useful. This property of a commodity is independent of the amount of labour required to appropriate its useful qualities. When treating of use-value, we always assume to be dealing with definite quantities, such as dozens of watches, yards of linen, or tons of iron. The use-values of commodities furnish the material for a special study, that of the commercial knowledge of commodities.5 Use-values become a reality only by use or consumption: they also constitute the substance of all wealth, whatever may be the social form of that wealth. In the form of society we are about to consider, they are, in addition, the material depositories of exchange-value.
Exchange-value, at first sight, presents itself as a quantitative relation, as the proportion in which values in use of one sort are exchanged for those of another sort,6 a relation constantly changing with time and place. Hence exchange-value appears to be something accidental and purely relative, and consequently an intrinsic value, i.e., an exchange-value that is inseparably connected with, inherent in commodities, seems a contradiction in terms.7 Let us consider the matter a little more closely.
A given commodity, e.g., a quarter of wheat is exchanged for x blacking, y silk, or z gold, &c.—in short, for other commodities in the most different proportions. Ins ...
1
1
Criminal Justice System
Shambri Chillis
June 11, 2022
Criminal justice system
The criminal justice system is essential to identify and prevent crimes in the community. Various functions of the criminale system now adhere to the development of technology. Modern technology helps the criminal justice system in different ways. It has made the job easier and has assisted in the prevention of crimes.
Role of criminal justice practitioners in the technology development
The Ccriminal justice practitioners are responsible for identifying and analyzing different crimes in the community. They are responsible for developing and implementing the technology in the criminal justice system because they can use it for different purposes. They can introduce the new trends in the criminal justice system like the officers can collect and gather the data through the technology. Human error can be reduced through it. The dataset can be maintained, and it is also essential for criminal justice practitioners to develop the technology to locate the criminals and track their local places through GPS. The technology cannot be developed untill the criminal officers implement it in the routine. The criminal system now has to use robots and cameras that help them get information about the criminals. The practitioners can also implement the technology by guiding the juniors to use it. The training is needed to make them understand the use of advanced technologies and to ensure that they use them in the right direction. The high-performance computer and internet systems are also essential for developing the technology, and it has been seen that the future will be bright regarding implementing technology (John S. Hollywood, 2018).
Controversial issues criminal justice policymakers face when considering an expansion in the use of DNA in criminal justice
Tthere are various controversial issues that criminal justice policymakers must consider while using DNA in the criminal justice system. The first thing that is criticized during the use of DNA is the fundamental human error, and iIt has been observed that there can be errors in the investigation, and people have to suffer. The issue in technology is also referred to as the error in using DNA because it might be possible that the results do not come correct at the first attempt. It involves several people who are not linked to the crimes but have to go for the fingerprinting tests by courts. However, DNA technology in criminal justice is highly advanced and has multiple benefits compared to disadvantages, but it has always faced significant controversy in the criminal justice system. The criminal justice system has to make sure that if DNA technology is being used, it must be error-free. The controversy has two opinions. There are two schools of thought regarding the use of DNA. One of the classes of experts thinks that DNA can be used to catch the different criminals. It is helpful in the family c ...
11American Government and Politics in a Racially DividSantosConleyha
1
1American Government
and Politics in a Racially
Divided World
chap ter
In 2016, Gov. Jack Markell signed a long-awaited resolution officially apologizing for the state’s role
in slavery. The apology for slavery illustrates the long and sometimes painful history of the United
States’ struggle with race, from the time of Thomas Jefferson, a slave owner, to President Barack
Obama, the first Black president of the United States.
01-McClain-Chap01.indd 1 11/24/16 8:34 PM
08/20/2017 - RS0000000000000000000000562545 (Anthony Ratcliff) - American
Government in Black and White
2 CHAPTER 1: AmericAn Government And Politics in A rAciAlly divided World
intro
D
ecember 6, 2015, marked the 150th anniversary of the abolish-
ment of slavery, when the U.S. Congress ratified the Thirteenth
Amendment to the Constitution. There were numerous events
recognizing the end of slavery, including an official White House event
presided over by President Obama. On February 11, 2016, Delaware
joined eight other states to formally apologize for slavery when Gover-
nor Jack Markell (D) signed the state’s joint resolution. Delaware’s reso-
lution acknowledged its participation in 226 years of
slavery first of both Native Americans and Africans in
the mid-1600s; by the close of the 1700s its entire
slave population was of African descent. The resolu-
tion also included acknowledgments that Delaware
criminalized humanitarian attempts to assist slaves
and that in later times Delaware passed and enforced
Jim Crow laws to deny the rights of African American
citizens for much of the twentieth century.1
On July 29, 2008, the U.S. House of Representa-
tives passed a nonbinding resolution, introduced and
championed by Representative Steven Cohen (D-TN),
which offered a formal apology for the government’s
participation in African American slavery and the
establishment of Jim Crow laws. The resolution said, in part, “African
Americans continue to suffer from the consequences of slavery and Jim
Crow—long after both systems were formally abolished—through
enormous damage and loss, both tangible and intangible, including the
loss of human dignity and liberty, the frustration of careers and profes-
sional lives, and the long-term loss of income and opportunity.”2
On June 18, 2009, the U.S. Senate unanimously passed a similar reso-
lution apologizing to African Americans for slavery and Jim Crow. The
Senate resolution said explicitly that the apology could not be used in
support of reparations (or compensation for past wrongs).3
The story of apologies for slavery is a complex one that highlights some of the
underlying dilemmas that face the U.S. political system—how to reconcile its stated
principles of how individuals should be treated with how the government actually
treats and has treated individuals. The apologies are intended to acknowledge the
nation’s complicity in a destructive and immoral institution, at ...
11Cancer is the uncontrollable growth of abnormal cellsSantosConleyha
1
1
Cancer is the uncontrollable growth of abnormal cells in the human body. It is defined by a malfunction in cellular mechanisms that control cell growth. Cells evade checkpoint controls and begin growing uncontrollably which resulting in an increase in abnormal cells, cancer cells. These cancer cells form a mass tissue known as a tumor. In the United States of America, cancer has been determined to be among the leading causes of mortality rates after cardiovascular conditions, where one in every four deaths is caused by cancer. The most common types of cancer include prostate cancer, lung cancer, and breast cancer. Risk factors for cancer include excess smoking, radiation exposure, genetics, and environmental pollution. Colon cancer, or colorectal cancer, affects the distal third of the large intestine, the colon, as well as the rectum, chamber in which feces is stored for elimination. Colorectal cancer is the third leading cause of death in cancer-related issues in the United States in both males and females (Beadnell et al., 2018). This essay explores the physiology and pathophysiology of colon cancer.
Polyps are tissue growths that generally look like small, flat bumps and are generally less than half an inch wide. They are generally non-cancerous growths that can develop with age on the inner wall of the colon or rectum. There are several types of polyps, such as hyperplastic. They are common and have a low risk of turning cancerous. Hyperplastic polyps found in the colon will be removed and biopsied. Pseudo polyps also referred to as inflammatory polyps, usually occur in people suffering from inflammatory bowel disease and are unlike other polyps. This type of polyp occurs due to chronic inflammation as seen in Crohn's disease and ulcerative colitis. However, a polyp cells which can turn out to be malignant. Villous adenoma or tubulovillous adenoma polyps carry a high risk of turning cancerous. They are sessile and develop flat on the tissue lining the organs. They might blend within the organ, making polyps not easily identifiable and difficult to locate for treatment. Adenomatous or tubular adenoma polyps have a high chance of being cancerous. When a polyp is found, it must be biopsied, and then will regular screenings and polyp removal will follow.
An adenocarcinoma is a cancer formed in a gland that lines an organ. This cancer impacts the epithelial cells, which are spread throughout the human body. Adenocarcinomas of the colon and rectum make up ninety-five percent of all colon cancers (Chang, 2020). Colon adenocarcinomas usually begin in the mucous lining the spread to different layers. Two subtypes of adenocarcinomas are mucinous adenocarcinoma and signet ring cells. Mucinous adenocarcinomas contain about sixty percent mucus which can cause cancer cells to spread faster and become more hostile than typical adenocarcinomas. Signet ring cell adenocarcinoma is responsible for less than one percent of all colon cancer. It is g ...
11SENSE MAKING Runze DuChee PiongBUS 700 LSantosConleyha
1
1
SENSE MAKING
Runze Du
Chee Piong
BUS 700 Leadership and Creative
Solution
s Implementation
Feb 14th 2021
SENSE MAKING
Sensemaking refers to an action or a process of making sense where meaning is given to something. Sensemaking is a process through which individuals give meaning to their collective experiences. Sensemaking is also a process of structuring the unknown by inserting stimuli into some framework kinds to enable individuals to understand or comprehend, attribute, to extrapolate and predict the meaning of something. Sensemaking is an activity that allows people to turn the ongoing complexity in the entire world into a situation that can be understood. Sensemaking Therefore, Sensemaking requires articulating the unknown because, in many cases, trying to put meaning to something strange is the only means by which one can understand it. For instance, the occurrence or the origin of COVID-19 in the entire world has been a phenomenon that has disturbed the heads of many trying to understand what it is, where it came from, who caused it, how it can be prevented and how it can be cured. In attempting to understand COVID 19, people came up with the explanations of what it is, what caused it, and that is where the scientists realized that this is a disease that is caused by a virus known as Coronavirus, since the condition merged in the year 2019, the virus was given the name coronavirus 19, and the disease it caused known as COVID 19. This is how sensemaking enables individuals to give meaning to something that can be understood easily by individuals.
The organization that I am familiar with that has experienced a current change in its operations is Starbucks. Starbucks is an American company that is known for its production and sell of coffee products. It was started in 1971 as a coffee selling company where it was majorly involved in roasting, marketing and selling coffee globally. It has more than 300 stores all over the world selling coffee. This organization has sold coffee within its stores since its initiation. However, because of the corona's onset, the management of this organization decided to change its operation to accommodate the changes in the environment depending on the restrictions imposed on businesses by the ministries of health all over the world. Starbucks company reacted to the industry changes brought about by COVID 19, where businesses were required to close their doors to enhance the measures of curbing the spread of coronavirus disease. Thus, the company embraced technology where it introduced Starbucks-pick up only stores that replaced the over 300 stores globally. The new stores required that no one could sit in as they take their coffee. Instead, everyone would be allowed only to take their orders from the store and to avoid congesting people in one place. Starbucks introduced Starbucks pick-up stores that use technology to supply coffee to customers. The business submitted a mobile app ...
119E ECUTIVE BAR AININ CEOS NE OTIATIN THEIR PAWITH EMSantosConleyha
119
E ECUTIVE BAR AININ : CEOS NE OTIATIN THEIR PA
WITH EMPLO EES OR CORPORATE E ICIENC
By Nathan Witkin
I INTRODUCTION
Rising executive pay is a significant problem that points to a structural
flaw in American corporations. This article presents a solution to that flaw
through which Chief Executive Officers (CEOs) negotiate their pay in
company resources with lower-paid employees. Exploring this solution also
unearths an explanation for capitalism s apparent drive toward inequality and
examines the historical development of corporations and trade unions in the
United States.
The problem is that managers and corporate directors will raise pay at the
top so long as that pay-setting process does not consider the pay of average-
and low-wage workers. The solution is that CEOs and other top executives
negotiate their pay in company resources with employees in a process that
determines the pay and bonuses of both sides. Microeconomic theory indicates
that confronting the tradeoffs of raising executive compensation with other
potential corporate expenditures—by negotiating this compensation with
workers from different parts of the company—will make executive
compensation more efficient.1 Also, historical analysis indicates a pattern in
which executive compensation became aligned with public interest only during
the period in which workers had significant power to negotiate their wages and
Master of Public Policy Candidate at eorgetown University s McCourt School of Public
Policy J.D., The Ohio State Moritz College of Law. The Author is an independent researcher,
originator of a variety of social innovations (co-resolution, interest group mediation, consensus
arbitration, dependent advocacy, the popular tax audit, the hostile correction, a partnership
between citizen review boards and community policing, and a two-state/one-land solution to the
Israeli-Palestinian conflict), and author of several ambitious theories (the shift in sovereignty
from land to people under international treaties, the use of impact bonds as a solution to climate
change, and resistance to the accelerating expansion of the universe as the cause of gravitation).
He is also a former solo-practitioner in criminal and family law.
1 N. RE OR MAN IW, PRINCIPLES O MICROECONOMICS ( th ed. 2012) (describing the first
principle of microeconomics as centered on trade-offs). Many basic microeconomic models
involve trade-offs between potential allocations of resources to achieve efficiency. See DAVID
BESAN O RONALD R. BRAEUTI AM, MICROECONOMICS 20 07 (5th ed. 201 ).
120 KAN. J.L. & P B. POL’Y Vol. I :1
benefits. This is not to say that the solution to executive compensation is a
return to unions, which developed as a separate organizational structure with
their own flaws and inefficiencies. Rather, a corporation that synthesizes the
inputs of all its employees will be able to maximize efficiency and
productivity, producing profits for shareholders and growth for the overall
econ ...
11CALIFORNIA MANAGEMENT REVIEW VOL. 51, NO. 4 SUMMER 2009 CMR.BERKELEY.EDU
The Emergence and
Evolution of the
Multidimensional
Organization
J. Strikwerda
J.W. Stoelhorst
“In terms of its impact, not just on economic activity, but also on human life as a
whole, the multidivisional organizational design must rank as one of the major
innovations of the last century.”—John Roberts1
T
he multidivisional, multi-unit, or M-form, is widely acknowledged
as the most successful organization form of the twentieth century.2
Firms that employ the M-form organize their activities in separate
business units and delegate control over the resources needed to
create economic value to the managers of these units. This organization form is
widespread, is central to the “theory in use” of managers, and serves as the basis
of most accounting systems. However, the organization of productive activities
in many contemporary firms violates the principle that is central to the M-form:
that business units are self-contained. The quest for synergies that has been high
on the corporate agenda since the late 1980s has resulted in the widespread
adoption of corporate account management, shared service centers, and matrix
organizations. As a result, most business units now depend at least in part on
resources that are controlled by other units. This raises fundamental questions
about the status of the M-form in contemporary firms.
Questioning the status of the M-form is not merely a theoretical fancy,
but is high on the agenda of managers as well. In this article, we report on
research that was commissioned by the Foundation for Management Stud-
ies, a Dutch organization of management executives. These practical men and
women shared a fundamental uneasiness about structuring their organizations.
On the one hand, many of them experienced problems with the M-form: high
employee costs, internal battles over resources, lack of standardization, lack of
cooperation, and loss of market opportunities. On the other hand, they did not
The Emergence and Evolution of the Multidimensional Organization
UNIVERSITY OF CALIFORNIA, BERKELEY VOL. 51, NO. 4 SUMMER 2009 CMR.BERKELEY.EDU12
see any viable alternatives to the multi-unit organization form. The need to
exploit synergies across business units was widespread, but it was unclear which
organizational designs are most appropriate to achieve this. This led to a research
project to explore the ways in which leading Dutch organizations, including
subsidiaries of foreign multinationals, have adapted the M-form to better exploit
synergies across business units.
As we expected, the results of the study vividly illustrate the fundamen-
tal tension between the need for contemporary firms to exploit synergies and
their need for clear accountability. However, an additional and unexpected
finding was that a number of firms in the study have evolved an organiza-
tional form that signals a new way of res ...
This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
A wound is a break in the integrity of the skin or tissues, which may be associated with disruption of the structure and function.
Healing is the body’s response to injury in an attempt to restore normal structure and functions.
Healing can occur in two ways: Regeneration and Repair
There are 4 phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. This document also describes the mechanism of wound healing. Factors that affect healing include infection, uncontrolled diabetes, poor nutrition, age, anemia, the presence of foreign bodies, etc.
Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
🔥🔥🔥🔥🔥🔥🔥🔥🔥
إضغ بين إيديكم من أقوى الملازم التي صممتها
ملزمة تشريح الجهاز الهيكلي (نظري 3)
💀💀💀💀💀💀💀💀💀💀
تتميز هذهِ الملزمة بعِدة مُميزات :
1- مُترجمة ترجمة تُناسب جميع المستويات
2- تحتوي على 78 رسم توضيحي لكل كلمة موجودة بالملزمة (لكل كلمة !!!!)
#فهم_ماكو_درخ
3- دقة الكتابة والصور عالية جداً جداً جداً
4- هُنالك بعض المعلومات تم توضيحها بشكل تفصيلي جداً (تُعتبر لدى الطالب أو الطالبة بإنها معلومات مُبهمة ومع ذلك تم توضيح هذهِ المعلومات المُبهمة بشكل تفصيلي جداً
5- الملزمة تشرح نفسها ب نفسها بس تكلك تعال اقراني
6- تحتوي الملزمة في اول سلايد على خارطة تتضمن جميع تفرُعات معلومات الجهاز الهيكلي المذكورة في هذهِ الملزمة
واخيراً هذهِ الملزمة حلالٌ عليكم وإتمنى منكم إن تدعولي بالخير والصحة والعافية فقط
كل التوفيق زملائي وزميلاتي ، زميلكم محمد الذهبي 💊💊
🔥🔥🔥🔥🔥🔥🔥🔥🔥
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) CurriculumMJDuyan
(𝐓𝐋𝐄 𝟏𝟎𝟎) (𝐋𝐞𝐬𝐬𝐨𝐧 𝟏)-𝐏𝐫𝐞𝐥𝐢𝐦𝐬
𝐃𝐢𝐬𝐜𝐮𝐬𝐬 𝐭𝐡𝐞 𝐄𝐏𝐏 𝐂𝐮𝐫𝐫𝐢𝐜𝐮𝐥𝐮𝐦 𝐢𝐧 𝐭𝐡𝐞 𝐏𝐡𝐢𝐥𝐢𝐩𝐩𝐢𝐧𝐞𝐬:
- Understand the goals and objectives of the Edukasyong Pantahanan at Pangkabuhayan (EPP) curriculum, recognizing its importance in fostering practical life skills and values among students. Students will also be able to identify the key components and subjects covered, such as agriculture, home economics, industrial arts, and information and communication technology.
𝐄𝐱𝐩𝐥𝐚𝐢𝐧 𝐭𝐡𝐞 𝐍𝐚𝐭𝐮𝐫𝐞 𝐚𝐧𝐝 𝐒𝐜𝐨𝐩𝐞 𝐨𝐟 𝐚𝐧 𝐄𝐧𝐭𝐫𝐞𝐩𝐫𝐞𝐧𝐞𝐮𝐫:
-Define entrepreneurship, distinguishing it from general business activities by emphasizing its focus on innovation, risk-taking, and value creation. Students will describe the characteristics and traits of successful entrepreneurs, including their roles and responsibilities, and discuss the broader economic and social impacts of entrepreneurial activities on both local and global scales.
A Visual Guide to 1 Samuel | A Tale of Two HeartsSteve Thomason
These slides walk through the story of 1 Samuel. Samuel is the last judge of Israel. The people reject God and want a king. Saul is anointed as the first king, but he is not a good king. David, the shepherd boy is anointed and Saul is envious of him. David shows honor while Saul continues to self destruct.
How to Download & Install Module From the Odoo App Store in Odoo 17Celine George
Custom modules offer the flexibility to extend Odoo's capabilities, address unique requirements, and optimize workflows to align seamlessly with your organization's processes. By leveraging custom modules, businesses can unlock greater efficiency, productivity, and innovation, empowering them to stay competitive in today's dynamic market landscape. In this tutorial, we'll guide you step by step on how to easily download and install modules from the Odoo App Store.
Temple of Asclepius in Thrace. Excavation resultsKrassimira Luka
The temple and the sanctuary around were dedicated to Asklepios Zmidrenus. This name has been known since 1875 when an inscription dedicated to him was discovered in Rome. The inscription is dated in 227 AD and was left by soldiers originating from the city of Philippopolis (modern Plovdiv).
Level 3 NCEA - NZ: A Nation In the Making 1872 - 1900 SML.pptHenry Hollis
The History of NZ 1870-1900.
Making of a Nation.
From the NZ Wars to Liberals,
Richard Seddon, George Grey,
Social Laboratory, New Zealand,
Confiscations, Kotahitanga, Kingitanga, Parliament, Suffrage, Repudiation, Economic Change, Agriculture, Gold Mining, Timber, Flax, Sheep, Dairying,
11821, 245 PM Nurses Touch Video Interaction Family in a S
1. 11/8/21, 2:45 PM Nurse's Touch Video Interaction Family in a
Stressful Situation
https://scorm.atitesting.com/courses/FCAEA235-130E-47FC-
A14E-88DF7D4186A1/1/launchpage.html 1/1
%SimulationName% Video Transcript
DR. KOVAC: How are you feeling, Mrs. Travis? MRS.
TRAVIS: I guess as expected. DR. KOVAC: Mr. Travis,
your wife did very well during the surgery. It took a little
longer than we expected. MR. TRAVIS: I was worried.
DR. KOVAC: We found a small tumor in her stomach. Because
of the size, the surgery was more complicated
than we anticipated. We were successful in removing the entire
tumor. However, I'm concerned about the
appearance of this tumor, and we noted some areas on her liver
and her pancreas that were abnormal. We
obtained many biopsies, and we should have the results soon. I
would like to admit her to the hospital and
observe her overnight. MR. TRAVIS: This can't be happening.
11/8/21, 2:41 PM Nurse's Touch Video Interaction Family in a
Stressful Situation
https://scorm.atitesting.com/courses/FCAEA235-130E-47FC-
A14E-88DF7D4186A1/1/launchpage.html 1/1
%SimulationName% Video Transcript
ESCORT: May I help you, Mr. Travis? MR. TRAVIS: I’m so
2. worried. I know I come up here every five minutes
or so. ESCORT: Can I get you a bottle of water or something?
MR. TRAVIS: No, thanks. I'm fine. Has anyone
called for me yet? ESCORT: Uh, no, there have been no calls
yet, but it has been a while. I can check again on
your wife if you would like. MR. TRAVIS: Yes, that would be
great. Thank you. ESCORT: I was just going to
call back. Do you have an update for Mr. Travis about how his
wife is doing? He hasn’t been able to sit still the
entire time that she’s been in surgery. If you don’t have
something to tell him, I’m going to just tell him that
everything is going to be just fine. MR. TRAVIS: Heather, do
you know something about my wife? Why is it
taking so long?
11/8/21, 2:39 PM Nurse's Touch Video Interaction Family in a
Stressful Situation
https://scorm.atitesting.com/courses/FCAEA235-130E-47FC-
A14E-88DF7D4186A1/1/launchpage.html 1/1
%SimulationName% Video Transcript
HEATHER: Mrs. Travis, you pushed your call light. Is there
something we can do for you? MRS. TRAVIS: My
husband went to the waiting room to get more coffee. I've never
seen him so nervous. Do you know how soon
they'll come and get me for surgery? HEATHER: We can check
on that. Right, Rose? ROSE: Yes, we can check
on that. MRS. TRAVIS: Thank you. My husband’s so nervous,
he’s making me nervous. I’m having a hard time
relaxing. I don’t know what to do to help him calm down so that
I can relax.
3. 11/8/21, 2:37 PM Nurse's Touch Video Interaction Family in a
Stressful Situation
https://scorm.atitesting.com/courses/FCAEA235-130E-47FC-
A14E-88DF7D4186A1/1/launchpage.html 1/1
%SimulationName% Video Transcript
HEATHER: Mr. Travis, is there anything I can do for you? I see
you looking out into the hallway often. Were
you looking for someone? MR. TRAVIS: Yeah, I'm just
watching for them to come and get my wife for surgery.
I thought maybe they'd get here early. We just want to get this
over with. She's been dealing with this pain for a
long time. We just want some answers. MRS. TRAVIS: My
husband’s always like this when he’s upset. You'd
think he was the one having surgery. We still have 10 minutes
until the scheduled time. You really need to calm
down, honey. Heather, what can you do here for nervous family
members?
11/8/21, 2:30 PM Nurse's Touch Video Interaction Family in a
Stressful Situation
https://scorm.atitesting.com/courses/FCAEA235-130E-47FC-
A14E-88DF7D4186A1/1/launchpage.html 1/1
%SimulationName% Video Transcript
ESCORT: Rose, this is Mr. and Mrs. Travis. She’ll take good
care of you. ROSE: Hello. I’m Rose. I’m the nurse
from the preoperative area. Mrs. Travis, will you please have a
4. seat? This is Heather. She is a nursing student.
She will be working with you today as well. MRS. TRAVIS:
Oh, okay. Nice to meet you. HEATHER: Hi. Nice
to meet you, too. Could you state your name and date of birth,
please? MRS. TRAVIS: Alexa Travis. December
12, 1986. HEATHER: Thank you. ROSE: Okay, we have a little
bit of paperwork to do before your surgery, so
let's get started. MRS. TRAVIS: Okay. ROSE: Heather, I want
you to start, and I will assist you along the way.
You’ve watched me before. I want you to do it this time.
HEATHER: Okay. Mr. Travis, I’m going to ask you to
step out for a moment while we complete this paperwork and
prepare Mrs. Travis for her surgery. This won’t
take long. You can wait in the surgery waiting room. And we’ll
come get you when we’re done. MR. TRAVIS:
You mean you want me to leave? My wife is having surgery this
morning. Can't I stay with her until she goes to
the operating room? MRS. TRAVIS: Honey.
Physical Examination & Health Assessment
8TH EDITION
CAROLYN JARVIS, PhD, APRN, CNP
Professor of Nursing
Illinois Wesleyan University
Bloomington, Illinois
and
Family Nurse Practitioner
Bloomington, Illinois
5. With Ann Eckhardt, PhD, RN
Associate Professor of Nursing
Illinois Wesleyan University
Bloomington, Illinois
Original Illustrations by Pat Thomas, CMI, FAMI
East Troy, Wisconsin
2
Table of Contents
Cover image
Title Page
Chapter Organization
Structure and Function
Subjective Data
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
Copyright
Dedication
6. About the Author
Contributors
Reviewers
Preface
Acknowledgments
Unit 1 Assessment of the Whole Person
Chapter 1 Evidence-Based Assessment
Culture and Genetics
References
Chapter 2 Cultural Assessment
Developmental Competence
3
kindle:embed:0006?mime=image/jpg
References
Chapter 3 The Interview
Developmental Competence
Culture and Genetics
References
7. Chapter 4 The Complete Health History
Culture and Genetics
Developmental Competence
References
Chapter 5 Mental Status Assessment
Structure and Function
Objective Data
Documentation And Critical Thinking
Abnormal Findings
Abnormal Findings for Advanced Practice
Summary Checklist: Mental Status Assessment
References
Chapter 6 Substance Use Assessment
Subjective Data
Objective Data
Abnormal Findings
Bibliography
Chapter 7 Domestic and Family Violence Assessment
8. Subjective Data
Objective Data
Abnormal Findings
References
Unit 2 Approach to the Clinical Setting
4
Chapter 8 Assessment Techniques and Safety in the Clinical
Setting
Developmental Competence
References
Chapter 9 General Survey and Measurement
Objective Data
Documentation and Critical Thinking
Abnormal Findings
References
Chapter 10 Vital Signs
Objective Data
9. Documentation and Critical Thinking
Abnormal Findings
References
Chapter 11 Pain Assessment
Structure and Function
Subjective Data
Objective Data
Documentation and Critical Thinking
Abnormal Findings
References
Chapter 12 Nutrition Assessment
Structure and Function
Subjective Data
Objective Data
Documentation and Critical Thinking
Abnormal Findings
Abnormal Findings for Advanced Practice
Summary Checklist: Nutritional Assessment
10. References
5
Unit 3 Physical Examination
Chapter 13 Skin, Hair, and Nails
Structure and Function
Subjective Data
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
Abnormal Findings for Advanced Practice
Summary Checklist: Skin, Hair, and Nails Examination
References
Chapter 14 Head, Face, Neck, and Regional Lymphatics
Structure and Function
Subjective Data
Objective Data
11. Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
Summary Checklist: Head, Face, and Neck, Including Regional
Lymphatics Examination
References
Chapter 15 Eyes
Structure and Function
Subjective Data
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
Abnormal Findings for Advanced Practice
Summary Checklist: Eye Examination
References
6
Chapter 16 Ears
12. Structure and Function
Subjective Data
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
Abnormal Findings for Advanced Practice
Summary Checklist: Ear Examination
References
Chapter 17 Nose, Mouth, and Throat
Structure and Function
Subjective Data
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
Abnormal Findings for Advanced Practice
References
13. Chapter 18 Breasts, Axillae, and Regional Lymphatics
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
Abnormal Findings for Advanced Practice
Summary Checklist: Breasts and Regional Lymphatics
Examination
References
Chapter 19 Thorax and Lungs
Structure and Function
Subjective Data
7
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
14. Abnormal Findings for Advanced Practice
Summary Checklist: Thorax and Lung Examination
References
Chapter 20 Heart and Neck Vessels
Subjective Data
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
Abnormal Findings for Advanced Practice
Summary Checklist: Heart and Neck Vessels Examination
References
Chapter 21 Peripheral Vascular System and Lymphatic System
Structure and Function
Subjective Data
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
15. Abnormal Findings
Abnormal Findings for Advanced Practice
Summary Checklist: Peripheral Vascular Examination
References
Chapter 22 Abdomen
Structure and Function
Subjective Data
Objective Data
8
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
Abnormal Findings for Advanced Practice
Summary Checklist: Abdomen Examination
References
Chapter 23 Musculoskeletal System
Structure and Function
16. Subjective Data
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings for Advanced Practice
Summary Checklist: Musculoskeletal Examination
References
Chapter 24 Neurologic System
Structure and Function
Subjective Data
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
Abnormal Findings for Advanced Practice
Summary Checklist: Neurologic Examination
References
Chapter 25 Male Genitourinary System
17. Structure and Function
Subjective Data
Objective Data
Health Promotion and Patient Teaching
9
Documentation and Critical Thinking
Abnormal Findings
Abnormal Findings for Advanced Practice
Summary Checklist: Male Genitalia Examination
References
Chapter 26 Anus, Rectum, and Prostate
Structure and Function
Subjective Data
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings
18. Abnormal Findings for Advanced Practice
Summary Checklist: Anus, Rectum, and Prostate Examination
References
Chapter 27 Female Genitourinary System
Structure and Function
Subjective Data
Objective Data
Health Promotion and Patient Teaching
Documentation and Critical Thinking
Abnormal Findings for Advanced Practice
Summary Checklist: Female Genitalia Examination
References
Unit 4 Integration: Putting It All Together
Chapter 28 The Complete Health Assessment
Documentation and Critical Thinking
Chapter 29 The Complete Physical Assessment
Sequence/Selected Photos
10
19. Chapter 30 Bedside Assessment and Electronic Documentation
Sequence/Selected Photos
References
Chapter 31 The Pregnant Woman
Structure and Function
Subjective Data
Objective Data
Documentation and Critical Thinking
Abnormal Findings for Advanced Practice
Summary Checklist: The Pregnant Woman
References
Chapter 32 Functional Assessment of the Older Adult
References
Illustration Credits
Index
Assessment Terms: English and Spanish
Assessment Terms: English and Spanish
20. 11
Chapter Organization
The following color bars are used consistently for each section
within a chapter to help locate
specific information.
12
Structure and Function
Anatomy and physiology by body system
13
Subjective Data
Health history through questions (examiner asks) and
explanation (rationale)
14
Objective Data
Core of the examination part of each body system chapter with
skills, expected findings, and
common variations for healthy people, as well as selected
abnormal findings
15
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This book and the individual contributions contained in it are
protected under copyright by the
Publisher (other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own
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evaluating and using any information, methods, compounds or
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Because of rapid advances in the medical sciences, in particular,
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Previous editions copyrighted 2016, 2012, 2008, 2004, 2000,
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International Standard Book Number: 978-0-323-51080-6
23. Executive Content Strategist: Lee Henderson
Senior Content Development Specialist: Heather Bays
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20
Dedication
To Paul, with love and thanks. You have read every word.
21
About the Author
Carolyn Jarvis received her PhD from the University of Illinois
at Chicago, with a research
interest in the physiologic effect of alcohol on the
cardiovascular system; her MSN from Loyola
24. University (Chicago); and her BSN cum laude from the
University of Iowa. She is Professor, School
of Nursing at Illinois Wesleyan University, where she teaches
Health Assessment, Pathophysiology,
and Pharmacology. Dr. Jarvis has taught physical assessment
and critical care nursing at Rush
University (Chicago), the University of Missouri (Columbia),
and the University of Illinois
(Urbana). Her current research interest concerns alcohol -
interactive medications, and she includes
Honors students in this research.
In 2016, Illinois Wesleyan University honored Dr. Jarvis for her
contributions to the ever-
changing field of nursing with the dedication of the Jarvis
Center for Nursing Excellence. The Jarvis
Center for Nursing Excellence equips students with laboratory
and simulation learning so that they
may pursue their nursing career with the same commitment as
Dr. Jarvis.
Dr. Jarvis is the Student Senate Professor of the Year (2017)
and was honored to give remarks at
commencement. She is a recipient of the University of
Missouri's Superior Teaching Award; has
taught physical assessment to thousands of baccalaureate
students, graduate students, and nursing
professionals; has held 150 continuing education seminars; and
is the author of numerous articles
and textbook contributions.
Dr. Jarvis has maintained a clinical practice in advanced
practice roles—first as a cardiovascular
clinical specialist in various critical care settings and as a
certified family nurse practitioner in
primary care. During the last 12 years, her enthusiasm has
25. focused on Spanish language skills to
provide health care in rural Guatemala and at the Community
Health Care Clinic in Bloomington.
Dr. Jarvis has been instrumental in developing a synchronous
teaching program for Illinois
Wesleyan students both in Barcelona, Spain, and at the home
campus.
22
23
Contributors
CHAPTER CONTRIBUTOR
Lydia Bertschi DNP, APRN, ACNP-BC
The co-contributor for Chapter 22 (Abdomen), Dr. Bertschi is
an Assistant Professor at Illinois
Wesleyan University School of Nursing and a nurse practitioner
in the intensive care unit at
UnityPoint Health—Methodist.
ASSESSMENT PHOTOGRAPHERS
Chandi Kessler BSN, RN
Chandi is a former Intensive Care Unit nurse and is an award-
winning professional photographer.
Chandi specializes in newborn and family photography in and
around Central Illinois.
Kevin Strandberg
26. Kevin is a Professor of Art Emeritus at Illinois Wesleyan
University in Bloomington, Illinois. He has
contributed to all editions of Physical Examination & Health
Assessment.
INSTRUCTOR AND STUDENT ANCILLARIES
Case Studies
Melissa M. Vander Stucken MSN, RN
Clinical Assistant Professor
School of Nursing
Sam Houston State University
Huntsville, Texas
Key Points
Joanna Cain BSN, BA, RN
Auctorial Pursuits, Inc.
President and Founder
Boulder, Colorado
PowerPoint Presentations
Daryle Wane PhD, ARNP, FNP-BC
BSN Program Director—Professor of Nursing
Department of Nursing and Health Programs
Pasco-Hernando State College
New Port Richey, Florida
Review Questions
Kelly K. Zinn PhD, RN
Associate Professor
School of Nursing
Sam Houston State University
Huntsville, Texas
TEACH for Nurses
27. Jennifer Duke
Freelancer
St. Louis, Missouri
Test Bank
24
Heidi Monroe MSN, RN-BC, CAPA
Assistant Professor of Nursing
NCLEX-RN Coordinator
Bellin College
Green Bay, Wisconsin
Test Bank Review
Kelly K. Zinn PhD, RN
Associate Professor
School of Nursing
Sam Houston State University
Huntsville, Texas
25
Reviewers
Valerie J. Fuller PhD, DNP, AGACNP-BC, FNP-BC, FAANP,
FNAP
Assistant Professor
School of Nursing
University of Southern Maine
Portland, Maine
Peggy J. Jacobs DNP, RNC-OB, CNM, APRN
28. Instructional Support and Outcomes Coordinator
School of Nursing
Illinois Wesleyan University
Bloomington, Illinois
Marie Kelly Lindley PhD, RN
Clinical Assistant Professor
Louise Herrington School of Nursing
Baylor University
Dallas, Texas
Jeanne Wood Mann PhD, MSN, RN, CNE
Assistant Dean;
Associate Professor
School of Nursing
Baker University
Topeka, Kansas
Judy Nelson RN, MSN
Nurse Educator
Nursing
Fort Scott Community College
Fort Scott, Kansas
Cheryl A. Tucker DNP, RN, CNE
Clinical Associate Professor;
Undergraduate Level II BSN Coordinator
Louise Herrington School of Nursing
Baylor University
Dallas, Texas
Melissa M. Vander Stucken MSN, RN
Clinical Assistant Professor
School of Nursing
Sam Houston State University
Huntsville, Texas
29. Kelly K. Zinn PhD, RN
Associate Professor
School of Nursing
Sam Houston State University
Huntsville, Texas
26
27
Preface
This book is for those who still carefully examine their patients
and for those of you who wish to
learn how to do so. You develop and practice, and then learn to
trust, your health history and
physical examination skills. In this book, we give you the tools
to do that. Learn to listen to the
patient—most often he or she will tell you what is wrong (and
right) and what you can do to meet
his or her health care needs. Then learn to inspect, examine, and
listen to the person's body. The
data are all there and are accessible to you by using just a few
extra tools. High-tech machinery is a
smart and sophisticated adjunct, but it cannot replace your own
bedside assessment of your patient.
Whether you are a beginning examiner or an advanced-practice
student, this book holds the content
you need to develop and refine your clinical skills.
This is a readable college text. All 8 editions have had these
30. strengths: a clear, approachable
writing style; an attractive and user-friendly format; integrated
developmental variations across the
life span with age-specific content on the infant, child,
adolescent, pregnant woman, and older
adult; cultural competencies in both a separate chapter and
throughout the book; hundreds of
meticulously prepared full-color illustrations; sample
documentation of normal and abnormal
findings and 60 clinical case studies; integration of the
complete health assessment in 2 photo essays
at the end of the book, where all key steps of a complete head-
to-toe examination of the adult,
infant, and child are summarized; and a photo essay
highlighting a condensed head-to-toe
assessment for each daily segment of patient care.
New to the Eighth Edition
The 8th edition has a new chapter section and several new
content features. Cultural Assessment
in Chapter 2 is rewritten to increase emphasis on cultural
assessment, self-assessment, and a new
section on spiritual assessment. The Interview in Chapter 3 has
a new section on interprofessional
communication; Mental Status Assessment in Chapter 5 now
includes the Montreal Cognitive
Assessment; Substance Use Assessment in Chapter 6 includes
additional content on opioid/heroin
epidemic and alcohol-interactive medications; Domestic and
Family Violence Assessment in
Chapter 7 includes all new photos, updates on the health effects
of violence, added information on
the health effects of violence, and additional content on child
abuse and elder abuse. The former
Vital Signs and Measurement chapter is now split into 2
chapters to increase readability; the Vital
31. Signs chapter (Chapter 10) stands alone with updated
information on blood pressure guidelines.
The Physical Examination chapters all have a new feature—
Health Promotion and Patient
Teaching—to give the reader current teaching guidelines. Many
chapters have all new exam photos
for a fresh and accurate look. The focus throughout is evidence -
based practice. Examination
techniques are explained and included (and in some cases,
rejected) depending on current clinical
evidence.
Pat Thomas has designed 15 new art pieces in beautiful detail
and 30 photo overlays. We have
worked together to design new chapter openers and anatomy;
note Fig. 11.4 on opioid targets, Figs.
14.1 and 14.2 on complex anatomy of skull and facial muscles,
Fig. 15.5 on complex eye anatomy;
Fig 23.8 on 3 images of complex shoulder anatomy showing
muscle girdle, Fig. 27.2 on complex
female internal anatomy, and many others. We have worked
with Chandi Kesler and Kevin
Strandberg in new photo shoots, replacing exam photos in
Chapters 6 (Substance Use Assessment),
23 (Musculoskeletal System), 24 (Neurologic System), 28 (The
Complete Health Assessment: Adult),
and many others.
All physical examination chapters are revised and updated, with
evidence-based data in
anatomy and physiology, physical examination, and assessment
tools. Developmental Competence
sections provide updated common illnesses, growth and
development information, and the
Examination section of each body system chapter details exam
32. techniques and clinical findings for
infants, children, adolescents, and older adults.
Culture and Genetics data have been revised and updated in
each chapter. Common illnesses
28
affecting diverse groups are detailed. We know that some
groups suffer an undue burden of some
diseases, not because of racial diversity per se, but because
these groups are overrepresented in the
uninsured/poverty ranks and lack access to quality health care.
The Abnormal Findings tables located at the end of the chapters
are revised and updated with
many new clinical photos. These are still divided into two
sections. The Abnormal Findings tables
present frequently encountered conditions that every clinician
should recognize, and the Abnormal
Findings for Advanced Practice tables isolate the detailed
illustrated atlas of conditions encountered
in advanced practice roles.
Chapter references are up-to-date and are meant to be used.
They include the best of clinical
practice readings as well as basic science research and nursing
research, with an emphasis on
scholarship from the last 5 years.
Dual Focus as Text and Reference
Physical Examination & Health Assessment is a text for
beginning students of physical examination as
well as a text and reference for advanced practitioners. The
33. chapter progression and format permit
this scope without sacrificing one use for the other.
Chapters 1 through 7 focus on health assessment of the whole
person, including health
promotion for all age-groups, cultural environment and
assessment, interviewing and complete
health history gathering, the social environment of mental
status, and the changes to the whole
person on the occasions of substance use or domestic violence.
Chapters 8 through 12 begin the approach to the clinical care
setting, describing physical data-
gathering techniques, how to set up the examination site, body
measurement and vital signs, pain
assessment, and nutritional assessment.
Chapters 13 through 27 focus on the physical examination and
related health history in a body
systems approach. This is the most efficient method of
performing the examination and is the most
logical method for student learning and retrieval of data. Both
the novice and the advanced
practitioner can review anatomy and physiology; learn the
skills, expected findings, and common
variations for generally healthy people; and study a
comprehensive atlas of abnormal findings.
Chapters 28 through 32 integrate the complete health
assessment. Chapters 28, 29 and 30
present the choreography of the head-to-toe exam for a
complete screening examination in various
age-groups and for the focused exam in this unique chapter on a
hospitalized adult. Chapters 31
and 32 present special populations—the assessment of the
pregnant woman and the functional
34. assessment of the older adult, including assessment tools and
caregiver and environmental
assessment.
This text is valuable to both advanced practice students and
experienced clinicians because of its
comprehensive approach. Physical Examination & Health
Assessment can help clinicians learn the
skills for advanced practice, refresh their memory, review a
specific examination technique when
confronted with an unfamiliar clinical situation, compare and
label a diagnostic finding, and study
the Abnormal Findings for Advanced Practice.
Continuing Features
1. Method of examination (Objective Data section) is clear,
orderly, and easy to follow.
Hundreds of original examination illustrations are placed
directly with the text to
demonstrate the physical examination in a step-by-step format.
2. Two-column format begins in the Subjective Data section,
where the running column
highlights the rationales for asking history questions. In the
Objective Data section, the
running column highlights selected abnormal findings to show a
clear relationship between
normal and abnormal findings.
3. Abnormal Findings tables organize and expand on material in
the examination section.
The atlas format of these extensive collections of pathology and
original illustrations helps
students recognize, sort, and describe abnormal findings.
35. 4. Genetics and cultural variations in disease incidence and
response to treatment are cited
throughout using current evidence. The Jarvis text has the
richest amount of cultural-
genetic content available in any assessment text.
5. Developmental approach in each chapter presents a prototype
for the adult, then age-
29
specific content for the infant, child, adolescent, pregnant
female, and older adult so
students can learn common variations for all age-groups.
6. Stunning full-color art shows detailed human anatomy,
physiology, examination
techniques, and abnormal findings.
7. Health history (Subjective Data) appears in two places: (1) in
Chapter 4, The Complete
Health History; and (2) in pertinent history questions that are
repeated and expanded in
each regional examination chapter, including history questions
that highlight health
promotion and self-care. This presentation helps students
understand the relationship
between subjective and objective data. Considering the history
and examination data
together, as you do in the clinical setting, means that each
chapter can stand on its own if a
person has a specific problem related to that body system.
8. Chapter 3, The Interview, has the most complete discussion
36. available on the process of
communication, interviewing skills, techniques and traps, and
cultural considerations (for
example, how nonverbal behavior varies cross-culturally and the
use of an interpreter).
9. Summary checklists at the end of each chapter provide a
quick review of examination steps
to help develop a mental checklist.
10. Sample recordings of normal and abnormal findings show
the written language you
should use so that documentation, whether written or electronic,
is complete yet succinct.
11. 60 Clinical Case Studies of frequently encountered
situations that show the application of
assessment techniques to patients of varying ages and clinical
situations. These case
histories, in SOAP format ending in diagnosis, use the actual
language of recording. We
encourage professors and students to use these as critical
thinking exercises to discuss and
develop a Plan for each one.
11. User-friendly design makes the book easy to use. Frequent
subheadings and instructional
headings assist in easy retrieval of material.
12. Spanish-language translations highlight important phrases
for communication during the
physical examination and appear on the inside back cover.
Supplements
• The Pocket Companion for Physical Examination & Health
37. Assessment continues to be a handy and current clinical
reference
that provides pertinent material in full color, with over 200
illustrations from the textbook.
• The Study Guide & Laboratory Manual with physical
examination forms is a full-color workbook that includes for
each
chapter a student study guide, glossary of key terms, clinical
objectives, regional write-up forms, and review questions. The
pages are perforated so students can use the regional write-up
forms in the skills laboratory or in the clinical setting and turn
them in to the instructor.
• The revised Health Assessment Online is an innovative and
dynamic teaching and learning tool with more than 8000
electronic assets, including video clips, anatomic overlays,
animations, audio clips, interactive exercises,
laboratory/diagnostic
tests, review questions, and electronic charting activities.
Comprehensive Self-Paced Learning Modules offer increased
flexibility to faculty who wish to provide students with tutorial
learning modules and in-depth capstone case studies for each
30
body system chapter in the text. The Capstone Case Studies
include Quality and Safety Challenge activities. Additional
Advance Practice Case Studies put the student in the exam room
and test history-taking and documentation skills. The
comprehensive video clip library shows exam procedures across
the life span, including clips on the pregnant woman.
Animations,
sounds, images, interactive activities, and video clips are
embedded in the learning modules and cases to provide a
dynamic, multimodal learning environment for today's learners.
38. • The companion EVOLVE Website
(http://evolve.elsevier.com/Jarvis/) for students and instructors
contains learning objectives, more than 300 multiple-choice and
alternate-format review questions, printable key points from the
chapter, and a comprehensive physical exam form for the adult.
Case studies—including a variety of developmental and cultural
variables—help students apply health assessment skills and
knowledge. These include 25 in-depth case studies with critical
thinking questions and answer guidelines. Also included is a
complete Head-to-Toe Video Examination of the Adult that can
be
viewed in its entirety or by systems.
• Simulation Learning System. The new Simulation Learning
System (SLS) is an online toolkit that incorporates medium- to
high-fidelity simulation with scenarios that enhance the clinical
decision-making skills of students. The SLS offers a
comprehensive
package of resources, including leveled patient scenarios,
detailed
instructions for preparation and implementation of the
simulation
experience, debriefing questions that encourage critical
thinking,
and learning resources to reinforce student comprehension.
• For instructors, the Evolve website presents TEACH for
Nursing,
PowerPoint slides, a comprehensive Image Collection, and a
Test
Bank. TEACH for Nurses provides annotated learning
objectives,
key terms, teaching strategies for the classroom in a revised
section
with strategies for both clinical and simulation lab use and a
focus
on QSEN competencies, critical thinking exercises, websites,
and
39. performance checklists. The PowerPoint slides include 2000
slides
with integrated images and Audience Response Questions. A
separate 1200-illustration Image Collection is featured and,
finally, the ExamView Test Bank has over 1000 multiple-choice
and alternate-format questions with coded answers and
rationales.
In Conclusion
31
http://evolve.elsevier.com/Jarvis/
Throughout all stages of manuscript preparation and production,
we make every effort to develop a
book that is readable, informative, instructive, and vital. Thank
you for your enthusiastic response
to the earlier editions of Physical Examination & Health
Assessment. I am grateful for your
encouragement and for your suggestions, which are incorporated
wherever possible. Your
comments and suggestions continue to be welcome for this
edition.
Carolyn Jarvis c/o Education Content Elsevier 3251
Riverport Lane Maryland Heights, MO 63043
32
Acknowledgments
These 8 editions have been a labor of love and scholarship.
40. During the 38 years of writing these
texts, I have been buoyed by the many talented and dedicated
colleagues who helped make the
revisions possible.
Thank you to the bright, hardworking professional team at
Elsevier. I am fortunate to have the
support of Lee Henderson, Executive Content Strategist. Lee
coordinates communication with
Marketing and Sales and helps integrate user comments into the
overall plan. I am grateful to work
daily with Heather Bays, Senior Content Development
Specialist. Heather juggled all the deadlines,
readied all the manuscript for production, searched out endless
photos for abnormal examination
findings, kept current with the permissions, and so many other
daily details. Her work is pivotal to
our success. Heather, you rock.
I had a wonderful production team and I am most grateful to
them. Julie Eddy, Publishing
Services Manager, supervised the schedule for book production.
I am especially grateful to Jodi
Willard, Senior Project Manager, who has been in daily contact
to keep the production organized
and moving. She works in so many extra ways to keep
production on schedule. I am pleased with
the striking colors of the interior design of the 8th edition and
the beautiful cover; both are the work
of Brian Salisbury, Book Designer. The individual page layout
is the wonderful work of Leslie
Foster, Illustrator/Designer. Leslie hand-crafted every page,
always planning how the page can be
made better. Because of her work, we added scores of new art
and content, and we still came out
with comparable page length for the 8th edition.
41. I am so happy and excited to welcome Dr. Ann Eckhardt to this
8th edition. Ann has revised
numerous chapters in this edition and is gifted with new ideas. I
hope her contributions continue
and grow. It has been wonderful to have a budding partner down
the hall to bounce ideas and
share chapter ideas and photo shoots.
I have gifted artistic colleagues, who made this book such a
vibrant teaching display. Pat Thomas,
Medical Illustrator, is so talented and contributes format ideas
as well as brilliant drawings. Pat and
I have worked together from the inception of this text. While we
cannot answer each other's
sentences, we have every other quality of a superb professional
partnership. Chandi Kesler and
Kevin Strandberg patiently set up equipment for all our photo
shoots and then captured vivid,
lively exam photos of children and adults. Julia Jarvis and Sarah
Jarvis also photographed our
infant photos with patience and clarity.
I am fortunate to have dedicated research assistants. Ani
Almeroth searched and retrieved
countless articles and sources. She was always prompt and
accurate and anticipated my every
request. Nicole Bukowski joined as a second research assistant
and has been helpful in many ways.
I am most grateful to Paul Jarvis, who read and reread endless
copies of galley and page proof,
finding any errors and making helpful suggestions.
Thank you to the faculty and students who took the time to
write letters of suggestions and
encouragement—your comments are gratefully received and are
42. very helpful. I am fortunate to
have the skilled reviewers who spend time reading the chapter
manuscript and making valuable
suggestions.
Most important are the members of my wonderful family,
growing in number and in support.
You all are creative and full of boundless energy. Your constant
encouragement has kept me going
throughout this process.
Carolyn Jarvis PhD, APRN
33
34
U N I T 1
Assessment of the Whole Person
OUTLINE
Chapter 1 Evidence-Based Assessment
Chapter 2 Cultural Assessment
Chapter 3 The Interview
Chapter 4 The Complete Health History
Chapter 5 Mental Status Assessment
Chapter 6 Substance Use Assessment
Chapter 7 Domestic and Family Violence Assessment
35
43. C H A P T E R 1
36
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 examinatio n 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:
1.1
• 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; follow -
up
with diabetic educator as needed.
• Now uses insulin pump. Reports HbA1c <7%.
• Finger fracture and ankle sprains during childhood (unable to
remember exact dates).
44. 37
• Bronchitis “a lot” as a child.
• Tympanostomy tubes at age 5 due to 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 emergency
department (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. Annual gynecologic examinations started at age
21
years. 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 5 ft 6 in. BMI 29 (overweight).
• Health promotion: Reports consistently wearing sunscreen
when
45. outside and completing skin self-examination 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 breast self-examination 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.
Physical examination:
• Normocephalic. Face symmetric. Denies pain on sinus
palpation.
• Vision tested annually. Has worn corrective lenses since 4th
38
grade. PERRLA.
• Scarring of 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.
46. • Breath sounds clear and equal bilaterally. Heart S1S2, neither
accentuated nor diminished. No murmur or extra heart sounds.
• Clinical breast exam 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 are interesting when considered from a life-cycle
perspective; 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 decreases the
risk of 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
47. 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 published 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
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
48. well in gathering the data (given adequate practice) but then
treat all the data as being equally
39
important. This leads to slow and labored decision making.
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 or
imaging 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
49. 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.14 What is often
referred to as nurses' intuition is likely
skilled pattern recognition by expert nurses.13
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, or ask another nurse to
validate the finding. 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).
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).
40
50. 1.2 (Alfaro-LeFevre, 2009.)
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 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 patient
goals or plans of care. 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 understand how today's interventions will help the
patient 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.5,6
Functioning at the level of expert in clinical judgment includes
using intuition. 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 from a
set of defined, structured rules, the expert practitioner uses
intuitive links, has the ability to see
41
salient issues in a patient situation, and knows instant
therapeutic responses.5,6 The expert has a
51. 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.12
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.1
Critical thinking is required for sound diagnostic reasoning and
52. clinical judgment. During your
career you will need to sort through vast amounts of data to
make 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.2,21
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 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.9 A 61-year-old man comes to your
clinic with complaints of shortness of breath. His history
reveals a 5-pound weight gain this week
and a “fluttering in his chest.” During the physical assessment
you find 2+ pitting edema in bilateral
lower extremities and an irregular apical pulse. Taken
individually, ankle edema, weight gain,
53. shortness of breath, and palpitations may appear unrelated, but
together they are signs of an
exacerbation of heart failure. Clustering of cues is extremely
important in identifying a correct
diagnosis. Another patient, an overweight 20-year-old female,
comes to your office 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) and avoid
assumptions that may bias your diagnosis.
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).
TABLE 1.1
Identifying Immediate Priorities
Principles of Setting Priorities
1. Complete a health history, including allergies, medications,
current medical problems, and reason for visit.
2. Determine whether any problems are related, and set
priorities. Priority setting evolves over time with changes in
priority depending on
the relationships between and severity of problems. For
example, if the patient is having difficulty breathing because of
acute rib pain,
54. 42
managing the pain may be a higher priority than dealing with a
rapid pulse.
Steps to Setting Priorities
1. Assign high priority to first-level priority problems such as
airway, breathing, and circulation.
2. Next attend to second-level priority problems, which include
mental status changes, acute pain, infection risk, abnormal
laboratory
values, and elimination problems.
3. Address third-level priority problems such as lack of
knowledge, mobility problems, and family coping.
Setting Priorities: Clinical Exemplar
You are working in the hospital and a patient is admitted to the
emergency department with diabetic ketoacidosis as evidenced
by a
blood glucose of >1100 mg/dL. The patient is lethargic and
cannot provide a history. Based on family report, he is 12 years
old and has
no significant medical, surgical, or medication history. Your
first-level priorities include assuring a stable airway and
adequate
breathing. Your second-level priorities include addressing
mental status changes and abnormal laboratory values by
intervening to
manage blood glucose levels. Once the patient has a stable
blood sugar and is alert/oriented, you address third-level
priorities, including
diabetic education, nutritionist consults, and referral to
community support groups as appropriate.
55. • 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 attended to after more urgent health
problems are addressed. Interventions to treat these problems
are
long term, and the response to treatment is expected to take
more
time. These problems may require a collaborative effort
between
the patient and health care professionals (Fig. 1.3).
1.3
Patients often require the assistance of an interdisciplinary team
of practitioners to treat complex
43
medical problems. Throughout your career, look for
opportunities to work in collaborative teams
and consult other practitioners as appropriate to care for your
patients. Remember, health is
complex and requires input from a variety of specialties (e.g.,
56. physical therapy, speech therapy,
occupational therapy). 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 and his or her input, as appropriate, in your outcome
identification. Patients are more likely
to participate actively in care and follow through with
recommendations if they are part of
developing the plan of care.
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.
Evidence-Based Assessment
Does honey help burn wounds heal more quickly? Do mobile
health technologies improve patient
compliance with medication administration? 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? Is aromatherapy an
57. effective treatment for postoperative
nausea and vomiting?
Health care is a rapidly changing field. The amount of medical
and nursing information available
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
ever before. 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). As early as the 1850s Florence
Nightingale was using research evidence to improve patient
outcomes during the Crimean War. It
was not until the 1970s, however, that the term evidence-based
medicine was coined.16 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
58. 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%.7
EBP is more than the use of best-practice techniques to treat
patients. The definition of EBP is
multifaceted and reflects holistic practice. Once thought to be
primarily clinical, EBP now
encompasses the integration of research evidence, clinical
expertise, clinical knowledge (physical
assessment), and patient values and preferences.16 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 traditional practice of auscultating
bowel sounds was found to be a poor indicator of returning GI
motility in patients having
59. 44
abdominal surgery.17,18 Following the steps to EBP, the
research team asked an evidence-based
question (Fig. 1.4). Next, best research evidence was gathered
through a literature search, which
suggested that early postoperative bowel sounds probably do not
represent return of normal GI
motility. The evidence was appraised to identify whether a
different treatment or assessment
approach was better. Research showed the primary markers for
returning GI motility after
abdominal surgery to be the return of flatus and the first
postoperative bowel movement. Based on
the literature, a new practice protocol was instituted, and
patient outcomes were monitored.
Detrimental outcomes did not occur; the new practice guideline
was shown to be safe for patients'
recovery and a better allocation of staff time. The research led
to a change of clinical practice that
was safe, effective, and efficient.
1.4 (Eckhardt, 2018.)
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 21 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
60. 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 qual ity 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.15
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 taught how to filter through the wealth
of scientific data and critique the
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.15 “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.”20
61. Collecting Four Types of Patient 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.
45
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
62. 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 probl em. 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. 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.
In acute hospital care the complete database 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, spiritual needs, 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
63. 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. For example, a patient with heart failure may follow
up with his or her primary care
practitioner at regular intervals to reevaluate medications,
identify changes in symptoms, and
discuss coping strategies.
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 an 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
64. compiled. An emergency database may be
compiled by questioning the patient, or if the patient is
unresponsive, health care providers may
need to rely on family and friends.
46
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 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.
65. 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 signi ficant 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 Force23 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.10 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. Interdisciplinary collaboration is an integral part of
patient care (Fig. 1.5). Providers,
nurses, dietitians, therapists and other health professionals must
66. work together to care for
increasingly complex patients.
1.5 (Yoder-Wise, 2015.)
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 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
47
periodic health checkups could induce unnecessary costs and
promote services that are not
recommended, advocates justify well-person visits because of
delivery of some recommended
preventive services and reduction of patient worry.11,19
The Guide to Clinical Preventive Services is a positive approach
to health assessment and risk
reduction.23 The Guide is updated annually and is accessible
online or in print. It presents evidence-
based 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 varying
67. 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-year-old
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
are important. In addition, you
should ask how her pump is functioning and whether she is
having any difficulties with blood
sugar control.
48
68. 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. The United States
is becoming a majority-minority
nation. Although non-Hispanic whites will remain the largest
single group, they will no longer
constitute a numeric majority. Emerging minority is a term that
has been used to classify the
populations, including African Americans, Latinos, and Asian
Americans, that are rapidly
becoming a combined numeric majority.22 By 2060 the U.S.
Census Bureau projects that minorities
will constitute 56% of the population. The Latino and Asian
populations are projected to nearly
double by 2060, and all other racial groups are expected to
increase as well. By 2060 nearly 29% of
the population will be Latino, 14% African American, 9%
Asian, and just over 1% American Indians
or Alaska Natives. In 2040 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.8
The United States is becoming increasingly diverse, making
cultural competence more important
and more challenging for health care providers. U.S. health care
providers also travel abroad to
69. 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. 1.6). International
interchanges are increasing among health care providers,
making attention to the cultural aspects of
health and illness an even greater priority.
1.6
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 varying
cultures may interpret symptoms
differently; therefore, asking the right questions is imperative
for you to gather data that are
accurate and meaningful. It is important to provide culturally
relevant health care that incorporates
cultural beliefs and practices. An increasing expectation exists
among members of certain cultural
groups that health care providers will respect their “cultural
health rights,” an expectation that may
70. 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
49
number of individuals from diverse cultural backgrounds
anticipated in the future, a concern for
the cultural beliefs and practices of people is increasingly
important.
50
References
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clinical judgment. 6th ed.
Elsevier: Philadelphia; 2017.
2. American Association of Colleges of Nursing. Essentials of
baccalaureate education
for professional nursing practice. [Available at]
https://www.aacnnursing.org; 2008.
3. American Nurses Association. Nursing: Scope and standards
of practice. 3rd ed.
American Nurses Publishing: Washington, DC; 2015.
4. Balas EA, Boren SA. Managing clinical knowledge for health
care improvements.
71. Bemmel J, McCray AT. Yearbook of medical informatics 2000.
Schattauer: Stuttgart,
Germany; 2000.
5. Benner P, Tanner CA, Chesla CA. Expertise in nursing
practice. Springer: New
York; 1996.
6. Benner P, Tanner CA, Chesla CA. Becoming an expert nurse.
Am J Nurs.
1997;97(6) [16BBB–16DDD].
7. Cochrane Collaboration. [Available at] www.cochrane.org;
2018.
8. Colby SL, Ortman JM. Projections of the size and
composition of the US
population: 2014 to 2060. Population Estimates and projections.
[US Census Bureau]
2015.
9. Croskerry P. From mindless to mindful practice—cognitive
bias and clinical
decision making. N Engl J Med. 2013;368:2445–2450.
10. Ezzati M, Riboli E. Behavioral and dietary risk factors for
noncommunicable
diseases. N Engl J Med. 2013;369(10):954–964.
11. Goroll AH. Toward trusting therapeutic relationships—in
favor of the annual
physical. N Engl J Med. 2015;373:1487–1489.
12. Hanneman SK. Advancing nursing practice with a unit-
based clinical expert.
72. Image (IN). 1996;28(4):331–337.
13. Harjai PK, Tiwari R. Model of critical diagnostic reasoning:
Achieving expert
clinician performance. Nurs Educ Perspect. 2009;30(5):305–
311.
14. Koharchik L, Caputi L, Robb M, et al. Fostering clinical
reasoning in nursing
students. Am J Nurs. 2015;115(1):58–61.
15. Lipscomb M. Exploring evidence-based practice: Debates
and challenges in nursing.
Routledge: New York; 2016.
16. Mackey A, Bassendowski S. The history of evidence-based
practice in nursing
education and practice. J Prof Nurs. 2017;33(1):51–55.
17. Madsen D, Sebolt T, Cullen L, et al. Listening to bowel
sounds: An evidence-
based practice project. Am J Nurs. 2005;105(12):40–50.
18. Massey RL. Return of bowel sounds indicating an end of
postoperative ileus: Is it
time to cease this long-standing nursing tradition? Medsurg
Nurs. 2012;21(3):146–
150.
19. Mehrotra A, Prochazka A. Improving value in health care—
against the annual
physical. N Engl J Med. 2015;373:1485–1487.
20. Melnyk BM, Fineout-Overholt E. Evidence-based practice in
nursing & healthcare.
2nd ed. Lippincott Williams & Wilkins: Philadelphia; 2011.
73. 21. National League for Nursing Accrediting Commission.
Accreditation manual and
interpretive guidelines by program type for postsecondary and
higher degree programs in
nursing. Author: New York; 2006.
22. Spector RE. Cultural diversity in health and illness. 9th ed.
Pearson: Indianapolis, IN;
2016.
23. U.S. Preventive Services Task Force (USPSTF). Published
recommendations.
[Available at] https://uspreventiveservicestaskforce.org; 2017.
51
https://www.aacnnursing.org
http://www.cochrane.org
https://uspreventiveservicestaskforce.org
52
C H A P T E R 2
53
Cultural Assessment
As a health professional, it is imperative that you learn to build
trusting relationships with patients.
Part of forming trust is listening to each patient's individual
74. needs and establishing an awareness of
his or her culture. You must be open to people who are different
from you, have a curiosity about
people, and work to become culturally competent (Fig. 2.1). A
cultural assessment is an integral
part of forming a full database of information about each
patient. Serious errors can occur due to
lack of cultural competence. If you fail to ask about traditional,
herbal, or folk remedies, you may
unknowingly give or prescribe a medication that has a
significant interaction. For example, ginseng
raises the serum digoxin level and can lead to adverse, even
fatal, consequences.18
2.1
A key to understanding cultural diversity is self-awareness and
knowledge of one's own culture.
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 you and influence your beliefs about
health and illness, coping
mechanisms, and wellness behaviors. Developing self-
awareness will make you a better health care
provider and ensure that you are prepared to care for diverse
clients. Recognizing your own
culture, values, and beliefs is an interactive and ongoing
process of self-discovery.18 A cultural
assessment of each patient is important, but a cultural self-
assessment is also an integral component
of becoming culturally competent. To understand another
person's culture, you must first
75. understand your own culture.
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
54
highlight the importance of cultural competence in health
care.40 The population of the United
States exceeded 321 million people in 2015 with only 61.6% of
the population identifying as white,
non-Hispanic.38 Over 13% of the U.S. population were born
elsewhere, and over 21% of the U.S.
population report speaking a language other than English in the
home.3,37 The national minority,
actually emerging majority, population makes up 38% of the
total. Among this emerging majority,
the largest ethnic group is Hispanic, who make up 17.6% of the
population and are the fastest-
growing minority group. The largest racial minority group is
76. African American or black (13.3%),
followed by Asians (5.6%), two or more races (2.6%), American
Indians and Alaska natives (1.2%),
and native Hawaiians and other Pacific Islanders (0.2%).38
There are demographic differences between the emerging
majority groups when compared with
non-Hispanic whites. These demographic differences include
age, poverty level, and household
composition. The number of relatives living in the household is
higher for all racial and ethnic
minorities compared to non-Hispanic whites, as is the number of
multigenerational families (Fig.
2.2). African Americans, American Indians, and Alaska natives
are more likely to have
grandparents who are responsible for the care of grandchildren
compared with other groups.37
2.2 (Courtesy Holly Birch Photography.)
Asians and non-Hispanic whites have the highest median
income, whereas African Americans
have the lowest household income followed by Hispanics. All
ethnic and racial minority groups
have poverty rates exceeding the national average of 14.8%.
Non-Hispanic whites have the lowest
reported poverty at 10%, whereas 25.2% of African Americans
and 24.7% of Hispanics live at or
below the poverty line.11 Contributing to the high rates of
poverty is low educational attainment.
Approximately 33% of Hispanics and 13% of African
Americans have less than a high school
education compared with 6.7% of non-Hispanic whites.33
Lower educational levels and lower
income levels are also correlated with likelihood of disability.
Approximately 20% of adults report
77. having a disability. African Americans were the most likely to
report a disability (29%), followed by
Hispanics (25.9%).6
Immigration
Immigrants are people who are not U.S. citizens at birth. Some
new immigrants have minimal
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 providers addr ess the
needs of this growing population.
In 2014 the population of the United States included over 42.2
million foreign-born individuals,
which accounted for 13.2% of the population. The number of
foreign-born individuals residing in
the United States has quadrupled since the 1960s and is
expected to almost double by 2065.3 During
your career, you will care for foreign-born individuals who have
unique health care needs. The
United States health care system is complex and difficult to
navigate for anyone. Keep in mind, the
health care system may be even more difficult for foreign-born
individuals with limited English
proficiency. Make sure that you identify interpreter needs early
and ask the appropriate cultural
55
assessment questions when caring for each patient.
Determinants of Health and Health Disparities
78. An individual's health status is influenced by a constellation of
factors known as social
determinants of health (SDOH).15 The social determinants of
health include economic stability,
education, social and community context, neighborhood and
built environment, and health and
health care (Fig. 2.3). The five social determinants of health are
interconnected and affect a person's
health from preconception to death. However, evidenced-based
research has consistently shown
that poverty has the greatest influence on health status.
2.3 (USSDHS, 2018.)
For the past two decades the goals of Healthy People have been
to eliminate health disparities. A
health disparity is “a particular type of health difference that is
closely linked with social, economic,
and/or environmental disadvantage. Health disparities adversely
affect groups of people who have
systematically experienced greater obstacles to health based on
their racial or ethnic group; religion;
socioeconomic status; gender; age; mental health; cognitive,
sensory, or physical disability; sexual
orientation or gender identity; geographic location; or other
characteristics historically linked to
discrimination or exclusion.”12
New health care delivery frameworks must strive for social and
physical environments that
promote quality of life free from preventable illness, disability,
and premature death. Public health
sectors must be encouraged to address the needs for safe and
affordable housing; reliable
transportation; nutritious food that is accessible to everyone;
safe, well-integrated neighborhoods
79. and schools; health care providers that are culturally and
linguistically competent; and clean water
and air.
Health Care Disparities Among Vulnerable Populations
Health disparities affect people who experience social,
economic, and/or environmental
disadvantage. These people are vulnerable populations and
include ethnic and racial minorities,
people with disabilities, and the LGBT community. Health care
disparities are measured by
comparing the percent of difference from one group to the best
group rate for a disease. One study
found a 33-year age difference between the longest- and
shortest-living groups in the United
States.13 In another example, African American children are
twice as likely to be hospitalized and
four times as likely to die from asthma as non-Hispanic
whites.13 Overall infant mortality in the
United States is 5.90 per 1,000 live births, but the mortality rate
for African American infants is 10.93
56
per 1,000 live births.27 Lack of health insurance may contribute
to health disparities. An estimated
10.6% of non-Hispanic whites do not have health insurance,
whereas more than 30% of Hispanics,
nearly 19% of non-Hispanic blacks, and almost 14% of Asians
lack basic insurance coverage.7
Few of the differences in health between ethnic and racial
groups have a biologic basis but rather
pertain to the social determinants of health. Disparities in
80. exposure to environmental contaminants,
violence, and substance abuse among some racial and ethnic
minorities suggest the need for a major
transformation of the neighborhoods and social contexts of
people's lives. Although overall quality
of health care is improving in the United States, access to car e
and health disparities are not
showing any improvement.14
National Cultural and Linguistic Standards
Many forms of discrimination based on race or national origin
limit the opportunities for people to
gain equal access to health care services. Many heal th and
social service programs provide
information about their services in English only. Language
barriers have a negative impact on the
quality of care provided, and those patients with language
barriers also have increased risk of
noncompliance to treatment regimens.
Because immigration occurs at high levels and immigrants with
limited English proficiency (LEP)
have particular needs, the Office of Minority Health published
the National Standards for Culturally
and Linguistically Appropriate Services in Health Care. This set
of 15 standards provides a blueprint to
improve quality of care and eliminate health disparities for
culturally diverse populations. Health
disparities affect the health of individuals and communities,
making this a major public health
concern in the United States.39
Linguistic Competence
Under the provisions of Title VI of the Civil Rights Act of
1964, when people with LEP seek health
care in settings such as hospitals, nursing homes, clinics,
81. daycare centers, and mental health centers,
services cannot be denied to them. English is the predominant
language of the United States.
However, among people at least 5 years old living in the United
States, 21% spoke a language other
than English at home.38 Of those, 62% spoke Spanish, 18%
reported speaking an Indo-European
language, 16% spoke an Asian language, and 4% spoke a
different language. Of people who spoke a
language other than English at home, nearly 42% reported that
they did not speak English “very
well.”38
When people with LEP seek health care, they are frequently
faced with receptionists, nurses, and
physicians who speak English only. Additional time and
resources are necessary to adequately care
for patients with LEP. The language barrier may lead to a
decreased quality of care due to limited
understanding of patient needs. To prevent serious adverse
health outcomes for LEP persons, it is
imperative that health care professionals communicate
effectively and utilize resources such as
interpreter services.
Chapter 3 describes in more detail how to communicate with
people who do not understand
English, how to interact with interpreters, and which services
are available when no interpreter is
available. It is vital that interpreters be present who not only
serve to verbally translate the
conversation but who can also describe to you the cultural
aspects and meanings of the person's
situation.
Culture-Related Concepts
82. Culture is a complex phenomenon that includes attitudes,
beliefs, self-definitions, norms, roles, and
values. It is also a web of communication, and much of culture
is transmitted nonverbally through
socialization or enculturation (Fig. 2.4).35 Socialization or
enculturation is the process of being raised
within a culture and acquiring the norms, values, and behaviors
of that group. According to the
Department of Health and Human Services Office of Minority
Health, a person's culture defines
health and illness, identifies when treatment is needed and
which treatments are acceptable, and
informs a person of how symptoms are expressed and which
symptoms are important.39
57
2.4
Culture has four basic characteristics: (1) learned from birth
through the processes of language
acquisition and socialization; (2) shared by all members of the
same cultural group; (3) adapted to
specific conditions related to environmental and technical
factors and to the availability of natural
resources; and (4) dynamic and ever changing.
Culture is a universal phenomenon, yet the culture that develops
in any given society is unique,
encompassing all the knowledge, beliefs, customs, and skills
acquired by members of that society.
However, within cultures some groups of people share different
beliefs, values, and attitudes.
Differences occur because of ethnicity, religion, education,
83. occupation, age, and gender. When such
groups function within a large culture, they are referred to as
subcultural groups.
Many people think about race and ethnicity as a part of the
concept of culture. Race reflects self-
identification and is typically a social construct referring to a
group of people who share similar
physical characteristics. The U.S. Census Bureau lists 15 racial
categories for respondents to choose
from: white, black (African American), American Indian or
Alaskan native, Asian Indian, Chinese,
Filipino, Japanese, Korean, Vietnamese, native Hawaiian,
Guamanian or Chamorro, Samoan, other
Pacific Islander, some other race, or more than one race. A
growing number of respondents are
identifying as more than one race, especially those in younger
generations. An additional question
asks respondents to identify whether they are of Hispanic
origin. Hispanic origin includes the
categories of Mexican, Puerto Rican, Cuban, and another
Hispanic, Latino, or Spanish origin. People
who self-identify as Hispanic can be of any racial category. For
example, Dominicans typically
identify as black Hispanics, whereas people from Argentina
identify as white Hispanics. Because
the terms race and origin cause confusion, the U.S. Census
Bureau is considering changing the race
and origin questions so that people can select all that apply,
with racial categories and Hispanic
origin combined in the same question.8
Race may be useful when determining disease prevalence, but
does not typically refer to specific
genetic or biologic characteristics that distinguish one group of
people from another. Throughout
84. the text, information on disease prevalence related to race is
presented in the culture and genetics
section of each chapter. As we learn more about the human
genome, we may find that genetic
variations become more important than overarching racial
classifications.
Ethnicity refers to a social group that may possess shared traits,
such as a common geographic
origin, migratory status, religion, language, values, traditions or
symbols, and food preferences. The
ethnic group may have a loose group identity with few or no
cultural traditions in common or a
coherent subculture with a shared language and body of
tradition. Similarly ethnic identity is one's
self-identification with a particular ethnic group. This identity
may be strongly adherent to one's
country of origin or background or weakly identified.
Acculturation is the process of adopting the culture and
behavior of the majority culture. During
the late 1800s and early part of the 1900s when the United
States experienced its greatest period of
immigration, the expectation was that immigrants would take on
the characteristics of the dominant
culture, known as assimilation. Immigrants were discouraged
from having a unique ethnic identity
in favor of the nationalist identity.
The recent wave of immigrants in the latter part of the 20th
century has developed different
strategies of acculturation. Rather than solely relying on
assimilation, new immigrants developed
new means of forging identities between the countries of origin
and their host country, such as
85. 58
“biculturalism” and “integration.”34 Assimilation is
unidirectional, proceeding in a linear fashion
from unacculturated to acculturated. However, biculturalism and
integration are bidirectional and
bidimensional, inducing reciprocal changes in both cultures and
maintaining aspects of the original
culture in one's ethnic identity (Fig. 2.5).
2.5
Those who emigrate to the United States from non-Western
countries may find the process of
acculturation, whether in schools or society, to be an extremely
difficult and painful process. The
losses and changes that occur when adjusting to or integrating a
new system of beliefs, routines,
and social roles are known as acculturative stress, which has
important implications for health and
illness.9,10,36 When caring for patients, please be aware of the
factors that contribute to acculturative
stress, as defined in Table 2.1.5
TABLE 2.1
Dimensions of Acculturative Stress
INSTRUMENTAL/ENVIRONMENTAL
SOCIAL/INTERPERSONAL SOCIETAL
Financial
Language barriers
Lack of access to health care
Unemployment
86. Lack of education
Loss of social networks
Loss of social status
Family conflict
Family separation
Intergenerational conflict
Changing gender roles
Discrimination/stigma
Level of acculturation
Political/historical forces
Legal status
Modified from Caplan, S. (2007). Latinos, acculturation, and
acculturative stress: a dimensional concept analysis. Policy
Politics
Nurs Pract, 8(2), 93-106.
Religion and Spirituality
Other major aspects of culture are religion and spirituality.
Spirituality is a broader term focused
on a connection to something larger than oneself and a belief in
transcendence. On the other hand,
religion refers to an organized system of beliefs concerning the
cause, nature, and purpose of the
universe, as well as the attendance of regular services.19
Religion is a shared experience of
spirituality or the values, beliefs, and practices into which
people either are born or that they may
adopt to meet their personal spiritual needs through communal
actions, such as religious affiliation;
attendance and participation in a religious institution, prayer, or
meditation; and religious practices
(Fig. 2.6). Some people define their spirituality in terms of
religion, whereas others identify