Tuesday, 19 August 2014

Bell’s Palsy


  • Bell’s palsy (facial paralysis) is due to peripheral involvement of the seventh cranial nerve on one side, which results in weakness or paralysis of the facial muscles.
  • The cause is unknown, but possible causes may include vascular ischemia, viral disease (herpes simplex, herpes zoster), autoimmune disease, or a combination.
  • Bell’s palsy may represent a type of pressure paralysis in which ischemic necrosis of the facial nerve causes a distortion of the face, increased lacrimation (tearing), and painful sensations in the face, behind the ear, and in the eye.
  • The patient may experience speech difficulties and may be unable to eat on the affected side owing to weakness.
  • Most patients recover completely, and Bell’s palsy rarely recurs.

Medical Management

  • The objectives of management are to maintain facial muscle tone and to prevent or minimize denervation.
  • Corticosteroid therapy (prednisone) may be initiated to reduce inflammation and edema, which reduces vascular compression and permits restoration of blood circulation to the nerve.
  • Early administration of corticosteroids appears to diminish severity, relieve pain, and minimize denervation.
  • Facial pain is controlled with analgesic agents or heat applied to the involved side of the face.
  • Additional modalities may include electrical stimulation applied to the face to prevent muscle atrophy, or surgical exploration of the facial nerve.
  • Surgery may be performed if a tumor is suspected, for surgical decompression of the facial nerve, and for surgical rehabilitation of a paralyzed face.

Nursing Management

Patients need reassurance that a stroke has not occurred and that spontaneous recovery occurs within 3 to 5 weeks in most patients. Teaching patients with Bell’s palsy to care for themselves at home is an important nursing priority.
Teaching Eye Care
Because the eye usually does not close completely, the blink reflex is diminished, so the eye is vulnerable to injury from dust and foreign particles. Corneal irritation and ulceration may occur. Distortion of the lower lid alters the proper drainage of tears. Key teaching points include the following:
  • Cover the eye with a protective shield at night.
  • Apply eye ointment to keep eyelids closed during sleep.
  • Close the paralyzed eyelid manually before going to sleep.
  • Wear wraparound sunglasses or goggles to decrease normal evaporation from the eye.
Teaching About Maintaining Muscle Tone
  • Show patient how to perform facial massage with gentle
  • upward motion several times daily when the patient can tolerate the massage.
  • Demonstrate facial exercises, such as wrinkling the forehead,
  • blowing out the cheeks, and whistling, in an effort to prevent muscle atrophy.
  • Instruct patient to avoid exposing the face to cold and drafts

Barium Swallow (Esophagography)


Barium swallow
, also known as esophagography, is the radiographic or fluoroscopic examination of the pharynx and the fluoroscopic examination of the esophagus after ingestion of thick and thin mixtures of barium sulfate.
This test, is commonly performed as part of the upper GI series, is indicated for patients with history of dysphagia and regurgitation. Further testing is usually required for a definitive diagnosis.
After the barium is swallowed, it pours over the base of the tongue into the pharynx. A peristaltic wave propels it through the entire length of the esophagus in about 2 seconds. When the peristaltic wave reaches the base of the esophagus, the cardiac sphincter opens, allowing the barium to enter the stomach. After passage of the barium, the cardiac sphincter closes. Normally, it evenly fills and distends the lumen of the pharynx and esophagus, and the mucosa appears smooth and regular.

  • To diagnose hiatal hernia, diverticula, and varices.
  • To detect strictures, ulcers, tumors, polyps, and motility disorders.

Patient Preparation
  1. Explain to the patient that this test evaluates the function of the pharynx and esophagus.
  2. Instruct the patient to fast after midnight before the test.
  3. If the patient is infant, delay the feeding to ensure complete digestion of the barium.
  4. Explain that the test takes approximately 30 minutes.
  5. Describe the milkshake consistency and chalky taste of the barium preparation the patient will ingest; although it’s flavored, it may be unpleasant to swallow.
  6. Tell him he’ll first receive a thick mixture and then a thin one and that he must drink 12 to 14 oz (355 to 414 ml) during the examination.
  7. Inform him that he’ll be placed in various positions on a tilting radiograph table and that radiographs will be taken.
  8. If gastric reflux is suspected, withhold antacids, histamine-2 (H2) blockers, and proton pump inhibitors, as ordered.
  9. Just before the procedure, instruct the patient to put a hospital gown without snap closures and to remove jewelry, dentures, hairpins, and other radiopaque objects from the radiograph field.
  10. Check the patient history for contraindications to the barium swallow, such as intestinal obstruction and pregnancy. Radiation may have teratogenic effects.
  1. The patient is placed in an upright position behind the fluoroscopic screen, and his heart, lungs, and abdomen are examined.
  2. The patient is instructed to take one swallow of the thick barium mixture; pharyngeal action is recorded using cineradiography.
  3. The patient is instructed to take several swallows of the thin barium mixture. Passage of the barium is examined fluoroscopically; spot films of the esophageal region are taken from lateral angles and from the right and left posteroanterior angles.
  4. To accentuate small strictures or demonstrate dysphagia, the patient may be asked to swallow a “barium marshmallow” (soft white bread soaked in barium) or a barium pill.
  5. The patient is then secured to the X-ray table and rotated to trendelenburg position to evaluate esophageal peristalsis or demonstrate hiatal hernia and gastric reflux.
  6. The patient is instructed to take several swallows of barium while the esophagus is examined fluoroscopically; spot films are taken.
  7. After the table is rotated to a horizontal position, the patient takes several swallows of the barium so that the esophageal junction and peristalsis may be evaluated.
  8. Passage of the barium is fluoroscopically observed and the spot films are taken with the patient in the supine and prone position.
  9. During fluoroscopic examination of the esophagus, the stomach and the duodenum are also carefully studied because neoplasms in these areas may invade the esophagus and cause obstruction.
Nursing Interventions for Barium Swallow
  1. Check the additional films and fluoroscopic evaluations haven’t been ordered before allowing the patient to resume his usual diet.
  2. Instruct the patient to drink plenty of fluids, unless contraindicated, to help eliminate the barium.
  3. Give cathartic as prescribed.
  4. Tell the patient to notify the physician if he fails to expel the barium in 2 to 3 days.
  5. Inform the patient that stools will be chalky and light colored for 24 to 72 hours.

Normal Results
  • The swallowed barium bolus pours over the base of the tongue into the pharynx.
  • A peristaltic wave reaches the base of the esophagus, the cardiac sphincter opens, allowing the bolus to enter the stomach. After the passage of the bolus, the cardiac sphincter closes.
  • The bolus evenly fills and distends the lumen of the pharynx and esophagus, and the mucosa appears smooth and regular.
Abnormal Results
  • Barium swallow may reveal hiatal hernia, diverticula, and varices.
  • Strictures, tumors, polyps, ulcers, and motility disorders, such as pharyngeal muscular disorders, esophageal spasms, and achalasia (cardiospasm) may be detected.

  • Barium retained in the intestine may harden, causing obstruction or fecal impaction.
  • Abdominal distention and absent bowel sounds, which may indicate constipation and may suggest barium impaction.

Bulimia Nervosa

  • The Diet-Binge-Purge Disorder”.
  • Is a disorder characterized by alternating dieting, binging and purging through vomiting, enema, and laxatives.
  • The person engages in episodes of starvation and other methods of controlling weight (diet pills, excessive exercise, enemas, diuretics, laxatives), then engages in uncontrolled and rapid eating for about two hours (over 8000 calories in 2 hours and 50,000 in 1 day) then terminates binging by inducing self to vomit, going to sleep or going to social activities.
  • Weight fluctuations are due to alternating fasting and binging.
    1. Bulimia means insatiable appetite. 
    2. Binging means eating an unusually large amount of food over a short period of time. 
    3. Purging is an attempt to compensate for calories consumed via self-induced vomiting or abuse of laxatives, diuretics, or enemas.
  • A chronic disorder that usually manifest first during late adolescence and early adulthood, around the ages 15-24 years. It almost always occurs after a period ofdieting.
  • The bulimic often belong to a family and society that place great value on external appearance. The person strives to be thin to be accepted because they believe self-worth requires being thin.
  • Usually of normal weight or obese, extrovert, reports self loathing, low self-esteem, has symptoms of depression, of fear of losing control, with self-destructive tendencies such as suicide.
  • These individuals are known to be perfectionist, achievers scholastically and professionally and highly dependent on the approval of others to maintain self-esteem. They hide their disorder because of fear of rejection.
  • Like anorexia, bulimia can kill. Even though bulimics put up a brave front, they are often depressed, lonely, ashamed, and empty inside. Friends may describe them as competent and fun to be with, but underneath, when they hide their guilty secrets, they are hurting. Feeling unworthy, they suffered from great difficulty talking about their feelings, which almost always include anxiety, depression, self-doubt, and deeply buried anger. Impulse control may be a problem like shoplifting, sexual adventurousness, alcohol and drug abuse, and other kinds of risk taking behavior in which the person acts with little consideration of consequences.
  • The person is aware that the behavior is abnormal, but is unable to stop because she is immobilized by her fear that she cannot stop her behavior voluntarily. The binge episode usually ends when the person becomes exhausted eating, develops GIT discomfort, runs out of food or is noticed by others.
  • After the episode she becomes guilty and depressed that she was unable to control herself, and engages in self-critism. Then she purges her self as a form of cleansing and punishment.

Common Complications Related to the Manner of Purging
  • Chronic inflammation of the lining of the esophagus due to induced vomiting, acidic gastric secretions irritates esophageal mucosa.
  • Rupture of esophagus and stomach.
  • Electrolyte imbalance causing cardiac arrythmias, hypokalemia due to diarrhea,hypochloremia due to vomiting, hyponatremia due to vomiting and diarrhea.
  • Dehydration.
  • Enlargement of the parotid gland.
  • Irritable bowel syndrome.
  • Rectal prolapse or abscess.
  • Dental erosion.
  • Chronic edema.
  • Fungal infection of vagina and rectum.

Nursing Diagnosis
  • Alterations in health maintenance.
  • Altered nutrition: Less than body requirements.
  • Altered nutrition: More than body requirements
  • Anxiety
  • Body image disturbance
  • Ineffective family coping; compromised
  • Ineffective individual coping
  • Self-esteem disturbance

Nursing Interventions
  1. Patient with bulimia are aware of their problems and they want to be helped because they feel helpless and unable to control themselves during episodes of binging. But because of their intense desire to please and need to conform they may resort to manipulative behavior and tell half-truths during interview to gain trust and acceptance of nurses. Create an atmosphere of trust. Accept person as worthwhile individual. If they know that no rejection or punishment is forthcoming they disclose their problem, they will be more open and honest.
  2. Develop strength to cope with problems. Encourage patient to discuss positive qualities about themselves to increase self-esteem.
  3. Help patient identify feelings and situations associated with or that triggers binge eating.
    • Assist to explore alternative and positive ways of coping.
    • Encourage making a journal of incident and feelings before-during and after a binge episode.
    • Make a contract with the patient to approach the nurse when they feel the urge to binge so that feelings and alternative ways of coping can be explored.
  4. Encourage adhering to meal and snack schedule of hospital. This decreases the incidence of binging, which is often precipitated by starvation and fasting.
  5. Encourage participating in group activities with other persons having the same eating disorder to gain additional support.
  6. For young adolescent living at home, encourage family therapy to correct dysfunctional family patterns.
  7. Cognitive behavioral therapy is the ideal therapy to help the bulimic understand the problem and explore appropriate behaviors.

Bipolar Disorder


A mood disorder, formerly known as manic depression is characterized by recurrent episodes of depression and mania. Either phase may be predominant at any given time or elements of both phases may be present simultaneously.

Risk Factors
  1. Biochemical imbalances
  2. Family genetics – one parent, child has 25% risk; two parents, 50-75% risk.
  3. Environmental factors such as stress, losses, poverty, social isolation.
  4. Psychological influences – inadequate coping, denial of disordered behavior.

Specific Biological Factors
  1. Possible excess of norepinephrine, serotonin, and dopamine.
  2. Increased intracellular sodium and calcium
  3. Neurotransmitters supersensitive to transmission of impulses
  4. Defective feedback mechanism in limbic system.

Signs and Symptoms
  1. Risk for self or others
  2. Impaired social interactions
  3. Mania
    • Persistent elevated or irritable mood
    • Poor judgment
    • Increase in talking and activities, grandiose view of self and abilities.
    • Impulsivity such as spending money, giving away money or possessions.
    • Impairment in social and occupational functioning
    • Decreased sleep
    • Distractibility
    • Delusions, paranoia, and hallucinations
    • Dislike of interference or intolerance of criticism
    • Denial of illness
    • Agitation
    • Attention seeking behavior
    • Depression

Nursing Diagnoses
  1. High risk for violence, directed at self or others
  2. Impaired verbal communication
  3. Anxiety
  4. Individual coping, ineffective
  5. Disturbance of self-esteem
  6. Alteration in though processes
  7. Alteration in sensory perceptions
  8. Self-care deficits
  9. Sleep pattern disturbances
  10. Alteration in nutrition

Therapeutic Nursing Management
  1. Environment
  2. Psychological treatment
    • Individual Psychotherapy – may be used to identify stressors and pattern of behavior.
    • Group therapy – establishes a supportive environment and redirect inappropriate behavior.
    • Family therapy – verbalizes family frustration and establishes a treatment plan for outpatient use.
  3. Somatic and Psychopharmacologic treatments
    • electroconvulsive therapy
    • Psychopharmacology

Nursing Interventions
  1. Assess client’s suicidal feelings and intentions and escalating behavior regularly.
  2. Set consistent limits on inappropriate behavior to help the client de-escalate.
  3. Establish a calm environment for the client.
  4. Reinforce and focus on reality.
  5. Provide outlets for physical activity but prevent client for escalating.
  6. Client may be very likable during “high periods”. Staff members need to avoid participating in this behavior, at other times, client may be very irritable and staff members should approach client quietly and with limits, if necessary.
  7. If the client cannot control self and other methods are not successful, staff may need to provide client protection if a threat of a self-harm or injury to other exist.
  8. Monitor client’s nutrition, fluid intake and sleep.
  9. Discuss with the client and family the possible environment or situational causes, contributing factors and triggers for a mood disorder with recurrent episodes of depression and mania.

Assist Patient from the Bed to Chair or Wheelchair

I. Purpose
  1. To strengthen the patient gradually.
  2. To provide a change in position. (In wheelchair to take her around for a change)

II. Equipment
  • Chair or wheelchair
  • Patient’s robe and slippers
  • Pillows
  • Blanket, sheet or draw sheet

III. Procedure
  1. See that the chair or wheelchair is in good condition.
  2. Place the chair conveniently at night angles to the bed—back of chair parallel to the foot of the bed and facing the head of bed.
  3. Place pillow on the seat of the chair. If using wheelchair, line it with a blanket or sheet and arrange pillows on the seat and against the back. Put the foot rest up and lock the wheels.
  4. Take the patient’s pulse
  5. Assist the patient to a sitting position on bed, i.e., put one arm under the head and shoulders and the other arm under her knees and pivot her to a sitting position with the legs hanging over the side of the bed.
  6. Watch the patient for a minute to defect any change in his color, pulse and respiratory rate.
  7. Put on patient’s robe and slippers. Place the foot stool under the patient’s feet.
  8. Stand directly in front of the patient and with a hand under each axilla, assist him to stand, step down and turn around, with his back to the chair. Let patient flex his knees and lower body to seat him to the chair. Anchor chair with foot or have someone hold it on. (Or let patient place his arm over your shoulders while you put your arm around his waist. Turn patient around with his back to the chair and seat him gently). Help him get comfortable in the chair.
  9. Adjust the pillows and wrap blanket over patient’s lap. If in a wheelchair adjust the foot rests.
  10. Observe frequently for changes in color and pulse rate, dizziness or sign of fatigue.
  11. To put him back to bed, assist to stand, help to turn and stand on stool and back to bed. Support patient while he sits on the side of bed. Remove robe and slippers. Pivot to a sitting position in bed, supporting her head and shoulders with one arm and her knees with the other arm, and lower slowly to bed in lying position.
  12. Draw up bedding. Take pulse after.

Assessment- Objective & Subjective Data

Review of clinical record
  1. Client records contain information collected by many members of the healthcare team, such as demographics, past medical history, diagnostic test results and consultations
  2. Reviewing the client’s record before beginning an assessment prevents the nurse from repeating questions that the client has already been asked and identifies information that needs clarification.

  1. The purpose of an interview is to gather and provide information, identify problems of concerns, and provide teaching and support.
  2. The goals of an interview are to develop a rapport with the client and to collect data
  3. An interview has 3 major stages:
      1. Opening: purpose is to establish rapport by creating goodwill and trust; this is often achieved through a self – introduction, nonverbal gestures (a handshake), and small talk about the weather, local sports team, or recent current event; the purpose of the interview is also explained to the client at this time.
      2. Body: during this phase, the client responds to open and closed-ended questions asked by the nurse.
      3. Closing: either the client or the nurse may terminate the interview, it is important fro the nurse to try to maintain the rapport and trust that was developed thus far during the interview process.
  4. Types of questions
    1. Closed questions used in directive interview
      • Re____ short factual answers; e.g. “Do you have pain?”
      • Answers usually reveal limited amounts of information
      • Useful with clients who are highly stressed and/or have difficulty communicating
    2. Open-ended questions used in nondirective interview
      • Encourage clients to express and clarify their thoughts and feelings; e.g. “How have you been sleeping lately?’
      • Specify the broad area to be discussed and invite longer answers
      • Useful at the start of an interview or to change the subject
    3. Leading questions
      • Direct the client’s answer; e.g. “You don’t have any questions about your medications, do you?”
      • Suggests what answer is expected
      • Can result in client giving inaccurate data to please the nurse
      • Can limit client choice of topic for discussion

Nursing History
  1. Collection of information about the effect of the client’s illness on daily functioning and ability to cope with the stressor (the human response)
  2. Subjective data
    • May be called “covert data”
    • Not measurable or observable
    • Obtained from client (primary source), significant others, or health professionals (secondary sources).
    • For example, the client states, “I have a headache”
    • Objective data
    • May be called “overt data”
    • Can be detected by someone other than the client
    • Includes measurable and observable client behavior
    • For example, a blood pressure reading of 190/110 mmHg.

Physical assessment
  1. Systematic collection of information about the body systems through the use of observation, inspection, auscultation, palpation and percussion
  2. A body system format for physical assessment is found below:
    • General assessement
    • Integumentary system
    • Head, ears, eyes, nose, throat
    • Breast and axillae
    • Thorax and lungs
    • Cardiovascular system
    • Nervous system
    • Abdomen and gastrointestinal system
    • Anus and rectum
    • Genitourinary system
    • Reproductive system
    • Musculoskeletal system

Psychosocial assessment
  1. Helpful framework for organizing data
  2. A suggested format for psychosocial assessment is found below:
    • Vocation/education/financial
    • Home and Family
    • Social, leisure, spiritual and cultural
    • Sexual
    • Activities of daily living
    • Health Habits
    • Psychological
  3. The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also be helpful for guiding data collection

  1. The nurse collects data from multiple sources: primary (client) and secondary (family members, support persons, healthcare professionals and records)
  2. Consultation with individuals who can contribute to the client’s database is helpful in achieving the most complete and accurate information about a client
  3. Supplemental information from secondary sources (any source other then the client) can help verify information, provide information for a client who cannot do so, and convey information about the client’s status prior to admission

Review of literature
  1. A professional nurse engages in continued education to maintain knowledge of current information related to health care
  2. Reviewing professional journals and textbooks can help provide additional data to support or help analyze the client database

Assessment - First Step in the Nursing Process

  • It is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm. 
  • It includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles. 


To establish a data base (all the information about the client):
  • nursing health history 
  • physical assessment 
  • the physician’s history & physical examination 
  • results of laboratory & diagnostic tests material from other health personnel

FOUR Types of Assessment
  1. Initial assessment – assessment performed within a specified time on admission 
    • Ex: nursing admission assessment 
  2. Problem-focused assessment – use to determine status of a specific problem identified in an earlier assessment 
    • Ex: problem on urination-assess on fluid intake & urine output hourly 
  3. Emergency assessment – rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems. 
    • Ex: assessment of a client’s airway, breathing status & circulation after a cardiac arrest. 
  4. Time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the client’s current status to baseline data previously obtained.

  1. Collection of data 
  2. Validation of data 
  3. Organization of data 
  4. Analyzing of data 
  5. Recording/documentation of data

  • Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of medical record

Collection of data 
  • gathering of information about the client 
  • includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status 
  • includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods) 
  • includes current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now) 
Types of Data 
  1. Subjective data 
    • also referred to as Symptom/Covert data 
    • Information from the client’s point of view or are described by the person experiencing it. 
    • Information supplied by family members, significant others; other health professionals are considered subjective data. 
    • Example: pain, dizziness, ringing of ears/Tinnitus 
  2. Objective data 
    • also referred to as Sign/Overt data 
    • Those that can be detected observed or measured/tested using accepted standard or norm. 
    • Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin 
Methods of Data Collection 
  1. Interview 
    • A planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling. 
    • it is used while taking the nursing history of a client 
  2. Observation 
    • Use to gather data by using the 5 senses and instruments. 
  3. Examination 
    • Systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results. 
    • should be conducted systematically: 
      1. Cephalocaudal approach – head-to-toe assessment 
      2. Body System approach – examine all the body system 
      3. Review of System approach – examine only particular area affected 
Source of data 
  1. Primary source – data directly gathered from the client using interview and physical examination. 
  2. Secondary source – data gathered from client’s family members, significant others, client’s medical records/chart, other members of health team, and related care literature/journals. 
    • In the Assessment Phase, obtain a Nursing Health History - a structured interview designed to collect specific data and to obtain a detailed health record of a client. 
Components of a Nursing Health History: 
    • Biographic data – name, address, age, sex, martial status, occupation, religion. 
    • Reason for visit/Chief complaint – primary reason why client seek consultation or hospitalization. 
    • History of present Illness – includes: usual health status, chronological story, family history, disability assessment. 
    • Past Health History – includes all previous immunizations, experiences with illness. 
    • Family History – reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness). 
    • Review of systems – review of all health problems by body systems 
    • Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily living, recreation or hobbies. 
    • Social data – include family relationships, ethnic and educational background, economic status, home and neighborhood conditions. 
    • Psychological data – information about the client’s emotional state. 
    • Pattern of health care – includes all health care resources: hospitals, clinics, health centers, family doctors. 

Validation of Data 
  • The act of “double-checking” or verifying data to confirm that it is accurate and complete. 
Purposes of data validation 
  1. ensure that data collection is complete 
  2. ensure that objective and subjective data agree 
  3. obtain additional data that may have been overlooked 
  4. avoid jumping to conclusion 
  5. differentiate cues and inferences 
  • Subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure. 
  • The nurse interpretation or conclusion based on the cues. 
  • Example: 
    • Red swollen wound = infected wound
    • Dry skin = dehydrated 

Organization of Data 

Uses a written or computerized format that organizes assessment data systematically.
  1. Maslow’s basic needs 
  2. Body System Model 
  3. Gordon’s Functional Health Patterns: 
Gordon’s Functional Health Patterns 
  1. Health perception-health management pattern. 
  2. Nutritional-metabolic pattern 
  3. Elimination pattern 
  4. Activity-exercise pattern 
  5. Sleep-rest pattern 
  6. Cognitive-perceptual pattern 
  7. Self-perception-concept pattern 
  8. Role-relationship pattern 
  9. Sexuality-reproductive pattern 
  10. Coping-stress tolerance pattern 
  11. Value-belief pattern 

Analyze data 
  • Compare data against standard and identify significant cues. Standard/norm are generally accepted measurements, model, pattern: 
    • Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic values, normal growth and development pattern 

Communicate/Record/Document Data 
  • nurse records all data collected about the client’s health status 
  • data are recorded in a factual manner not as interpreted by the nurse 
  • Record subjective data in client’s word; restating in other words what client says might change its original meaning.