MIDTERM

RELEVANT ETHICO-LEGAL GUIDELINES IN CONDUCTING HEALTH ASSESSMENT

Values
 are enduring beliefs or attitudes about the worth of a person, object, idea, or action.

Behavior Example
Ignoring a health professional’s A client with heart disease who values hard work ignores
advice advice to exercise regularly.
Inconsistent communication or A pregnant woman says she wants a healthy baby, but
behavior continues to drink alcohol and smoke tobacco.
Numerous admissions to a health A middle-aged obese woman repeatedly seeks help for back
agency for the same problem pain but does not lose weight.
Confusion or uncertainty about A woman wants to obtain a job to meet financial obligations, but
which course of action to take also wants to stay at home to care for an ailing husband.
Table 1. Behaviors that may indicate Unclear values

Beliefs
 (or opinions) are interpretations or conclusions that people accept as true.

Attitude
 are mental positions or feelings toward a person, object, or idea (e.g., acceptance, compassion,
openness).

Ethics
 study of human acts or conduct from a moral perspective as to whether they are good or bad;
practices or beliefs of a certain group of individuals; and the expected standards of moral
behavior of a specific or particular group as described in their respective code of professional
ethics

Bioethics
 ethics applied to human life or health

Morality
 private, personal standards of what is right and wrong in conduct, character, and attitude

Legal
 refers to a law that is in effect and must be observed and followed.

Law
 the sum total of rules and regulations by which a society is governed; as such, a law is created
by the people and exists to regulate all persons.

Functions of the law in Nursing

1. It provides a framework for establishing which nursing actions in the care of clients are legal.
2. It differentiates the roles of nurses from other health care professionals.
3. It helps establish the boundaries of independent nursing action.
4. It assists in maintaining a standard of nursing practice by making nurses accountable under the
law.

Credentialing
 The process of determining and maintaining competence in nursing practice. It is a three-step
process that includes: licensure, certification, and accreditation.
o Licensure – a license is a legal permit that a government agency grants to an individual
to engage in a particular profession and to use a specific title, e.g. R.N. for registered
nurses, L.P.T. for teachers, etc.
o Certification – is the voluntary practice of validating that an individual nurse has met the
minimum standards of nursing competence in specialty areas, e.g. operating room,
maternal-child nursing, community health nursing, etc. nurses maintain certification
standards.
o Accreditation – the approval of basic nursing education programs offered by either a
state college/university or a private corporation. This ensures that standards of nursing
education are complied with to a minimum.

Ethico-Legal Considerations
 Four major moral principles:
o Autonomy – the innate right of the patient to have his/her own opinions, perspective, and
decision; the right to self-determination
o Beneficence – doing what is good and/or what is right for the patient
o Nonmaleficence – doing no harm
o Justice – fairness in treating patients

Behavior Example
Autonomy The client/family may expect the healthcare provider or the nurse to respect their
right to refuse a treatment. Primary responsibility for decision making may rest
with others, such as the family, elders, or religious community.

Veracity Clients may not value truth-telling for life-threatening conditions, because this may
eliminate hope and, therefore, hasten death.

Nonmaleficence Discussion of advance directives and issues such as cardiopulmonary

resuscitation may be viewed as physically and emotionally harmful to the client.

Beneficence The client/family may expect health care providers to promote client well-being
and hope, and provide treatment that will help prolong life.
Table 2. Examples of culturally competent nursing care

Ethical Decision-Making
Many nursing problems are not moral problems at all, but simply questions of good nursing
practice. An important first step in ethical decision making is to determine whether a moral situation
exists. Responsible ethical reasoning is rational and systematic. It should be based on ethical principles
and codes rather than on emotions, intuition, fixed policies, or precedent.

Nurse’s Obligations in Ethical Decision-Making

 Maximize the client’s well-being.
 Balance the client’s need for autonomy with family members’ responsibilities for the
client’s well-being.
 Support each family member and enhance the family support system.
 Carry out hospital policies.
 Protect other clients’ well-being.
 Protect the nurse’s own standards of care.

 Other principles:
o Altruism – concern for the welfare and well-being of others
o Fidelity – being true to one’s word
o Veracity – being completely truthful with patients
o Accountability – accepting responsibility for one’s own actions
o Privacy – the practice of maintaining the security and confidentiality of the patient/client
and his/her records
o Confidentiality – the right of an individual to have personal, identifiable medical
information kept private
o Human dignity – respect for the inherent worth and uniqueness of individuals and
populations.
o Integrity – acting in accordance with an appropriate code of ethics and accepted
standards of practice

Patient’s Bill of Rights

1. The patient has the right to considerate and respectful care.

2. The patient has the right to and is encouraged to obtain from physicians and other direct caregivers
relevant, current, and understandable information concerning diagnosis, treatment and prognosis.

3. The patient has the right to make decisions about the plan of care prior to and during the course of
treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and
hospital policy and to be informed of the medical consequences of this action. .

4. The patient has the right to have an advance directive (such as a living will, health care) concerning
treatment or designating a surrogate decision maker with the expectation that the hospital will honor
the intent of that directive to the extent permitted by law and hospital policy.

5. The patient has the right to every consideration of his privacy.

6. The patient has the right to expect that all communications and records pertaining to his/her care
should be treated as confidential by the hospital, except in cases such as suspected public health
hazards where reporting is permitted or required by law.

7. The patient has the right to review the records pertaining to his/her medical care and to have the
information explained or interpreted as necessary except when restricted by law.
8. The patient has the right to expect that, within its capacity and policies, a hospital will make
reasonable response to the request of a patient for appropriate and medically indicated care and
services.

9. The patient has the right to ask and be informed of the existence of business relationships among
the hospital, educational institutions, other health care providers, or players that may influence the
patient’s treatment and care.

10. The patient has the right to consent to or decline to participate in proposed research studies or
human experimentation affecting his care and treatment or requiring direct patient involvement, and to
have those studies fully explained prior to consent.

11. The patient has the right to expect reasonable continuity of care when appropriate and to be
informed by physicians and other caregivers available and realistic patient care options when hospital
care is no longer appropriate.

12. The patient has the right to be informed of hospital policies and practices that relate to patient care,
treatment, and responsibilities.

Data Privacy Act of 2012 (Republic Act 10173)

An act protecting individual personal information in information and communications systems in the
government and the private sector, creating for this purpose a national privacy commission, and for
other purposes.

GUIDELINES OF AN EFFECTIVE INTERVIEW AND HEALTH HISTORY

An interview is a planned communication. The nurse interviews the patient to obtain a nursing history.
The interview can be understood in terms of its four phases, which include the preparatory phase,
introduction, working phase, and termination.

Phases
 Preparatory Phase
o Before initiating the interview, the nurse prepares to meet the patient by reading current
and past records and reports, when available. During this phase, it is important not to let
one's stereotypes and prejudices affect the nurse–patient relationship. Nurses who are
aware of their own prejudices can deal with them constructively.

 Introduction Phase
o The interview's introduction is crucial because it sets the tone not only for the remainder
of the interview but also for every following nurse–patient interaction. At the end of this
phase of the interview, the patient should know the name of the primary nurse and what
he or she can expect of nursing care, should sense that the nurse is competent and
cares about him or her, and should know what is expected of him or her in terms of
developing the plan of care and participating in its execution.

 Working Phase
o During the working phase of the interview, the nurse gathers all the information needed
to form the subjective database. The accuracy, completeness, and relevance of the
database depend on the nurse's use of the interviewing and basic communication
techniques.

 Termination Phase
o The successful interview is concluded carefully. A patient should be advised that the
interview is coming to an end. It is helpful to recapitulate the interview, highlighting key
points. Both the patient and the nurse should be satisfied that the important data are
recorded. A helpful strategy is to ask the patient after the summary: “Is there anything
else you would like us to know that will help us plan your care?” This gives the patient an
opportunity to add data the nurse did not think to include.

Communication
Good communication between nurses and patients is essential for the successful outcome of
individualized nursing care of each patient. To achieve this, however, nurses must understand and help
their patients, demonstrating courtesy, kindness and sincerity. Also, they should devote time to the
patient to communicate with the necessary confidentiality.

Effective communication requires an understanding of the patient and the experiences they
express. It requires skills and simultaneously the sincere intention of the nurse to understand what
concerns the patient. To understand the patient only is not sufficient but the nurse must also convey
the message that enables the patient to understand the willingness to help.

Factors affecting communication

1. Level of developmental and age
 Infants
 Toddlers and Pre-schoolers
 School age
 Adolescent
 Young adulthood, Middle adulthood
 Old age

2. Level of consciousness

3. Emotional state and level of stress

4. Language spoken

5. Individual values, beliefs, perspectives, and perception

6.Culture

7.Medical treatment

Therapeutic Communication
Therapeutic communication promotes understanding and can help establish a constructive relationship
between the nurse and the client.
Table 3. Therapeutic communication techniques
Technique Description Example
Using silence Accepting pauses or silences that Sitting quietly and waiting attentively
may extend for several seconds or until the client is able to put thoughts
minutes without interjecting any verbal into words.
response.
Providing a general Using statements or questions that (a) “Perhaps you would like to talk about
lead encourage the client to verbalize, (b) it?”
choose a topic of conversation, and
(c) facilitate continued verbalization.
“Can you tell me about your
experience?”
Being specific and Making statements that are specific “Rate your pain from 0-10.”
tentative rather than general.

Using open-ended Asking broad questions that lead or “How have you been feeling?”
questions invite the client to explore (elaborate,
clarify, describe, compare, or “Tell me more please.”
illustrate) thoughts or feelings.

Using touch Providing appropriate forms of touch Holding a client’s hand.

to reinforce caring feelings. Because
tactile contacts vary considerably Giving a client a pat on the back for
among individuals, families, and achieving a goal.
cultures, the nurse must be sensitive
to the differences in attitudes and
practices of clients and self.

Restating or Actively listening for the client’s basic Client: “I couldn’t manage to eat any
paraphrasing message and then repeating those dinner last night— not even the
thoughts and/or feelings in similar dessert.”
words.
Nurse: “You had difficulty eating
yesterday.”

Client: “Yes, I was very upset after my

family left.”

Seeking A method of making the client’s broad “Would kindly say that again?”
clarification overall meaning of the message more
understandable. “Im not sure I understand what you
mean.”

Offering self Suggesting one’s presence, interest, or “I can stay with you for a while.”
wish to understand the client without
making any demands or attaching “I can help you dress up.”
conditions that the client must comply
with to receive the nurse’s attention.

Technique Description Example

Giving information Providing, in a simple and direct “Your surgery is scheduled tomorrow at
manner, specific factual information the 11am.”
client may or may not request.
“I’m afraid I cannot help you with that
but I can ask the doctor for you.”

Presenting reality Helping the client to differentiate the real “Your magazine is here in the drawer. It
from the unreal. has not been stolen.”

Acknowledging Giving recognition, in a nonjudgmental “You walked twice as far today with
way, of a change in behavior, an effort your walker. That’s good.”
the client has made, or a contribution to
a communication.
You seem to be rubbing your eyes a lot.
Is there something wrong with them?”

Clarifying time or Helping the client clarify an event, Client: “I vomited this morning.”
sequence situation, or happening in relationship to
time. Nurse: “Was that after breakfast?”

Client: “I feel that I have been asleep

for weeks.”

Nurse: “You had your operation

Monday, and today is Tuesday.”

Focusing Helping the client expand on and Client: “My wife says she will look after
develop a topic of importance. me, but I don’t think she can, what with
the children to take care of, and they’re
always after her about something —
clothes, homework, what’s for dinner
that night.”

Nurse: “Sounds like you are worried

about how well she can manage.”

Reflecting Directing ideas, feelings, questions, or Client: “What can I do?”

content back to clients to enable them to
explore their own ideas and feelings Nurse: “What do you think would be
about a situation. helpful?”

Client: “Do you think I should tell my

husband?”

Nurse: “You seem unsure about telling

your husband.”
Technique Description Example
Summarizing and Stating the main points of a “During the past week, you were able
planning discussion to clarify the relevant to…”
points discussed.
“For 2 days, we have been doing your
leg exercises really well, so…”

Barriers to therapeutic communication include challenging, probing, changing the subject,

defensiveness, false reassurances, disagreeing, judgments, rejection and minimization, and
stereotyping.

Table 4. Non-therapeutic communication

Technique Description Example
Stereotyping Offering generalized and oversimplified “Women are complainers.”
beliefs about groups of people that are
based on experiences too limited to be “Most people don’t have any pain after
valid.
this type of surgery.”
Agreeing and Agreeing and disagreeing imply that the Client: “I don’t think Dr. B is a very good
disagreeing client is either right or wrong and that doctor. He doesn’t seem interested in
the nurse is in a position to judge this. his clients.”

Nurse: “Dr. B is head of the department

of surgery and is an excellent surgeon.”

Being defensive Attempting to protect a person or health Client: “Those night nurses must just sit
care services from negative comments. around and talk all night. They didn’t
answer my light for over an hour.”

Nurse: “I’ll have you know we literally

run around on nights. You’re not the
only client, you know.”

Challenging Giving a response that makes clients Client: “I felt nauseated after that red
prove their statement or point of view. pill.”

Nurse: “Surely you don’t think I gave

you the wrong pill?”

Probing Asking for information chiefly out of Client: “I didn’t ask the doctor when he
curiosity rather than with the intent to was here.”
assist the client.
Nurse: “Why didn’t you?”
Technique Description Example
Testing Asking questions that make the client “Do you think I am not busy?” (forces
admit to something. the client to admit that the nurse really
is busy)

Rejecting Refusing to discuss certain topics with

“Let’s discuss other areas of interest
the client. to you rather than the two problems
you keep mentioning.”
Changing topics Directing the communication into “I can’t talk now, I’m on my break.”
and subjects areas of self-interest rather than
considering the client’s concerns is “Oh I think its not going to do you any
often a self-protective response to a good, let’s talk about something
topic that causes anxiety.
instead.”

Passing judgment Giving opinions and approving or “That’s not good enough.”
disapproving responses, moralizing,
or implying one’s own values. “What you did was wrong (right).”

Giving common Telling the client what to do. Client: “Should I move from my home
advice to a nursing home?”

Nurse: “If I were you, I’d go to a

nursing home, where you’ll get your
meals cooked for you.”

Unwarranted Using clichés or comforting “I’m sure everything will turn out all
reassurance statements of advice as a means to right.”
reassure the client.
“Don’t worry.”

Special considerations related to Age, Cultural and Emotional Variables

1. Age
Always consider the developmental level of the client in reference to age since
vocabulary, grammar, intonation, and education play important and major roles and may also
come into conflict.

2. Cultural variables
Communication and culture are closely interconnected. Through communication, the
culture is transmitted from one generation to the next, and knowledge about the culture is
transmitted within the group and to those outside the group. Communicating effectively with
clients of various ethnic and cultural backgrounds is critical to providing culturally competent
nursing care. Cultural variations are seen in both verbal and nonverbal communication.

Verbal communication
Understand that although English is considered as the universal language, many
cultures do not first and foremost teach English as part of their educational program, thus
creating a barrier to effective communication. Utilize guidelines when speaking or interviewing
individuals who do not speak or have little understanding of the English language.

1. Always ask if the client (and significant other) needs assistance in translation.
Require an interpreter; address the question to the client, not the interpreter;
observe the body language that the client assumes when listening and talking to the
interpreter; be aware of common expressions that the client uses during the
interview or conversation; and avoid utilizing a family member (especially a child) to
interpret since a child might not be exposed to the proper concepts they are
developmentally ready for.
2. Avoid slang words, filler words, medical terminologies and abbreviations.
3. Augment spoken words with gestures or pictures.
4. Frequently validate the client’s understanding with what is being communicated.

Nonverbal communication
To communicate effectively with culturally diverse clients, the nurse needs to be aware
of two aspects of nonverbal communication behaviors: what nonverbal behaviors mean to the
client and what specific nonverbal behaviors mean in the client’s culture.

1. Eye movement during communication has cultural foundations.

2. Facial expression can also vary among cultures.
3. Body posture and hand gestures are also culturally learned.
4. Touching involves learned behaviors that can have both positive and negative
meanings.

3. Emotional variables

HOLISTIC NURSING ASSESSMENT

General Status

General Appearance
This part of the exam is often overlooked.  Be sure to note the manner of dressing, grooming, and
hygiene:  Abnormal:  sloppy clothes, body odor, dirty clothes, etc.

 Facial Appearance
Note facial expressions and appearance.  Abnormal:  depression and some other diseases can cause
an inappropriate facial expression.
 Posture
A normal reaction to hospitalization can make a person tense and unable to relax.  Do note if they are
too tense or too relaxed.

 Motor Assessment
Includes patient’s gait, speech, and general motor activity.  Speech and motor activity are the most
pertinent to our mental status examination.  Abnormal:  altered speech and motor activity can indicate
depression, organic disease or other functional disease.

 General Behavior
This is the: “First Impressions” category.  Is patient open to your questions?  Is the patient
cooperative?  Is the patient relaxed?  Abnormal:  belligerence, hostility, combativeness, would be
considered a sign of some type of disease process.

 Intellectual Functioning
Intellectual here means the higher brain functions of cognition which were mentioned earlier.  By the
higher brain functions, we mean that there must be some thought used, the brain must be used to its
fullest capacity; i.e. thought, integration of memory and the conscious mind.

 Orientation
Most nurses are familiar with this phase of brain function.  Orientation is measured in time, person,
place, and event. 

 Communications Skills
This category includes vocabulary used, information facts, spelling and reading. Assess these areas
only if needed.

 Abstract Reasoning
This area includes the ability of the person to be able to interpret abstract concepts. 

Abnormal
The disorder of not being able to think abstractly is called concrete thinking. 

 Attention Span
Clinically speaking, this category includes the ability to pay attention to the interviewer and to
concentrate on the subject of the interview. Abnormal: Patients with short attention span but
understands the lengthiness of the interview. Short attention span however, may be evident in children
with ADHD. 

 Memory
Most memory deficits will be apparent during the history-taking process.  First, test the patient for long-
term (remote) memory by asking birthdays, anniversary children’s birthdays, etc.  Test short-term
memory by asking recent events. 
Abnormal:  Of course, lack of memory is abnormal.  If the patient exhibits partial loss or transient loss
of memory, that is significant, and needs to be assessed carefully.  Also of great significance, is if the
patient makes up answers to your questions (confabulation).  When testing memory it is best to ask
questions which can be easily verified.  Recent memory can be assessed by asking the name of an
object or address

 Judgment
This area can also be assessed during the health survey.  Note if the patient has acted with good
judgment prior to admission to the hospital and if the patient can make decisions for himself or does he
ask constantly what another individual thinks is best for his care.  Do they continue to use good
judgment while in the hospital? 

 Mood and Affect

Assessment of mood is usually a simple task for most nurses.  There are physical signs that the patient
exhibits, that will give a clue to their mood.  Also do not forget that mood changes can be subtle and
can happen quite unexpectedly. 
.
Affect means assessing the patient’s mood and their behavior.  Affect means the “appropriateness” of
their mood and behavior. 

 Thought cohesiveness
If a person’s affect is inappropriate or grossly pathological, there is probably a thought process
disturbance.  Always remember that certain disorders are functional; but in any case, psychiatric
attention and treatment may be necessary.

Mental Status

Children and Adolescent

Infancy: 0-6 mos.

 Smiles back
 Rolls over
 Turns to sound
 Babbles
 Plays with objects

6-12 mos.
 Stranger anxiety
 Sits upright/walks
 Responds to name
 Object constancy
 Says 1-2 words

12-18 mos.
 Reciprocal play
 Eats with spoon
 Tolerates noises
 Jumps with 2 feet
 Says 4-6 words

18-24 mos.
 Words for feeling
 Balance on 1-foot
 Brushes teeth/hair
 2-3-word sentence
 Pretend play

24-36 mos.
 Toilet trained
 Throws ball
 Uses “I”
 Uses “big/little”

36-60 mos.
 Uses scissors
 Climbs a ladder
 Uses sentences
 Draws a line
 Symbolic play

6-7 years old:

 Rides a bike
 Jumps rope
 Keeps himself/herself busy
 Practices skills to become better
 Enjoys working with others
 Likes to copy adults
 Plays with friends of the same gender

8-9 years old:

 More fluid movement
 Dresses and grooms self
 Uses certain tools (hammer, spade)
 Can count backwards names months and days of the week in order
 Knows the date
 Likes to compete
 Becomes interested in boy-girl relationship

10-12 years old:

 Reads well
 Writes stories
 Social life blooms
 Respects parents
 Increased capacity for technology
 Mastery of basic math functions

Points to consider during the assessment:

Appearance: Dress, grooming, unusual physical characteristics

Behavior: Activity level, mannerisms, eye contact, manner of relating to parent/therapist, motor
behavior, aggression, impulsivity

Socio-Emotional/Mood/Affect: Shy, fearful, labile, sad, blunt, irritable, aggressive, passive, depressed,
anxious, risk to self or others State regulation

Cognitive: Attention span and play are age appropriate, problem-solving ability

Communication/Language: Verbal/nonverbal, receptive/expressive, age appropriate

Sensorimotor: Visual, auditory, tactile, vestibular, proprioceptive, taste, textures, smells (avoidant,
neutral, seeking)

Gross Motor Coordination: motor planning, muscle tone (low, floppy, tense), postural stability

Fine Motor Coordination: tremors, seizures

Adaptive Functioning: Age appropriate self-care, feeding, toileting

Strengths: Adaptive capacity, strengths & assets, cooperation

ADULTS

Assessment of the client’s mental status involves the following:

 Level of consciousness - Consciousness can be defined as a state of general awareness of
oneself and the environment; consciousness is the most sensitive indicator of neurologic
change.
 Behavior, body movements, and affect
 Facial expressions
 Pattern of speech
 Mood, feelings and expressions

Assessment of risk factors:

 Trauma
 Hemorrhage
 Tumors
 Infection
 Toxicity
 Hypertension
 Cigarette smoking
 Stress
 Aging process
 Hypoxic conditions
 Chemicals, either ingested or environmental

Glasgow Coma Scale – a method of assessing the mental status of patients

Glasgow Coma Scale

MOTOR RESPONSE POINTS Score
Obeys a simple response 6
Localizes painful stimuli 5
Normal flexion (withdrawal) 4
Abnormal flexion (decorticate posturing) 3
Extensor response (decerebrate posturing) 2
No motor response to pain 1
VERBAL RESPONSE POINTS Score
Oriented 5
Confused conversation 4
Inappropriate words 3
Responds with incomprehensible sounds 2
No verbal response 1
EYE OPENING POINTS Score
Spontaneous 4
In response to sound 3
In response to pain 2
No response, even to painful stimuli 1
Table 5. The Glasgow Coma Scale

Interpretation: The highest possible score is 15 points.

 Generally, brain injury is classified as:
 SEVERE, with GCS < 8-9
 MODERATE, GCS 8 or 9–12
 MINOR, GCS ≥ 13.
 Individual elements as well as the sum of the score are important. Hence, the score is
expressed in the form "GCS 9 = E2 V4 M3 at 07:35 A.M.". Generally when a patient is in a
decline of their GCS score, the nurse or medical staff should assess the cranial nerves and
determine which of the twelve have been affected.
 Other common terms are used to describe assessment of LOC (e.g. alert, drowsy, confused,
stuporous, comatose). It is important that the terms used are well defined and are used
consistently. You want a change in terminology to represent a change in the patient, not the
interpretation of the terminology. At change of shift, perform a neurologic exam with the
incoming nurse to ensure clear communication of the patient’s previous status.

Alert:
 awake, looks about
 responds in a meaningful manner to verbal instructions or gestures
Drowsy:
 oriented when awake but if left alone will sleep
Confused:
 disoriented to time, place, or person
 memory difficulty is common
 has difficulty with commands
 exhibits alteration in perception of stimuli, may be agitated  
Stuporous:
 generally unresponsive except to vigorous stimulation
 may make attempt at verbalization to vigorous/repeated stimuli
 opens eyes to deep pain
Comatose:
 unarousable and unresponsive
 some localization or movement may be acceptable within the comatose category depending on
the coma definitions e.g. light coma to deep coma
 does not open eyes to deep pain

The difference between Coma and Sleep:

 sleeping persons respond to unaccustomed stimuli
 sleeping persons can be roused to normal consciousness
 sleeping persons are capable of mental activity (dreams)
 cerebral oxygen uptake does not decrease during sleep as it often does in coma

Psychosocial, Moral and Cognitive Development

Moral development

Lawrence Kolhberg’s theory of moral development states that we progress through three levels
of moral thinking that build on our cognitive development.

Level 1: Preconventional
Throughout the preconventional level, a child’s sense of morality is externally controlled.
Children accept and believe the rules of authority figures, such as parents and teachers.  

 Stage 1:  Obedience and Punishment  Orientation

Stage 1 focuses on the child’s desire to obey rules and avoid being punished.

 Stage 2: Instrumental Orientation

Stage 2 expresses the “what’s in it for me?” position, in which right behavior is defined by
whatever the individual believes to be in their best interest. Stage two reasoning shows a limited
interest in the needs of others, only to the point where it might further the individual’s own
interests.

Level 2: Conventional
Throughout the conventional level, a child’s sense of morality is tied to personal and societal
relationships yet children continue to accept the rules of authority figures.
 Stage 3: Good Boy, Nice Girl Orientation
In stage 3, children want the approval of others and act in ways to avoid disapproval.

 Stage 4: Law-and-Order Orientation

In stage 4, the child blindly accepts rules and convention because of their importance in
maintaining a functioning society.

Level 3: Postconventional
Throughout the postconventional level, a person’s sense of morality is defined in terms of more
abstract principles and values. People now believe that some laws are unjust and should be changed
or eliminated. This level is marked by a growing realization that individuals are separate entities from
society and that individuals may disobey rules inconsistent with their own principles.

 Stage 5: Social-Contract Orientation

In stage 5, the world is viewed as holding different opinions, rights, and values. Such
perspectives should be mutually respected as unique to each person or community. Laws are
regarded as social contracts rather than rigid edicts.

 Stage 6: Universal-Ethical-Principal Orientation

In stage 6, moral reasoning is based on abstract reasoning using universal ethical
principles. Generally, the chosen principles are abstract rather than concrete and focus on ideas
such as equality, dignity, or respect. Laws are valid only insofar as they are grounded in justice,
and a commitment to justice carries with it an obligation to disobey unjust laws.

Cognitive development

Jean Piaget's theory of cognitive development suggests that children move through four
different stages of mental development. Piaget believed that children take an active role in the learning
process as they perform experiments, make observations, and learn about the world. As kids interact
with the world around them, they continually add new knowledge, build upon existing knowledge, and
adapt previously held ideas to accommodate new information. The stages are:

1. The Sensorimotor Stage

 Ages: Birth to 2 Years
 Major Characteristics and Developmental Changes:
 The infant knows the world through their movements and sensations
 Children learn about the world through basic actions such as sucking, grasping, looking, and
listening
 Infants learn that things continue to exist even though they cannot be seen
 They are separate beings from the people and objects around them
 They realize that their actions can cause things to happen in the world around them

2. The Preoperational Stage

 Ages: 2 to 7 Years
 Major Characteristics and Developmental Changes:
 Children begin to think symbolically and learn to use words and pictures to represent
objects.
 Children at this stage tend to be egocentric and struggle to see things from the perspective
of others.
 While they are getting better with language and thinking, they still tend to think about things
in very concrete terms.

3. The Concrete Operational Stage

 Ages: 7 to 11 Years
 Major Characteristics and Developmental Changes
 During this stage, children begin to thinking logically about concrete events
 They begin to understand the concept of conservation; that the amount of liquid in a short,
wide cup is equal to that in a tall, skinny glass, for example
 Their thinking becomes more logical and organized, but still very concrete
 Children begin using inductive logic, or reasoning from specific information to a general
principle

4. The Formal Operational Stage

 Ages: 12 and Up
 Major Characteristics and Developmental Changes:
 At this stage, the adolescent or young adult begins to think abstractly and reason about
hypothetical problems
 Abstract thought emerges
 Teens begin to think more about moral, philosophical, ethical, social, and political issues
that require theoretical and abstract reasoning
 Begin to use deductive logic, or reasoning from a general principle to specific information

PAIN
 Pain is “an unpleasant sensory and emotional experience associated with actual or potential
tissue damage or described in terms of such damage”

 The concept of TOTAL PAIN encompasses the multidimensional factors that contribute to the
patient’s experience of pain. It may include all of the following: Intellectual Pain, Emotional Pain,
Interpersonal Pain, Financial Pain, Spiritual Pain, Bureaucratic Pain, and Physical Pain.

Goal of Pain assessment

 to capture the individual’s pain experience in a standardized way
 to help determine type of pain and possible etiology
 to determine the effect and impact the pain experience has on the individual and their ability to
function.
 basis on which to develop treatment plan to manage pain
 to aid communication between interdisciplinary team members.
Classification of Pain

 Nociceptive pain is due to the stimulation of nerve fibers that transmit signals in a normal way
from nerve endings to brain centers.
 Somatic pain – pain originating from muscle, soft tissue or bone. It is usually well
localized and described as deep, aching, or dull. It may be worse with movement. Some
examples are bone metastases, osteoarthritis, and muscle/tissue damage as in burns.
 Visceral pain – pain originating from internal organs or viscera surrounding them. It is
usually less well localized and can be referred*. Often described as deep aching,
cramping, or squeezing. Some examples are bowel obstruction, brain tumor, and
appendicitis.

 Neuropathic pain is the abnormal sustained stimulation of the nerve fibers that transmit signals
from the nerve ending to brain center and/or from a dysfunction in the central nervous system.
 It can be dysesthetic pain – described as burning, electrical sensations or pins and
needles and/or
 lancinating pain – described as stabbing or shooting.
 Some examples are post-herpetic neuralgia, spinal cord compression, diabetic
neuropathy, plexopathies, phantom limb, or central pain from a stroke

SELF REPORTING should be the primary source of information when completing a pain
assessment. Trust the client’s assessment of pain. Lack of pain expression does not necessarily
mean absence of pain.

The exception for patient self-reporting is with non-verbal, non-cognizant persons (i.e. the
cognitively impaired). For these populations, behavioral observations that are validated by family
and caregivers are the primary source of information for a pain assessment. For the cognitively
impaired patient, use the ABBEY PAIN ASSESSMENT and/or a visual or faces pain scale instead
of verbal questions. Body language should also be observed: facial expressions, verbalizations,
behavior during activity, movements and gestures.

NOTE:
 When pain is identified in more than one site, an assessment is completed for each site.
 A COMPREHENSIVE PAIN ASSESSMENT should be re-done if there is a significant change in
the pain, any modification to the pain management plan, or if a new pain has been identified.
 Following analgesic administration, the assessment of pain severity on a scale of 0-10 using a
pain scale would be the minimum assessment to be completed to monitor analgesic
effectiveness in meeting patient’s goal.
 Pain assessments should be DOCUMENTED so that all members of the care team will have a
clear understanding of the pain. Location of documentation to be consistent within each care
site

Education
 Discuss the concept of pain prevention with the patient and family, in an effort to lessen the pain
experience before pain becomes difficult to manage.
 Teach patients and families to report changes in pain, pain that is new, and pain that does not
improve after intervention.
 Some patients, particularly the elderly, may underreport pain because they:
 Have not been taken seriously in the past
 fear being labeled a “complainer”
 want to appear stoic, an important characteristic in some cultures
 expect pain with aging, when in fact it is common but not a normal part of aging
 choose to avoid medications and side effects

 Education for patient and family should occur regarding these concerns to ensure they report
their pain in a trusting and caring environment.
 Include the patient and family in decision making to determine a care plan that values the
patient’s wishes, emphasizing the shared goals of care.

Figure 3. Pain Assessment Scale

VIOLENCE

Definition: any behavior that involves physical force that has the intent to hurt, damage, and even kill
an individual; "the intentional use of physical force or power, threatened or actual, against oneself,
another person, or against a group or community, that either results in or has a high likelihood of
resulting in injury, death, psychological harm, maldevelopment, or deprivation. (WHO, 2020)

NEGLECT is the absence of care necessary to maintain the health and safety of a vulnerable
individual such as a child or older adult. ABUSE is mistreatment of a person especially with cruelty in a
repeated manner. Nurses, in their many roles (e.g., home health nurse, pediatric nurse, emergency
department nurse), can often identify and assess cases of violence against others.

As a result, they are often considered MANDATED REPORTERS, meaning that they are
required, by law, to report suspected abuse, neglect, or exploitation. MANDATED REPORTING is
designed to detect cases of abuse and neglect at an early stage, protect children, and facilitate the
provision of services to children and families.

General Classification

1. Self-directed violence - refers to violence in which the perpetrator and the victim are the same
individual
2. Interpersonal violence - refers to violence between individuals, and is subdivided into family and
intimate partner violence and community violence.

3. Collective violence - refers to violence committed by larger groups of individuals

Types of Violence

1. Child violence (Child maltreatment, Child abuse and neglect) - Abuse and neglect are serious
problems that can have lasting harmful effects on children. Maltreatment can disrupt the
development of the brain as well as compromise the nervous and immune systems.

2. Intimate partner violence (Battered wife, Boy-Girlfriend) - Intimate partner violence occurs
between two people in a close relationship. Intimate partners may be current or former spouses
or dating partners. There are four main types of violence:  physical violence, sexual violence,
threats of physical and sexual violence, and emotional abuse.

3. Sexual violence (Sexual harassment / assault, Rape) - Sexual violence refers to sexual acts
that are forced against someone’s will. These acts can be physical, verbal, or emotional.

4. Suicide (Fatal and Nonfatal behavior) - Suicidal behavior exists along a continuum from thinking
about ending one’s life (“suicidal ideation”), to developing a plan, to non-fatal suicidal behavior
(“suicide attempt”), to ending one’s life (“suicide”).

5. Gang violence (Bullying, Peer violence) – gang violence has many connotations; as such they
may refer to a whole organization where leadership is of key importance and oftentimes
questionable; groups where intimidation and the commission of criminal acts are held to a high
degree; potential and prevalent use of power and authority within a group where members
agree on specific goals; and identification of a status in society.

Guidelines in assessing violence

1. Assess all clients comprehensively.

2. Talk to clients alone in a safe, private environment.
3. Ask simple and direct questions.
4. Take the client’s history.
5. Send important messages to clients.
6. Assess client safety.
7. Involve peers, colleagues, and staff involved.
8. Make referrals.
9. Document findings.
10. Mandatory reporting of violence.
Culture and Ethnicity

Nurses' practice must incorporate cultural needs and beliefs into their nursing practice to
provide care that is individualized for the client and appropriate to the client's needs. During the
assessment phase of the nursing process, the nurse assesses the client's and family member's cultural
background, preferences and needs, after which the nurse modifies the plan of care accordingly.

Data obtained from a cultural assessment will help the patient and nurse to formulate a mutually
acceptable, culturally responsive treatment plan. The first step in cultural assessment is to learn about
the meaning of the illness of the patient in terms of the patient’s unique culture.

Guidelines in cultural assessment

1. Awareness
One of the most important elements emphasized in pursuit of competent cultural care is
identifying your own beliefs and culture before caring for others. Self-awareness involves not only
examining one’s culture but also examining perceptions and assumptions about the client’s culture.
Developing this self-awareness can bring into view the caregiver’s biases or culturally-imposed
beliefs. It can also shed light on oppression, racism, discrimination, and stereotyping and how these
affect nurses personally and their work.

2. Acceptance
Acceptance becomes a powerful tool, but one that demands solidarity between nurse and
patient. How can patients love and accept themselves in ways that promote healing if we, as
nurses, are not willing to offer them acceptance in their myriad of problems and complexities?
Through the simple act of acceptance, nurses can become an agent of healing, whether or not they
are aware of it.

In other words, healing has meaningful implications that reach beyond the current medical
model’s definition as “the absence of disease.” As the patient is able to articulate meaningful events
of life and to be heard without judgment, he or she becomes more conscious or “awakened” to
patterns that have blocked health progress, and therefore able to choose transformational
behaviors, with the continuing support of the nurse.

3. Asking
There is no way nurses can be expected to be aware of and practice cultural sensitivity at all
times because most religions and cultures have been developed over centuries and are full with
practices that carry symbolic meaning. When in doubt, the best way to provide sensitive care to
patients of diverse cultures is to ask.

Questions a nurse might ask may be of the following nature:

a. Client’s interpretation of the illness

b. How the illness began or started
c. Treatment options
d. Client expectations
e. Fears, Anxiety, and other psychological factors
f. Health practices
g. Country of origin

Once assessment is done, CULTURAL NEGOTIATION can take place in terms of agreeing on
a treatment regimen that is acceptable to both patient and provider. It is imperative that a negotiation
take place in order to better cater to the client’s needs and desires. Cultural negotiation is finding ways
in which the client and the nurse explore possibilities of treatment, care, and achievement of desired
outcomes.

This cultural assessment and culturally oriented care enable the nurse to:

1. Identify ways with which the client's culture and its features impact on their perceptions, beliefs,
values, experiences with health, wellness, illness, suffering, and even death

2. Remain accepting, respectful and welcoming of human diversity

3. Facilitate more holistic assessments and plans of care as based on the client's culture

4. Deep and strengthen their commitment to nursing and their insight into the nursing profession
as based on culturally based nurse-patient relationships which emphasize the importance of the
whole person rather than viewing the patient as simply a set of symptoms or an illness

5. Integrate their full and in-depth cultural knowledge into the treatment of patients

6. Develop and integrate open mindedness into nursing care which can lead to some innovative,
non-traditional, alternative nursing interventions such as spiritually based therapies like
meditation and anointing.

Religious Practices

Briefly defined, RELIGION is an organized and formalized set of beliefs and practices that are
based on a god or a number of different gods; and SPIRITUALITY is defined as connectedness of the
individual with others, the environment, the universe, an unseen higher power which is not a god, and
connectedness within the self which is also referred to intrapersonal connectedness.

Religions have an established set of beliefs, practices, values and rituals. Many religions around
the globe are geographically centered, and because of this fact many religions may have cultural and
ethnical underpinnings.
Spirituality, on the other hand and quite contrary to popular opinion often does not have any
established set of beliefs, practices, values or rituals. Some of the concepts and practices like
meditation and connectedness are, at times, shared by some religious and spiritual people.

Religious practices may include rituals, sermons, commemoration or veneration (of deities),
sacrifices, festivals, feasts, trances, initiations, funerary services, matrimonial services, meditation,
prayer, music, art, dance, public service, or other aspects of human culture.

Religion and nursing practice - Adherence to the particular set of beliefs, values, and practices
that constitute their religion may be of great importance to clients and their families. It is therefore
essential that nurses should acquire at least a basic knowledge of the most common religions in order
to deliver holistic care that meets their patients' needs. Religious beliefs may have implications for diet,
dress, and medication, as well as procedures followed at birth and death.

Examples of religious practices are:

1. Roman Catholic
a. Recognizes the Pope in the Vatican
b. Rituals – The Seven Sacraments
c. Fasting before the Holy week / Lent
d. Fridays are traditionally regarded as fasting days
e. Abortion and artificial insemination are not accepted and regarded as morally evil
f. Euthanasia is morally wrong
g. Against suicide
h. Hear mass at least once a week
i. Receive the Eucharist before Communion
j. Comfort in priests in times of crisis
k. Natural methods of birth control
l. Does not support human experimentation especially the human embryo

2. Protestants
a. Sacraments – Baptism and Holy Communion
b. Fast on Fridays and Lent
c. Abortion is “acceptable” only when there is sufficient reason why it is to be performed
d. Does not support euthanasia
e. Against suicide

3. Jehovah’s witness
a. Refuse blood transfusions including autologous transfusions
b. Abortion is regarded as murder
c. Intravenous fluid treatment is unacceptable
d. Smoking, drinking alcohol are not acceptable
e. Not strictly vegetarian but will only eat meat occasionally
f. God’s intervention at the end of the world is imminent

4. Mormons
a. No clergy
b. Rejects infant baptism
c. Oppose abortion
d. Does not allow smoking, alcohol consumption, tea, coffee, and use of illicit drugs
e. Primarily vegetarian
f. Fast each month (on the first Sunday)
g. Sacred undergarments (some Mormons)

5. Islam
a. One God – Allah; prophet – Mohammed
b. Five pillars of Islam
c. Prohibits eating pork and its by-products
d. Alcohol is forbidden
e. Circumcision is not compulsory but is considered hygienic
f. Suicide and euthanasia is explicitly forbidden
g. Abortion is wrong, depending on just cause
h. Niqab – piece of clothing that women wear to cover the face
i. Does not allow touching an adult person of the opposite sex, except for the spouse
j. Women may refuse to be examined by a male member of the health team
k. Cremation is forbidden
l. Burial takes place within 24 hours of death

6. Judaism
a. Pork and shellfish are forbidden
b. All meat must be killed in an approved way – Shechita
c. Meat and milk must not be consumed at the same meal
d. Observes the Sabbath every week (sunset Friday to sunset Saturday)
e. Avoid touching when dealing with the opposite sex unless medically necessary
f. Women will keep their limbs and bodies completely covered
g. Circumcision is fundamental but not a requirement
h. Does not forbid abortion but does not allow it on demand
i. Forbids suicide and euthanasia
j. Allows organ donation
k. Dying clients should not be left alone; the client’s body ponce dead should be touched as
little as possible
l. Some do not permit post mortem unless required by law

7. Hinduism
a. Believes in reincarnation
b. Most are vegetarians and avoid dairy products
c. Onions, garlic and alcohol are avoided
d. The cow is considered sacred
e. Opposed to abortion except when necessary
f. Cleanliness and modesty are basic features
g. Organ donation and transplantation are left to the decision of the client (individual is not
coerced)
8. Buddhism
a. Does not adhere to gods and a strict sense of doctrines
b. Rejects abortion (unless it is a lesser evil)
c. Prohibits eating meat
d. Alcohol is avoided

9. Rastafarian
a. Adhere to dietary precautions as stated in the Old Testament
b. Some are strict vegetarians and avoid additives
c. Some may reject synthetic medications and accept only natural ones

10. INC – Church of Christ

a. No format when praying
b. Baptism means Dedication
c. Does not celebrate Christmas or fiesta; does not observe Holy week, All Saint’s
d. Worship separates men from the women
e. Does not approve cremation
f. Supports family planning and artificial contraception
g. Does not believe in superstition
h. Members do not preach
i. Believes in Judgment Day
j. Does not eat Dinuguan

Nutritional Status

Nutrition is the sum of all the interactions between an organism and the food it consumes. In other
words, nutrition is what a person eats and how the body uses it.

ESSENTIAL NUTRIENTS
The body’s most basic nutrient need is water. Because every cell requires a continuous supply
of fuel, the most important nutritional need, after water, is for nutrients that provide fuel, or energy.
Carbohydrates, fats (lipids), protein, and water are referred to as MACRONUTRIENTS, because they
are needed in large amounts (e.g., hundreds of grams) to provide energy. MICRONUTRIENTS are
those vitamins and minerals that are required in small amounts (e.g., milligrams or micrograms) to
metabolize the energy-providing nutrients

Macronutrients
Carbohydrates
Carbohydrates are composed of the elements carbon (C), hydrogen (H), and oxygen (O)
and are of two basic types: simple carbohydrates (sugars) and complex carbohydrates
(starches and fiber). Natural sources of carbohydrates also supply vital nutrients, such as
protein, vitamins, and minerals that are not found in processed foods. Processed carbohydrate
foods are relatively low in nutrients in relation to the large number of calories they contain. High
sugar-content (and solid fat) foods are referred to as “empty calories.” In addition, alcoholic
beverages contain significant amounts of carbohydrate, but very few nutrients and, thus, they
are also empty calories.

Proteins
Amino acids, organic molecules made up primarily of carbon, hydrogen, oxygen, and
nitrogen, combine to form proteins. Every cell in the body contains some protein, and about
three quarters of body solids are proteins.

Lipids
Lipids are organic substances that are greasy and insoluble in water but soluble in
alcohol or ether. Fats are lipids that are solid at room temperature; oils are lipids that are liquid
at room temperature. In common use, the terms fats and lipids are used interchangeably. Lipids
have the same elements (carbon, hydrogen, and oxygen) as carbohydrates, but they contain a
higher proportion of hydrogen.

Micronutrients
Vitamins
A vitamin is an organic compound that cannot be manufactured by the body and is
needed in small quantities to catalyze metabolic processes. Thus, when vitamins are lacking in
the diet, metabolic deficits result. Vitamins are generally classified as fat soluble or water
soluble. The body cannot store water-soluble vitamins; thus, people must get a daily supply in
the diet.
Fat-soluble vitamins include A, D, E, and K. The body can store these vitamins, although
there is a limit to the amounts of vitamins E and K the body can store. Therefore, a daily supply
of fat- soluble vitamins is not absolutely necessary.

Minerals
Minerals are found in organic compounds, as inorganic compounds, and as free ions.
Calcium and phosphorus make up 80% of all mineral elements in the body. The two categories
of minerals are macrominerals and microminerals.
Macrominerals are those that people require daily in amounts over 100 mg. They include
calcium, phosphorus, sodium, potassium, magnesium, chloride, and sulfur. Microminerals are
those that people require daily in amounts less than 100 mg. They include iron, zinc,
manganese, iodine, fluoride, copper, cobalt, chromium, and selenium.

Factors affecting Nutrition

1. Development - Different needs for individuals in the various stages of growth and development.
People in rapid periods of growth (i.e., infancy and adolescence) have increased needs for
nutrients.

2. Sex/Gender - Nutrient requirements are different for men and women because of body
composition and reproductive functions. The larger muscle mass of men translates into a
greater need for calories and proteins. Because of menstruation, women require more iron than
men do prior to menopause. Pregnant and lactating women have increased caloric and fluid
needs.
3. Ethnicity and Culture - Ethnicity often determines food preferences. Traditional foods are eaten
long after other customs are abandoned.

4. Personal preferences - People develop likes and dislikes based on associations with a typical
food. A child who loves to visit his grandparents may love home cooked meals because they
are served in the grandparents’ home while another child may prefer food from fast food chains.

5. Beliefs about food - Beliefs about effects of foods on health and well-being can affect food
choices. Many people acquire their beliefs about food from television, magazines, and other
media.

6. Lifestyle - Certain lifestyles are linked to food-related behaviors. People who are always in a
hurry probably buy convenience grocery items or eat restaurant meals. People who spend
many hours at home may take time to prepare more meals. Individual differences also influence
lifestyle patterns (e.g., cooking skills, concern about health). Some people work at different
times, such as evening or night shifts. They might need to adapt their eating habits to this and
also make changes in their medication schedules if they are related to food intake.

7. Religious practices - Religious practice also affects diet. Some Roman Catholics avoid meat on
certain days, and some Protestant faiths prohibit meat, tea, coffee, or alcohol. Both Orthodox
Judaism and Islam prohibit pork. Orthodox Jews observe kosher customs, eating certain foods
only if they are inspected by a rabbi and prepared according to dietary laws.

8. Medications - The effects of drugs on nutrition vary considerably. They may alter appetite,
disturb taste perception, or interfere with nutrient absorption or excretion. Nurses need to be
aware of the nutritional effects of specific drugs when evaluating a client for nutritional
problems.

9. Alcohol consumption - Excessive alcohol use contributes to nutritional deficiencies in several

ways. Alcohol may replace food in a person’s diet, and it can depress the appetite.

10. Health - An individual’s health status greatly affects eating habits and nutritional status. Missing
teeth, ill-fitting dentures, or a sore mouth makes chewing food difficult.

11. Advertising - Food producers try to persuade people to change from the product they currently
use to the brand of the producer. Popular actors are often used in television, radio, Internet, and
print to influence consumers’ choices. Advertising is thought to influence people’s food choices
and eating patterns to a certain extent.

12. Psychological factors - Although some people overeat when stressed, depressed, or lonely,
others eat very little under the same conditions. Anorexia and weight loss can indicate severe
stress or depression.