Foundations Outline: Functional Assessment

This is an outline of suggested information to study for Foundations of the Nursing Practice

The texts use to compose this outline are:

• Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of nursing: The art and science of nursing care (7th ed.). Philadelphia: Lippincott, Williams and Wilkins. (ISBN 978-0-7817-9383-4) 
• Hunt, R. (2013) Introduction to community-based nursing (5th ed.). Philadelphia: Lippincott, Williams and Wilkins. (ISBN 978-1-60913-686-4) 
• Smeltzer, S., Bare, B., et al. (2010). Brunner and Suddarth’s Textbook of medical-surgical nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins. (ISBN 978-1-4511-1483-6) 
• Kee, J., Hayes, E., & McCuistion, L. (2012). Pharmacology: A nursing process approach (7th ed.). St. Louis: Elsevier. (ISBN 978-1-4377-1711-2) 
• Lubkin, I.M., & Larsen, P. (2013). Chronic illness: Impact and intervention (8th ed). Sudbury, MA: Jones and Bartlett. (ISBN 978-1-4496-4905-0) 

I. Functional Assessment

A. Basic Concepts

Principles and patterns related to growth and development across the lifespan

• Havighurst's age periods and developmental tasks:
• (Taylor's, pg 1496, 363t, 367, 380, 387, 394, 398, 410, 418, 388)
• Developmental Theme
• Havighurst believed living and growing are based on learning and one must continually learn
• Described learning behaviors as developmental tasks
• Successful achievement of tasks leads to happiness, unsuccessful = unhappy
• Infancy to Childhood:
• achieving physiologic stability
• learning to eat solid foods
• learning to walk and talk
• simple concepts of reality
• learning to relate emotionally to others
• learning to control elimination of body waste
• learning to distinguish between right and wrong
• learning sex differences and sexual modesty
• Middle Childhood
• learning skills necessary for games
• learning to get along with age mates
• developing skills in reading, writing, and math
• developing conscience, morals, scale of values
• achieving personal independence
• Adolescence:
• accepting one's body
• achieving masculine or feminine gender role
• achieving emotional independence from parents and others
• preparing for a career
• preparing for marriage and family life
• achieving socially responsible behavior
• acquiring ethical system as guide for behavior
• Young Adulthood:
• selecting a mate
• learning to live with partner
• starting family/child rearing
• managing a home
• occupation
• civic responsibility
• finding social group
• Middle Adulthood:
• adjusting to physical changes
• maintaining occupation
• assisting children to become adults
• relating to one's spouse
• adjusting to aging parents
• achieving social and civic responsibility
• Later Maturity:
• adjusting to decreasing strength and health
• adjusting to retirement and reduced income
• adjusting to death of a spouse
• establishing explicit affiliation with one's age group
• establishing satisfactory living arrangements
• Psychosocial Development:
• Taylor's, 363-364
• Freud- emphasizes the effect of instinctual human drives on behavior. Identified the underlying stimulus for human behavior, the libido. 
• Four Major Components:
• unconscious mind (contains memories, motives, fears, not easy  recalled)
• id (self gratification by quickest easiest available means)
• ego (mediator of desires)
• superego (represents one's conscience)
• Five Stages of Freudian Development
• Anal Stage ( 8 months to 4 years)- toilet training is crucial
• Phallic Stage (3-7 years)- increased interest in gender differences and in his or her own gender
• Latency Stage (7-12 years)- increasing sex-role identification with aren't of same sex prepares child for adult roles in relationships
• Genital Stage (12-20 years)- sexual pressures and conflicts cause turmoil for the adolescent
• Erikson- based on Freud but expanded to include social and cultural influences. Believed development is made up of distinct stages, characterized by the achievement of goals that are affected by the social environment and significant others. (Taylor, pg 365)
• Four Major Concepts:
• stages of development
• developmental goals or tasks
• psychosocial crises
• process of coping
• Trust vs Mistrust (Infancy)- infants rely on caregivers to meet basic needs. Mistrust is result of inconsistent, inadequate, or unsafe care.
• Autonomy vs Shame and Doubt (Toddler)- motor and language skills develop. If caregivers are overprotective or have expectations that are too high, shame and doubt, along with feelings in inadequacy may develop
• Initiative vs Guilt (Preschool)- allows preschooler to take initiative in learning so the child seeks out new experiences and explores. If child experiences restrictions or reprimands, the child hesitates to attempt more challenging skills.
• Industry vs Inferiority (School Aged Children)- focuses on achievements, gains pleasure from finishing projects and receiving recognition. If child is not accepted by parents or peers, child develops feelings of inferiority and lack of self worth
• Identity vs Role Confusion (Adolescence)- hormonal changes, sex characteristics, mood swings. Rebellion is normal. Role confusion occurs when teen is unable to establish identity and sense of direction.
• Intimacy vs Isolation (Young Adulthood)- unity identity of self with identity of friends. Fear of commitments results in isolation and loneliness.
• Generativity vs Stagnation (Middle adulthood)- involvement with family, friends, and community. Concern for the next generation. Desire to make contribution to the world. If these tasks are not met, stagnation results, the person becomes self absorbed, and regresses to earlier levels of coping. 
• Ego Integrity vs Despair (Later Adulthood)- reminiscing about life events provides a sense of fulfillment and purpose. If one believes life has been a series or failures or missed directions, a sense of despair might prevail. Needs sense of accomplishment.
• Piaget (Taylor's, pg 364) Cognitive Developmental Theory- learning occurs as the result of the internal organization of an event, forming a mental schema (plan) and serving as a base for further schemata as one grows and develops.
• Sensorimotor Stage- Birth to 24 months. Marked by progression through a series of developmental stages:
• 0-1 month- basic reflexes, sucking
• 1-4 months- enjoyment and repetition of random behaviors; smiling, sucking thumb
• 4-8 months- relates own behavior to change in environment; shakes rattle to hear sounds, manipulates spoon to eat
• 8-12 months- coordinates more than one thought pattern at a time to reach a goal; only objects in sight are considered permanent
• 12-18 months- recognizes permanence of objects; can understand simple commands
• 18-24 months- begins to develop reasoning and can anticipate events
• Preoperational Stage-
• 2-7 years
• use of symbols through increased language skills and pictures
• divided into two stages
• pre conceptual stage- 2-4 years
• intuitive stage- 4-7 years
• play activities help child understand life events and relationships
• Concrete Operational Stage, 7-11 years
• learn by manipulating concrete or tangible items
• can classify objects according to two or more characteristics
• logical thinking is developed
• gain ability to incorporate other's perspectives
• Formal Operational Stage, 11 years or older
• abstract thinking 
• deductive reasoning
• general concepts are related to specific situations and alternatives are considered
• the world is evaluated by testing beliefs in an attempt to establish values an demeaning in life
• Kholberg, Moral Development (Taylor, pg. 369)
• theory of moral development, closely follows pIAGET
• a person's moral development is influenced by cultural effects of one's perceptions of justice in interpersonal relationships
• moral development is result of child and caregivers communications during early childhood as child is trying to please parents
• morality emerges as subset of beliefs or values and governs choices made throughout life
• rules made by society are challenged and evaluated as a person either accepts social rules or rejects them
• Three Levels
• Preconventional: based on external control, perception of good and bad develops, the thought of receiving an award overcomes fear of punishment, so actions that satisfy this desire are selected
• Conventional Level: identifying with significant other and conforming to their expectations. Respects values and ideas of friends and family, regardless of consequences. Behavior follows social or religious rules. Kohlberg believed many adults to be at this stage.
• Postconventional Level: moral judgement that is rational and internalized into one's standards or values. Correct behavior is defined in terms of society's laws. Concern for equality for all human beings. Guided by personal values or standards regardless of this set by society.
• Gilligan, Moral Development
• represented conception of morality from female view point
• Females are developing a morality or response and care
• Males are developing morality of justice
• Males associate morality with obligations, rights and justice
• Women associate morality with meeting the needs of others
• Three levels:
• Level 1, Selfishness- focuses on ones own needs. woman might isolate herself to avoid getting hurt. transitions to responsibility to care for oneself with desire to care for others
• Level 2, Goodness, societal values adopted, acceptance by others is critical, ability to protect and care for others is defying characteristic of female goodness, woman questions asks if her own needs are important, transitions from goodness to truth
• Level 3, Nonviolence- reconciliation of selfishness and responsibility, nonviolence governs all judgements and actions, care becomes obligation toward self and others, moral problems are usually considered within the context of maintaining relationships and promoting welfare or preventing harm of others.
• Fowler, Spiritual Development (Taylor's, pg. 370)
• Six Stages:
• Prestage- Undifferentiated Faith
• Stage1, Intuitive Projective Faith
• Stage 2, Mythical Literal Faith
• Stage 3, Synthetic Conventional Faith
• Stage 4, Individuative Reflective Faith
• Stage 5, Conjunctive Faith
• Stage 6, Universalizing Faith
• Patterns and Health Problems across the Lifespan
• Infants: (Taylor's, pg. 381)
• Accidental Injuries:
• obstructed airway
• choking risk
• five downward thrusts between shoulders
• if ineffective, five downwards thrusts to lower third of sternum
• if still ineffective, give rescue breaths
• Suffocation:
• occurs most commonly during cosleeping
• Infant Colic:
• uncontrollable, extended crying, in an otherwise healthy and well fed baby
• generally occurs during first three months
• has been referred to as the "100 Day Syndrome"
• infant cries loudly and draws legs up to abdomen
• despite symptoms, infants gains weight
• exact cause not known, suspicions are:
• immature digestive sytstem
• swallowing excess air
• feeding too rapidly
• improper feeding techniques
• allergies could lead to spasmodic contractions of the intestines
• immature nervous system causing baby to tense up when stimulated 
• Failure to Thrive:
• condition of inadequate growth
• resulting from infants inability to obtain or use calories for growth
• infants with FTT have signs of malnutrition and delayed development
• Causes and contributing factors:
• physiologic causes
• inadequate funds to buy food
• use of fad diet
• inedequate nutritional knowledge
• insufficient breast milk
• disturbances in maternal-child attachment
• Sudden Infant Death Syndrome
• sudden death of infant under 1 year of age
• unexpected in light of infants history
• postmortem exam fails to reveal cause of death
• leading cause of death in infants 1 month to 1 year with most deaths occurring between 2 and 4 moths
• exact cause unknown
• believed to be associated with neurologic regulation of cardiac and respiratory control
• african american infants are at greater risk
• healthy infants up to age 6 months should sleep on their backs on a firm surface in a safety approved crib
• other risk factors include:
• smoke exposure
• overheating
• soft bedding or stuffed toys
• Preschoolers 
• Communicable Diseases:
• communicable diseases and respiratory tract infections are common
• increased interaction with other children at daycare and nursery school
• Dental Carries become common if teeth are neglected
• Speech Disorders might become apparent
• School Aged Children
• Communicable diseases
• Scabies- parasitic skin disorder caused by infestation of sarcoptes scabiei (itch mite). Endimic among school children and institutionalized populations as a result of close personal contact. The female mite burrows into the epidermis, lays eggs, and dies in the burrow after 4 to 5 weeks. The eggs hatch in 3-5 days and larvae mature and complete their life cycle. Infectious period: the entire course of the infestation. Topical application of scabicide such as premethren (Elimite) kills the mites. Elimite is applied to cool, dry skin at least 30 minutes after bathing. Massaged thouroughy and gently into all skin surfaces from head to soles of feet. Frequent hand washing important. Clothing, bedding, pillowcases should be changed daily, washed and dryer on hot, for 1 week. Nonwashable toys should be sealed in bags for at least four days.
• Impetigo- Contagious bacterial infection of skin by beta-hemolytic streptococci or staphylococci, or both. Occurs during hot humid months. Can occur because of poor hygiene, can be primary or secondary infection as from a bite or preexisting rash such as atopic dermatitis or poison ivy or poison oak. Most common sites are face and around mouth, then down neck, hands, and extremities. Leisions begin as vesicles or pustules surrounded by edema and redness. Lesions progress to an exudative and crusting stage. After crusting, the visicular fluid becomes cloudy and the vesicles rupture, leaving honey colored crusts covering ulcerated bases.  Contact isolation. Allow lesions to air dry. Topical antibiotic ointments. Oral antibiotics if topical are ineffective. Child needs separate towels, linens, and dishes. Assessment includes:
• lesions
• erythema
• pruritis
• burning
• secondary lymphnode involvement
• head lice
• Obesity
• ADHD
• Learning Disabilities
• Enuresis (bed wetting)- benign self-limiting disorder, usually ending between 6 and 8 years
• Scoliosis- occurs most often in girls between 10 and 13
• Adolescent
• Motor Vehicle Accidents
• most common cause of mortality 
• Substance Abuse
• marijuana, alcohol, prescription drugs, inhaling vapors
• Suicide
• more prevalent in adolescents than any other age group
• third leading cause of death (second is homocides)
• depression possible factor
• verbal or nonverbal indicators of suicide should not be ignored
• immediate referral should be made to professional trained in suicide intervention
• Pregnancy
• mother are poor
• do not complete high school
• hush risk for complications
• Nutritional Problems
• fad dieting
• anorexia
• bulimia
• fast food and busy lifestyle leads to increased caloric intake
• males account 15% of persons with anorexia or bulimia
• overweight children likely to be overweight adults
• STI's
• causes:
• lack of knowledge
• lack of psychosocial maturity
• embarrassment
• denial of need to plan ahead and use condoms
• Chlamydia is most common

Factors influencing growth, development, functional ability, and health promotion or problems:

• Genetic factors:
• Temperment:
•  primarily inborn but can be influenced by environment
• babies are usually easy, slow to warm, or difficult
• Sex:
• men can procreate even late in life while women cannot conceive after menopause
• Age:
• preschool and school aged children need more cognitive guidance to function
• risk for falls is higher with younger children and older adults
• hip fracture is most disabling injury
• Individual preferences and patterns:
• older adults may prefer to live alone
• Physical condition:
• sleep wake patterns change with age
• impact of lack of physical activity
• sensory perception becomes less acute
• drug distribution, metabolism, and excretion change with aging
• SPICES tool: helps to identify older adults at risk for negative outcomes (Taylor, pg 424)
• S- sleep disorder
• P- problems with eating or feeding
• I- incontinence
• C- confusion
• E- evidence of falls
• S- skin breakdown

Nursing Process

• Assessment: gather and organize data
• Obtain health history: ADL's, sleep wake patterns, dietary patterns, smoking, alcohol/sustance abuse, immunization history, domestic abuse
• Assess factors affecting health status: risk behaviors, health promotion activities, physical activity level, sexual behaviors, cognitive development
• Obtain objective data:
• Barthel Index Score:
• used to measure performance in basic ADL's
• uses 10 variables describing ADL's and mobility
• feeding
• moving from wheelchair to bed and returning
• personal Hygiene (wash face, comb hair, shave, clean teeth)
• getting on and off toilet
• ascend and descend stairs
• dressing
• controlling bowels
• controlling bladder
• a higher score (0-100) is associated with a greater likelihood of being able to live at home with a degree of independence following discharge from the hospital
• still widely used although modified
• Denver Developmental Screening Test:
• commonly known as Denver Scale
• test for screening cognitive and behavioral problems in preschoolers
• scale reflects what percent of a certain age can perform a certain task
• tasks are grouped into 4 categories:
• social contact
• fine motor skill
• language
• gross motor skill
• Includes:
• smiles spontaneously
• knocks two building blocks together
• speaks three words other than mom or dad
• hops on one leg
• most widely used tool for screening developmental problems in children
• Assesment of Spiritual Wellbeing
• designed to establish a way to provide a nursing diagnosis of spirituality
• 21 point scale
• APGAR
• ACTIVITY, muscle tone
• PULSE, heart rate
• GRIMACE, reflex irritability
• APPEARANCE, skin color
• RESPIRATIONS

• Review labs and other diagnostic data:
• cholesterol levels
• lipid profile measures serum cholesterol, triglyceride, and lipoprotein levels
• desired range for serum cholesterol is less than 200mg/dL
• LDL less than 130mg/dL
• HDL at 30 to 70 mg/dL (protects against coronary artery disease)
• Lipoprotein-a increases artherosclerotic plaques and increases clots
• oral contraceptives may increase lipid level
• instruct client to avoid high cholesterol meals with evening meal prior to test
• vision and hearing screenings
• Presbycusis-sensorineural hearing loss associated with aging. Leads to degeneration or atrophy of ganglion cells in the cochlea and  a loss of elasticity of basilar membranes. Leads to compromise of vascular supply to the inner ear, with changes in ear structure
• height and weight
• blood pressure
• cancer screenings
• Analysis: collaborate with patient and other members of the healthcare team, identify actual or potential problems, develop nursing diagnosis
• Identify nursing diagnosis
• Prioritize needs using Maslow's hierarchy of needs
• physiological
• safety and security
• love and belonging
• self esteem
• self actualization
• develop a plan of care

Child Abuse

• Interventions
• support child through physical assessment
• assess injuries
• if shaken baby syndrome is suspected, monitor for decrease in consciousness or increased ICP
• report suspected abuse; nurses are legally required to report all cases of suspected child abuse to the appropriate local or state agency
• place child in safe environment
• document in an objective manner
• assess parents (coping mechanisms, support systems)
• assist family in identifying stressors
• refer to appropriate support groups

Elder Abuse

• Interventions:
• assess for physical injuries
• ensure victim is removed from threatening environment
• adhere to mandatory abuse reporting laws
• notify caseworker
• document