Health & Health Promotion

VII.
Health & Health Promotion

A. Definitions
1. Health
a. Traditional Western model: "freedom from disease"
b. World Health Organization (1958): a "state of complete physical,

mental and social wellbeing and not merely the absence of
disease and infirmity"
2. Wellness: a multidimensional state of being; functioning at maximum

potential, regardless of state of health
3. Health promotion behavior: behavior in which the client views health

as a goal and engages in behaviors designed to achieve or maintain
that goal
4. Health care: includes prevention, early detection, treatment and

rehabilitation for clients with potential for or existing illness or disability
5. Health belief model

a. Psychological and behavioral theory
b. Attempts to explain individual health behaviors
c. Health behaviors are based on three factors

i. the individual's perception of susceptibility of illness
ii. the individual's perception of seriousness of the illness
iii. the likelihood that the person will take preventive action
d. Modifying factors
i. cultural beliefs
ii. economics
iii. political factors
iv. social factors
v. personal beliefs
B. Healthy People 2020

1. The US Department of Health and Human Services originally released
Healthy People in 1990
2. Statement of national health objectives designed to identify the most

significant preventable threats to health and to establish national goals to
reduce these threats
3. The goals of the project

a. increase quality and years of healthy life
b. eliminate health disparities
C. The Patient Protection and Affordable Care Act (Public Law 111-148) - also
known as "Obamacare" (2010):
1. Provides for quality and affordable health care for all Americans
2. 10 titles or sections, including the following provisions:

a. Title II: expands Medicaid coverage
b. Title III: closes the gap in prescription drug coverage in Medicare (Part
D)
c. Title IV: establishes the National Prevention, Health Promotion, and

Public Health Council - for supporting preventative health care
d. Title VIII: establishes the Community Living Assistance Services and

Supports (CLASS Act) - for support for people with disabilities
D. Health promotion model

1. Developed by Nola Pender (1982; revised 1996)
2. Health promotion depends on seven factors of cognition-perception

a. importance of health to the person
b. perceived control of health
c. perceived self-efficacy
d. definition of health
e. perceived health status
f. perceived health benefits from the health-promoting behavior
g. perceived barriers to the health-promoting behavior
E. Disease prevention behaviors: behaviors designed to decrease the

likelihood/risk of illness
1. Primary care
a. health promotion and disease prevention
b. applied to clients considered physically and emotionally healthy
c. example: exercise programs, healthy diet
2. Secondary care
a. early detection of illness
b. focuses on individuals who are experiencing health problems and

illnesses and who are at risk for complications
c. activities are directed at diagnosis and prompt treatment
d. example: breast self examination, cholesterol screening
3. Tertiary care
a. prevention of further deterioration in disease or disability
b. occurs when a defect or disability is permanent and irreversible
c. activities are directed at rehabilitation
d. example: alcoholics anonymous
F. Health screening risk appraisal

1. Used to analyze all that is known about a person's entire life situation,
including personal and family medical history, occupation, and social
environment in order to estimate his or her risk of disability or death as
compared with the national averages
2. Can prevent or minimize illness and disability

1. Primary - Prevent
2. Secondary - Screen
3. Tertiary -
Treat
G. Risk factors - probability of acquiring a particular health problem

1. Varies with age, race, ethnicity, gender
2. Risk increases with certain lifestyle choices, such as smoking, occupation, diet,
environment
3. Modifiable risk factors include such things as occupation, work stress, and diet
4. Non-modifiable risk factors include race, age and gender
5. Examples: risk factors are important in

a. coronary artery disease
i. history of smoking
ii. history of high cholesterol
iii. genetic predisposition
iv. obesity
b. cancer (general)
i. high consumption of caffeine
ii. genetic predisposition
iii. environmental exposure to carcinogens
c. colon cancer
i. over 50 years of age
ii. family history of colon polyps or cancer
iii. urban living
iv. diet high in fats and low in fiber
d. tuberculosis
i. history of exposure to someone with tuberculosis (TB)
ii. history of travel or living outside United States
iii. history of prison time
iv. HIV infection
v. cancer chemotherapy
vi. malnutrition
vii. homelessness
viii. history of intravenous drug use
ix. medical workers
e. diabetes: candidates for screening

i. strong family history of diabetes mellitus
ii. markedly obese
iii. obstetrical history of babies weighing over nine pounds at birth
iv. obstetrical history of miscarriage or fetal death
v. pregnant women between 24 to 28 weeks gestation
vi. history of gestational diabetes
H. Risky behaviors - behaviors that impact the health of individuals

1. adolescence (12 to 19 years)
a. eating disorders
i. anorexia nervosa - restrictive eating
ii. bulimia nervosa - binge eating followed by purging
b. injury prevention
i. wearing of seat belts
ii. wearing of helmets
iii. sports injuries
iv. homicide and suicide
c. substance abuse
i. tobacco
ii. underage drinking
iii. illicit drug use
d. sexual behavior
i. number of sex partners
ii. use of contraception
iii. unintended pregnancy
iv. exposure to sexually transmitted infections - use of condoms
2. young adult (post-adolescence through age 40)

a. eating disorders - onset of obesity
b. injury prevention
i. motor vehicle accidents
ii. occupational hazards
iii. homicide and suicide
c. substance abuse
i. tobacco
ii. alcohol use
d. sexual behavior
i. sexually transmitted disease - use of condoms
ii. unintended pregnancy
e. stress
i. changing roles
marriage
beginning a new family
starting a new job
ii. depression
3. middle adult (40 to 65 years)
a. obesity
b. lack of exercise
c. substance abuse
i. tobacco
ii. alcoholism
d. lack of preventative health care
e. stress
i. job
ii. family / divorce
iii. acceptance of aging
4. older adult (age 65 and older)

a. obesity
b. lack of exercise
c. substance abuse
i. tobacco
ii. alcoholism
d. injury prevention
i. falls
ii. seat belts
iii. suicide
iv. multiple medications
I. Screening recommendations for the average American, including the following

1. For everyone
a. Cholesterol - baseline at age 20; every 5 years if normal
b. Blood pressure screening ( measuring blood pressure )
c. Colonoscopy (visualization of the entire colon) - once every 10 years after turning 50
(unless there is a family history)
d. Guaiac test for occult blood every year after the age of 50
e. Tuberculosis skin test (intradermal injection of antigen), followed by chest x-ray if

positive results
f. Diabetes - fasting plasma glucose (ideally 8 to 12 hours fasting)
g. Vision - regular check-ups
h. Dental - regular check-ups and cleanings should be performed every six months
i. Hearing - recommended every 10 years; every 3 years after age 50
j. Well child care - birth to age 6
k. Physical exam - every 1 to 5 years depending on risk factors and health concerns
l. Scoliosis screening - onset of adolescence
m. Immunizations
i. (non-childhood) - tetanus booster (every 10 years), influenza, pneumococcal and
Zostavax (for shingles) vaccines
ii. childhood immunizations - see link below for up-to-date information
2. Women
a. mammography
b. clinical breast exam
c. monthly breast self exam
d. Papanicolaou test (or Pap smear) - beginning at age 21
3. Men
a. prostate-specific antigen (PSA) test - routine screening no longer recommended
b. digital rectal exam
c. testicular self-exam - starting at age 15
Health Promotion & Health Screening

The following programs and health screenings are currently recommended and/or mandated as part of
a healthy person's regular health assessment in the U.S.
Everyone
Dental exam
regular visits will help to identify any tooth or gum problems before they progress
should begin within six months of a child's first tooth and no later than the first birthday
regular check-ups and cleanings should be performed every six months
Hearing test
ear problems can be signs of health, development or communication issues
electrophysiologic test: used to measure newborn's hearing ability based on electrical information
from the auditory nervous system
pure tone audiometry: used for children aged 4 years and older
specific candidates for screening includes: perinatal infection (rubella, herpes, cytomegalovirus),
chronic ear infections, Down syndrome, low birth weight infants, family history of hearing
impairment
mandated by school districts or a state's education or health department
recommended every 10 years; every 3 years after age 50
Vision test
regular examinations can prevent many leading causes of blindness and can help correct poor
vision
the American Optometric Association suggests that
children under the age of 3 years-old should be screened during regular pediatric appointments
school-age children have their vision check every two years
adults up to age 40 should be checked every 2 to 3 years
adults after age 40 should have their vision checked every other year or more frequently if they
have diabetes or hypertension
basic vision testing typically includes
visual acuity: tested using the Snellen eye chart, using either letter of the alphabet or the letter "E"
for younger children
glaucoma screening
mandated by school districts or a state's education or health department
Blood pressure test
according to the American Heart Association, men and women aged 18 and older should be
screened for high blood pressure at least once every two years (unless there is a family history of
cardiovascular disease)
screening for children and adolescents is also recommended but an optimal interval has yet to be
determined
recommended screening method
auscultatory method with a properly calibrated sphygmomanometer and correctly fitting cuff
person should be seated quietly in a chair for at least five minutes with feet on the floor and arms
supported at heart level
at least two measurements are taken, two minutes apart
be aware of "white coat hypertension"
prehypertensive individuals (systolic pressure 120 to 139 mm Hg and diastolic pressure 80 to 89
mm Hg) should be counseled on lifestyle modifications such as weight reduction, exercise, diet, and
smoking cessation
systolic pressure greater than 140 mm Hg and/or diastolic greater than 90 mm Hg should be
referred to a health care provider for possible antihypertensive drug therapy
Cholesterol test: baseline at age 20; every 5 years if normal
Well-child care
well-child care (birth to age 6 years) includes routine care, comprehensive health promotion and
disease prevention exams; vision and hearing screenings; hight, weight, and head circumference;
routine immunizations; and developmental and behavioral appraisal in accordance with
the American Academy of Pediatrics (AAP) and the Centers for Disease Control and
Prevention (CDC) guidelines
scoliosis screening
early detection and intervention is important because untreated scoliosis can lead to
disfigurement, impaired mobility, and cardiopulmonary complications
recommendations vary but generally performed at onset of adolescence
screenings (typically in 6th grade) are mandated by school districts or a state's education or
health department
Physical exam
every 1 to 5 years depending on risk factors and health concerns
rectal exam: annually over age 40
stool check for blood (Stool Occult Blood): annually
Skin cancer screening & self-exam
the American Cancer Society encourages periodic self-examinations by visually inspecting any
new, misshapen or discolored moles or lesions
regular screenings are included in a routine physical exam
Colonoscopy
screening used to check for cancer or precancerous growths in the colon or rectum
the average person should have a colonoscopy once every 10 years after turning 50 (unless there
is a family history of colon cancer)
Immunizations (non-childhood)
tetanus immunization booster: every 10 years
influenza vaccine: annually
pneumococcal vaccine: at age 65 (or all persons aged 19 to 64 years with chronic or
immunosuppressive medical conditions, e.g., asthma)
Men
Testicular self-exam
testicular cancer is the most common type of cancer in men between the ages of 15 and 24 and is
highly curable when caught early
men should visually inspect and palpate the skin on the scrotum and testicles in front of a mirror,
following a warm bath or shower
Digital rectal exam
the most direct way for a health care provider to screen for prostate and colorectal cancer
men age 50 and older (or earlier for those at high risk for cancer) may benefit from an annual digital
rectal exam as part of the routine physical exam
Prostate-specific antigen (PSA) test
this blood test measures the amount of PSA in a man's blood
as men age, PSA levels naturally rise
elevated PSA levels means there is an enlarged prostate, which may be an indicator of prostate
cancer
typically combined with the digital rectal exam
formerly an annual screening for all men over 50 was recommended; routine screening is no longer
recommended unless a risk exists
Women
Pap smear
detects the earliest signs of cervical cancer by checking for any changes in the cells of the cervix
the American College of Obstetricians and Gynecologists (ACOG) recommends that women should
have their first Pap test three years after first having sex, but no later than age 21
the test should be performed yearly until the age of 30
women ages 30 to 65 should have the test every 2 to 3 years after 3 consecutive normal Pap
smears
women 70 years and older can stop having Pap smears after 3 consecutive normal Pap smears
without any abnormal Pap smears in the last 10 years
Clinical breast exam
helps health care providers discover breast cancer in its early stages
women in the 20s and 30s should have a clinical breast exam as part of the regular, routine
physical, at least every 3 years
women ages 40 and older should have yearly clinical breast exams
Mammogram
used to detect and diagnose breast cancer
the American Cancer Society recommends that "women age 40 and older should have a screening
mammogram every year and should continue to do so for as long as they are in good health"
Self breast exam
monthly breast exams should be performed to detect any changes in their breasts and underarm
areas
should be performed throughout one's life, beginning in the 20s
should be done at the same time each month (preferably 7 days after onset of the menstrual cycle,
when the breasts are less tender)
it should be emphasized that self-exams are not a substitute for mammography or regular exams
conducted by a health care professional
Bone density test
used for screening for osteoporosis, the test uses bones that are more likely to break due to
osteoporosis, e.g. hip and lower spine
most popular bone density test is dual energy x-ray absorptiometry (DEXA)
a baseline bone density test should be done at age 50 or at a time coinciding with menopause
Measuring Blood Pressure

Proper procedure
Positioning client
typically the client is sitting, resting his/her arm on a table so the brachial artery is level with the
heart
the health care provider may order measurements in the supine, sitting, and standing positions
(Note: a decrease in standing systolic blood pressure greater than 10 mm Hg is associated with
dizziness, fainting, systolic hypertension, diabetes, individuals taking diuretics or some psychotropic
drugs)
Use of an appropriately-sized cuff (see table below) - cuff should encircle at least 80% of the arm
cuff too small: can lead to false readings of elevated blood pressure
cuff too large: may lead to falsely low readings
cuff wrapped too loosely: produces a false high reading
Cuff should be inflated to 30 mm Hg above palpated systolic blood pressure
inaccurate inflation level produces a false low systolic reading
Cuff should be deflated at a rate of 2 to 3 mm Hg/second
deflating cuff too slowly produces false high diastolic reading
deflating cuff too quickly produces a false low systolic and false high diastolic reading
Typically the first and the last sounds are recorded, but there are actually five distinct phases of
sounds (Korotkoff sounds)
Korotkoff sounds: five phases of sounds heard through the stethoscope
Phase 1
when the cuff pressure equals the systolic pressure
a sharp tapping sound
Phase 2
a swishing sound (caused by the arterial blood flow)
if the cuff is deflated too slowly, the sounds vanish temporarily

Phase 3 resumption of crisp tapping sounds
resumption of crisp tapping sounds
Phase 4
an abrupt muffling of sound
some practitioners record this point as the diastolic pressure
Phase 5
silence
blood flow has returned to normal and is now laminar
Blood pressure should be measured

Before the client takes any morning dose of any antihypertensive
No less than one hour after exercising, smoking, or consuming caffeine
After allowing about 10 minutes to adjust to the temperature of the examining room
Common errors made when measuring upper extremity blood pressure
Lack of observer training
incorrect cuff size selection
incorrect client position
rapid cuff deflation
inadequate pre-measurement rest
monitor not kept at eye level
observer bias
Equipment misuse
Effect of the office setting
"White Coat Hypertension"
masked hypertension
Measuring peripheral blood pressure in the legs
Use the popliteal artery behind knee as a stethoscope auscultatory site
Position the client prone or sitting with knees slightly flexed
Use wide, long cuff; wrap it so that the bladder is over the posterior aspect of midthigh
Systolic blood pressures in legs are 20-40 mmHg higher than in the brachial artery
Diastolic pressure in the legs is about the same as in the brachial artery
Choosing the proper cuff size
Arm Circumference
Cuff Type
Cuff size
22 to 26 centimeters
"small adult" cuff
12 x 22 centimeters
"adult" cuff
16 x 30 centimeters
"large adult" cuff
16 x 36 centimeters
"adult thigh" cuff
16 x 42 centimeters
CANCER SCREENING RECOMMENDATIONS

The information presented in the table is an overview of the recommended cancer screening tests
based on gender and age for asymptomatic individuals who are at average risk.
Cancer Screening
Name of Test
Gender Age
Recommendations
Breast Cancer
Breast self-
female
Monthly
examination
20 years and
older
(BSE) &
clinical breast
exam (CBE)
Every 3 years
40-44 years -
Cancer Screening
Name of Test
Gender Age
Mammography
Recommendations
option to start
annual breast
cancer
screening with
Annually
mammograms;
45-54 years
Every 2 years
55 years and
older
Colorectal Cancer and
Colonoscopy
Polyps
male &
50 years and
female
older
Flexible
Every 10 years
Every 5 years
sigmoidoscopy
50 years and
older
Guaiac-based
Yearly tests
fecal occult
Cervical cancer
blood test
50 years and
(gFOBT)
older
Papanicolaou
(Pap) test and
female
21; 21-29
Every 3 years
years
pelvic exam
Every 5 years
Age 30-65,
Pap test plus
with 3 normal
HPV test
consecutive
Pap test
results
Age 65 and
older (if all
previous tests
No testing
Cancer Screening
Name of Test
Gender Age
Recommendations
were normal)
Endometrial (uterine) cancer
Endometrial
female
tissue sample
At menopause
Annually, if
for both
indicated
average and
high risk
women
Prostate cancer
Digital rectal
male
Starting at age
Routine screening
exam &
50 years,
no longer
prostate-
discuss with
recommended
specific
HCP
antigen (PSA)
blood test
General
Cancer check-
male &
Age 20 years
up
female
and older -
Annually/periodic
periodic health
exams to
screen for
cancers of the
thyroid, oral
cavity, skin,
lymph nodes,
testes, and
ovaries
American Cancer Society, 2015
J. Compliance
1. Definition: adherence to primary or secondary prevention
recommendations
2. Factors influencing compliance
Cancer Screening
Name of Test
Gender Age
Recommendations
a. personal meaning and perceptions: knowledge, values,

beliefs, outcome expectations
b. social factors: environmental context, social

relationships, social support, societal norms, economic
resources
c. deficiencies in the health care system: access, costs,

wait time, monolingual services
K. Noncompliance
1. An individual's informed decision not to adhere to a
therapeutic recommendation
2. Individual unable or unwilling to alter habitual behaviors or

adopt new behaviors necessary to a prescribed
therapeutic regimen
VIII. Health Assessment

A. Health assessment overview
1. Purpose
a. data collection
b. supplement, confirm or refute historical data
c. identify changes in client's status
Cancer Screening
Name of Test
Gender Age
Recommendations
d. evaluate the outcomes of care
2. Types: comprehensive, problem-centered, follow-up, emergency
3. Components of health assessment: history and physical

Therapeutic and adverse effects may be potentiated by complementary and alternative therapies
(CAT), including ginseng, sage, nightshade, celery, coriander, and saw palmetto extract. Additionally,
alcohol and OTC medications (especially NSAIDs) affect drug actions and potentiate adverse effects.
Be sure to specifically ask your clients if they are using any alternative or complementary therapies.
4. History
a. present health/history of present illness
i. onset
ii. location of symptoms (or pain)
iii. quality of discomfort
iv. precipitating or aggravating factors
v. duration of symptoms
vi. associated findings
b. general health status (as perceived by client)
c. medical and surgical history - events, treatment and outcomes, allergies, immunization status
d. family history and risk factors (including lifestyle, genetics)
e. social history
f. occupation
g. activity level - leisure activities and exercise regimen
h. sleep pattern
i. nutrition
j. medications; including substance use/abuse, tobacco use, prescription and over-the-counter,

vitamins
k. complementary and alternative therapies (CAT)
l. psychosocial factors and support systems
5. Physical exam
a. recommended equipment
b. client positions
i. Fowler's - anterior, posterior for breath sounds
ii. supine and dorsal recumbent (for abdominal assessment)
c. ensure privacy
d. assess general appearance and behaviors
i. gender and race
ii. age
iii. obvious signs of distress
iv. body type
v. posture
vi. gait
vii. body movements
viii. hygiene
ix. dress
x. affect and mood
xi. speech
e. measure vital signs

i. pulse: rate, rhythm, force or strength
ii. respiration: rate, rhythm, quality
iii. body temperature

oral range: 97.5 - 99.5 F (36.4 - 37.5 C)
measure core temperature: rectal, tympanic, esophageal, temporal artery, gastrointestinal
radio pill, urinary bladder
measure surface temperature: skin, axilla, or mouth
body temperature normally varies with age, exercise, hormone levels, circadian rhythm
(time of day), stress, the environment
f. measure height and weight

height-for-age reference charts
measuring height with client standing or lying down; proxy measurements such as arm span
may also be used
Equipment Needed for the Physical Exam

The following items are typically used when conducting a physical examination. Be sure to have all the
equipment organized and within easy reach.
Platform scale with height attachment
Skinfold calipers
Sphygomomanometer
Stethoscope with bell and diaphragm endpieces
Thermometer
Flashlight or penlight
Otoscope/opthalmoscope
Tuning fork
Nasal speculum (if short, broad speculum not included with otoscope)
Tongue depressor
(Skin-marking) pen
Flexible tape measure and ruler (marked in centimeters)
Reflex hammer
Sharp object, e.g., sterile needle
Cotton balls
Bivalve vaginal speculum
Clean gloves
Lubricant
Fecal occult blood test materials
Gown and drapes for client
Eye chart
6. Physical exam skills

a. inspection
i. process of observing the differences between normal physical signs and deviations
ii. requires knowledge of normal physical findings throughout the lifespan
iii. principles of Inspection

use good lighting and with whole body part visible
observe each area for size, shape, color, and position
compare body parts bilaterally for symmetry
b. palpation
use touch to assess resistance, resilience, roughness, texture and mobility
palpation may be either light or deep in pressure
use light palpation to determine tenderness
deep palpation usually depresses the area by 1 to 2 inches; use it to examine specific organs
use palmar surface of fingers to determine position, texture, size, consistency, and pulsation;
also presence and shape of mass
use back of hand or inner aspect of the wrist to test temperature
use palm of hand to sense vibration
c. percussion
tap the body with fingertips: to detect fluid, or to assess location, size, density (air, fluid, solid)
and borders of organs.
tapping the body produces vibration and sound waves which you hear as percussion tones
methods
direct: striking the body surface with two fingers
indirect: striking the middle finger of the non-dominant hand on the back surface with the
fingers of the dominant hand rather than the body surface, while keeping the palm and
remaining fingers off the body
character of percussion sounds depends on the density of the tissue being percussed
d. auscultation
i. listening (with unassisted ear or stethoscope) to sounds made by the body
ii. stethoscope
bell - low pitched sounds
diaphragm - high pitched sounds
iii. assess presence of sounds and their character

frequency (high or low pitch)
loudness (loud or soft)
quality (blowing, gurgling, booming, thud-like, hollow, flat)
duration (short, moderate, long)
e. olfaction: use of sense of smell to differentiate common body odors from abnormal ones
Character of Percussion Sounds

Term
Character or Description of Sound
Dullness
Thud-like sound of soft intensity

High pitched
Moderate duration
Usually heard over solid organs (such as heart, liver)
Flatness
Flat sound of soft intensity

High pitched
Short duration
Usually heard over muscle
Term
Hyperresonance
Booming sound of very loud intensity

Very low pitch
Long duration
Usually heard in the presence of trapped air (such as emphysematous
lung)
Resonance
Hollow sound of moderate to loud intensity

Low pitched, long duration
Usually heard over lungs
Tympany
Drum-like, loud
High-pitched
Moderate duration
Usually found over spaces containing air such as the stomach
B. Eye
1. History
a. current findings, including
Term

i. onset and precipitating factors
ii. aggravating or alleviating factors
b. past problems
c. family history - glaucoma, cataracts
d. harmful exposure - chemical sunlight
e. self-care abilities
f. use of corrective lenses
2. Physical exam
a. vision test
i. distant vision - Snellen E Chart
ii. near vision - Rosenbaum chart held at "reading" distance (or

12 to 14 inches from eyes)
b. extraocular muscle functions: six cardinal fields of gaze
c. external eye structures

i. symmetry
ii. eyelids and eyelashes
Term

iii. eyeball position
iv. lacrimal apparatus
v. cornea and lens
vi. iris and pupil
vii. accommodation and reaction to light
viii. conjunctiva moist and clear
d. internal eye structures and red reflex: examine the clients right
eye with health care providers right eye
e. optic disc
f. retinal vessels
3. Geriatric alterations of eye

a. arcus senilis: white yellow material around the cornea
b. pupils often miotic (smaller) with slower dilation
c. iris may appear paler
d. retina may appear paler
e. disc may be slightly smaller and more opaque
Term

f. decreased tear production resulting in dryness
g. presbyopia: decreased ability of the lens to change shape to

accommodate for near vision
h. color perception may be dimmed
C. Ear
1. History
a. presenting problem or injury
b. presence of hearing loss
c. use of hearing assist
d. associated findings, e.g., earache, discharge, tinnitus, vertigo
e. onset
Term
f. precipitating factors
g. aggravating and alleviating factors
h. lifestyle factors: swimming, musician, environmental noise

exposure
i. medical history
j. family history of allergy or hearing disease
k. medications
2. Inspection - external ear

a. observe size, shape and symmetry of both ears
b. auricles are normally level with each other, and upper point of
attachment is in a straight line with the lateral canthus of the
eye
c. inspect ear skin for color, lesions, rash and scaling
d. inspect area behind auricle for tophus
3. Palpation
Term
a. palpate auricle, tragus and mastoid area for tenderness and

elevated local temperature
b. palpate auricle, tragus and mastoid area for tenderness and

elevated local temperature
c. estimate size of external auditory meatus
4. Otoscopic examination
a. adult: grasp auricle and pull up and back to straighten external ear canal before inserting
otoscope
b.
child: grasp auricle and pull down and back
c. inspect ear canal for redness, swelling, discharge, crusting and foreign bodies
d. expect a small amount of moist, cerumen (ear wax); may be honey to dark brown in color
in African Americans and Caucasians
Term
i. cerumen is usually dry and flaky in Asians, Native Americans, and the elderly
ii. client may require removal of ear wax, particularly older adults
e. tympanic membrane
i. normal finding: translucent, shiny, light gray, taut disk; free from tears or breaks
ii. test its mobility: ask client to say "ah" or swallow; intact membrane will vibrate slightly
5. Hearing acuity - four tests

a. gross hearing is tested by client's response to normal conversation
b. whispered word or ticking watch test
c. Weber test: a hearing test using a vibrating tuning fork that is held at various points along
the midline of the skull and face (bone conduction only); used to detect hearing loss
i. using a tuning fork set to vibrate at 512 cycles per second (CPS), place perpendicularly
on the midline vertex of the skull
ii. ask asked client to report in which ear sound is heard (if heard in one ear, suspect
sensorineural loss in the other)
iii. normal hearing is when the tone produced by the tuning fork sounds at the same
volume in each ear
d. Rinne test - compares sound conduction of air versus bone; normally air conduction (AC)
is greater than bone conduction (BC)
Term

i. set tuning fork to vibrate
ii. place on mastoid process
iii. ask client whether the sound is heard and when it can no longer be heard; note how
long the sound can be heard
iv. when client states that sound is gone, immediately move the tuning fork to about 2
centimeters from auditory canal
v. ask the client again whether there is sound and when it stops
vi. normal finding - latter sound should be heard twice as long as that of mastoid sound
6. Geriatric alterations
a. ear lobes may appear pendulous
b. presbycusis - starting at age 50, slowly progressive
c. cerumen dries and accumulates, decreasing acuity
D. Mouth and pharynx
Term
1. Inspection: normal findings

a. temporomandibular joint: smooth jaw excursion; easy mobility
b. lips and buccal mucosa: symmetrical, pink; smooth and moist
c. teeth and gums: 32 adult teeth; pink gums
d. tongue: symmetry; pink; moist; papilla present
e. hard and soft palate: hard palate is pale, immovable with transverse rugae; soft palate
is pink and movable
f. Oropharynx: symmetrical; midline uvula, tonsils may be present on either side
a. mucosa may be
drier
Term
b. sense of taste may

be diminished
c. decreased saliva
d. lips thinner, shiny
e. teeth may appear

yellowish
f. tongue may appear

smoother
E. Skin
g. tooth loss may occur

with osteoporosis
1. General appearance - inspection

a. color
Term
i. varies with body part, and from person to person
ii. color ranges

"white" skin: ivory or light pink to ruddy pink
dark skin: light to dark brown or olive
b. alterations in skin color

i. hyperpigmentation
ii. hypopigmentation
iii. cyanosis: bluish ting usually associated with lack of

oxygen
iv. jaundice: yellowish color associated with liver

failure
v. erythema: localized redness due to increased

hemoglobin or stasis of blood in the capillaries
vi. mottled
c. moisture
d. temperature
e. texture - varies from part to part

i. smooth or rough
Term
ii. supple or tight
iii. indurated
f. turgor
i. normally decreases with age
ii. decreased in dehydration
iii. test by pinching the skin (over the sternum or

forehead) and note how quickly it returns to its
previous state
g. vascularity
i. capillaries are more fragile in older people (senile
purpura)
ii. petechiae: flat red or purple freckles
h. edema
i. peripheral
ii. generalized (anasarca)
iii. ascites (around abdomen)
iv. pitting (grading scale +1, +2, +3, +4) or non-pitting
Pitting Edema Grading Scale

Grading
Measure of Indentation
Duration of Indentation
1+
Barely detectable @ about 2 mm
Immediate rebound
2+
2 - 4 mm
A few seconds to rebound
3+
4 - 6 mm
About 10 - 12 seconds to rebound
4+
6 - 8 mm
More than 20 seconds to rebound
Assessment process:
Press on the area being assessed for about 5 seconds
Note the depth (in millimeters) of indentation and the time needed for the tissue to spring back
i. lesions
i. normal finding - free of lesions
ii. age-related changes include keratosis senilis, cherry angiomas, and atrophic warts
iii. primary lesions

macule
flat circumscribed change in skin color
measles, freckles
patch: macule that is larger than 1 cm
papule
superficial thickening of the skin

wart
plaque
papules coalesced to from an elevated surface wider than 1 cm
psoriasis
cyst
encapsulated fluid-filled cavity
sebaceous cyst
pustule
turbid fluid (pus) in the cavity
acne, impetigo
vesicle
elevated fluid filled cavity (1 cm)
blister
bulla
vesicle that is larger than 1 cm
burns
pustule: elevated, pus-filled vesicle or bulla
nodule: solid, hard, or soft palpable mass extending deeper into the dermis than a papule
iv. secondary lesions (arise from primary lesions)

scale: shedding flakes of keratinized skin tissue
crust: dry blood or serum or pus on the skin when vesicles or pustules burst
lichenification: rough, thickened, hardened area of epidermis from chronic irritation
scar: flat irregular area of connective tissue
excoriation
ulcer: deep irregular shape area of skin loss that can extend into the dermis or subcutaneous
tissue
fissure: linear crack with sharp edges that extends into the dermis
keloid: elevated area of excess scar tissue
erosion
v. for every lesion, note the following eight aspects:

color
location
texture
size
shape
type
grouping
distribution
j. hair
i. hirsutism: excessive hairiness
ii. alopecia: lack of hair
k. nails
l. factors affecting skin condition

i. hygiene
ii. nutritional status
iii. underlying disorders
2. Geriatric skin changes

a. wrinkling
b. head and body hair loss and graying
c. thinner skin
d. more freckles
e. hypopigmented patches
f. skin is drier, especially on lower extremities
g. less perspiration
h. all skin becomes less elastic; hanging parts sag
i. toenails may be thick, distorted, and yellowish
j. lesions: cherry angiomas, senile keratosis, atrophic warts
k. "liver spots" - small, flat, brown macules
F. Heart
1. Assess the heart through the anterior thorax (front chest)
2. Inspection and palpation

a. client in supine position or with head elevated at 45 degrees
b. anatomical landmarks of the heart

i. second right intercostal space - aortic area
ii. second left intercostal space - pulmonic area
iii. third left intercostal space - Erb's point
iv. fourth left intercostal space - tricuspid area
v. fifth left intercostal space - mitral (apical) area
vi. epigastric area at tip of sternum
c. apical impulse
i. fourth or fifth left intercostal space, midclavicular line
ii. may or may not be seen
iii. normally a short, gentle tap
Heart Sounds
For best sound quality, please make sure you have your headphones plugged in.
NORMAL HEART SOUNDS
1. First & second heart sounds

a. The first heart sound is produced by the closing of the mitral and tricuspid valves
b. The second heart sound is produced by the closing of the aortic and pulmonic valves
Download File
First & Second Heart Sounds

Copyright 2016 by Medi-Wave Inc. Used with permission.
2. Innocent murmur
Usually seen with non-cardiac conditions, such as pregnancy, hyperthyroidism, anemia
Heard early in systole
Download File
Innocent Murmur
Copyright 2016 by MedEdu LLC. Used with permission.
ABNORMAL HEART SOUNDS
Extra Heart Sounds
1. Third heart sound (gallop)
a. Heard early in diastole
b. Along with 1st and 2nd heart sounds, the extra sound sounds like tennessee
c. Listen using bell of stethoscope at the cardiac apex with client in supine position
Download File
Third Heart Sound (Gallop)

2. Fourth heart sound (gallop)
a. Associated with coronary heart disease, aortic stenosis
b. Heard in late diastole, just prior to 1st heart sound; the extra sound sounds like kentucky
c. Listen using bell of stethoscope pressed lightly on skin of chest with client in supine position
Download File
Fourth Heart Sound (Gallop)

Systolic Murmurs
3. Innocent murmur - see/listen above
4. Aortic stenosis - mild

a. Loud murmur early in systole (musical murmur)
b. Caused by turbulent blood flow into the aorta
c. Listen using diaphragm of stethoscope with client in supine position

Download File
Aortic Stenosis - Mild

Diastolic Murmurs
5. Aortic regurgitation - mild
a. Caused by a bicuspid (thickened) aortic valve
b. Listen using diaphragm of stethoscope over Erbs point with client in sitting position, leaning
forward
Download File
Aortic Regurgitation - Mild

6. Mitral stenosis - mild
a. Commonly due to rheumatic heart disease
b. Listen using bell of stethoscope over mitral valve with client left lateral position
i. first heart sound is increased in intensity
ii. second heart sound is normal and unsplit

Download File
Mitral stenosis - Mild

Other
7. Pericardial friction rub
a. A sign of pericardial inflammation, heard in infective endocarditis, myocardial infarction and
rheumatic fever
b. Scratchy, grating or squeaking sound
c. Listen using bell of stethoscope over left lateral sternal border to hear one systolic sound and two
diastolic sounds
Download File
Pericardial Friction Rub

3. Auscultation
a. listen with client sitting, lying supine and in left lateral recumbent position
b. use stethoscope to auscultate heart sounds
c. S1: closing of the mitral valve

i. after long diastolic pause and before short systolic pause
ii. heard best at apex
d. S2: closing of aortic valve

i. after short systolic pause and before long diastolic pause
ii. heard best over aorta - second right intercostal space
iii. high pitched, dull in quality
e. pulse deficit: apical pulse is greater than radial pulse
f. murmurs: extra sounds that occur because of turbulent blood flow
i. grading system
ii. asymptomatic or symptomatic
iii. thrill: tremor or vibration
iv. systolic murmurs occur between S1 & S2
v. diastolic murmurs occur between S2 & S1
g. extra heart sounds: 3rd & 4th sound gallop

To help you remember one of the differences about right-sided and left-sided murmurs,
remember: RILE
Right-sided heart murmurs are louder on Inspiration. Left-sided heart murmurs are louder on Expiration.
Heart Murmurs
Evaluating heart murmurs
Intensity of the murmur (see table below)
Graded on a scale of 1 to 6 (sometimes a scale of 1 to 5 is used)
Each grade should be given in relation to the range used, e.g., grade 3/6
The larger the number of the grade, the louder the murmur
Intensity of a Heart Murmur
Grade
Sound of Heart Murmur
A quiet murmur; difficult to hear, even with careful auscultation over a

localized area (point of maximal impulse or PMI)
A quiet murmur; heard with the stethoscope placed over its localized area
(PMI)
Moderately loud murmur; no thrill
Loud murmur, heard over a widespread area; no palpable thrill
A loud murmur with an associated precordial thrill
Very loud murmur; loud enough so that it can be heard with the
stethoscope raised just off chest wall; thrill
NOTE: A PRECORDIAL THRILL IS A "PURRING" SENSATION OR FINE VIBRATION OF THE

CHEST WALL THAT INDICATES ABNORMAL TURBULENT BLOOD FLOW; IT IS A 'PALPABLE
MURMUR'.
When the sound occurs in the cycle of the heartbeat
Location of where the sound is heard in the chest and whether it also can be heard in the neck or back
Sound pitch (high, medium, low)
Any other factors affecting the sound, i.e., breathing, physical activity, or change in body position
Listen to an innocent murmur - for best sound quality, please make sure you have your
headphones plugged in.
Download File
Innocent Murmur
Blood Pressure Basics

Blood pressure is the measurement of the force applied to the walls of the arteries as the heart pumps
blood through the body.
Factors affecting arterial blood pressure
Age
newborns have low blood pressure
blood pressure typically increases with age
Arterial elasticity
elastic vessels let blood flow at lower pressures
rigid, sclerotic vessels require higher pressures

Autonomic nervous system
stimulation of the sympathetic nervous system:
occurs when a decrease in pressure is detected
norepinephrine is released, producing increased heart rate, increased conduction speed,
increased contractility and peripheral vasoconstriction
stimulation of the parasympathetic nervous system:
occurs when an increase in pressure is detected
acetylcholine is released, which decreases heart rate, lessens atrial and ventricular contractility
and conductivity
Cardiac output
as cardiac output increases, so does blood pressure
if either stroke volume or the heart rate increases, so does cardiac output
Exercise
a faster heart rate means a higher systolic blood pressure
regular aerobic exercise can prevent and reduce high blood pressure, since it helps reduce weight
and stress
Resistance - friction between the blood and walls of the blood vessels creates a force called
resistance
the force must be overcome by blood pressure
factors that alter resistance cause changes in blood pressure
resistance in the systemic portion of circulation is called peripheral resistance
Viscosity - related to the ease with which molecules flow past one another
too many red blood cells (RBCs) or plasma proteins increases pressure
lower viscosity, from anemia or lack of RBCs, decreases pressure
Weight
the higher your weight, the higher your blood pressure
a weight loss of 5 - 10 pounds can lower and help control blood pressure
How the body controls blood pressure
Arterial blood pressure (BP) increases when there is a related increase in the following:
cardiac output,
peripheral resistance, and
blood volume
Intrinsic control - chemoreceptors continuously control blood flow according to:
the tissues' use of oxygen
the amount of carbon dioxide in the brain
Extrinsic control - overrides intrinsic control when necessary
for rapid, short-term adjustments, the body monitors blood pressure via stretch receptors
(baroreceptors) in the walls of the carotid sinus and the aortic arch
slow, long-term control of blood pressure is achieved through
excretion of sodium and water by the kidney,
the activity of the renin-angiotensin system,
the atrial natriuretic factor, and
antidiuretic hormone
2. Internal carotid arteries in neck
a. palpate each separately along margin of sternocleidomastoid
b. normal findings: strong thrusting pulse
c. auscultate both sides
d. normal findings: no sound heard
e. constriction causes bruit
3. Jugular veins
a. client in supine position with head elevated at 45 degrees
b. normal findings: pulsations not evident
c. jugular venous pressure (JVP): not to exceed 3 cm above level

of sternal angle
4. Peripheral arteries and veins
a. pulse
i. locations
ii. normal range of peripheral pulses

infants: 120 to 160 beats/minute
toddlers: 90 to 140 beats/minute
preschool/school-age: 75 to 110 beats/minute
adolescent/adult: 60 to 100 beats/minute
iii. factors affecting rate

exercise - decreases resting heart rate because heart muscle able to pump large quantities
of blood
temperature - each degree (Fahrenheit) elevation above normal causes an increase of 7 to
10 beats per minute
stress: increase in heart rate due to fight or flight mechanism
drugs
hemorrhage - less blood in the body requires more pumping per minute
postural changes
pulmonary conditions causing poor oxygenation
iv. rhythm - regular (normal) or irregular
v. strength
reflects volume of blood ejected with each beat
grading system
vi. equality
vii. dysrhythmias , alterations, e.g., heart murmurs
b. tissue perfusion
i. temperature
ii. color, e.g., cyanotic
iii. clubbing
iv. edema
v. skin and nail texture
vi. hair distribution on lower extremities
vii. presence of ulcers
The radial pulse is felt on the wrist, just below the thumb (image)
Pulse Locations
Head
Temporal: over temporal bone lateral to eye
Carotid: over the carotid artery in the neck (used in CPR)
Chest
Apical: between the 4th and 5th intercostal space, usually mid-clavicular line
Arms
Brachial: in the antecubital area of the arm
Radial: on the thumb side of the wrist
Ulnar: on the medial wrist
Legs
Femoral: below the inguinal ligament
Popliteal: behind the knee
Posterior tibial: on the inner side of each ankle
Dorsalis pedis: along top of foot
ECG Strips
Interpreting an ECG
1. Rhythm: determine is regular or irregular, with or without patterns

a. Ventricular rhythm: measure R to R intervals
b. Atrial rhythm: measure P to P intervals
2. Rate: count the number of QRS complexes over a 6 second interval and multiply by 10 to determine
heart rate
3. P wave: represents atrial depolarization
4. PR interval: represents AV conduction
5. QRS interval: represents ventricular depolarization and contraction
6. T wave: represents ventricular repolarization
7. QT interval: represents the time of ventricular activity including both depolarization and
repolarization
a. Measure the beginning of the QRS complex to the end of the T wave
b. Normal: 0.36 to 0.44 seconds (9 to 11 small boxes) varies with gender, age and heart rate
8. ST segment: represents the early part of ventricular repolarization

Normal Sinus Rhythm
Atrial Fibrillation
Rhythm: irregular
Rate: very fast
P wave: absent
PR interval: absent
QRS complex: normal, but may be widened
Atrial Flutter
Rhythm: regular or irregular
Rate: very fast
P wave: not observable
PR interval: not measurable
QRS complex: normal
Sinus Arrhythmia
Rhythm: irregular; varies with respiration
Rate: normal; may increase during inspiration and decrease with expiration
P wave: normal
PR interval: normal
QRS complex: normal
Sinus Bradycardia
Rhythm: regular
Rate: slow
P wave: normal
PR interval: normal
QRS complex: normal
Sinus Tachycardia
Rhythm: regular
Rate: fast
P wave: normal
PR interval: normal
QRS complex: normal
Ventricular Fibrillation
Rhythm: very irregular
Rate: not measurable

P wave: absent
QRS complex: none
Ventricular Tachycardia Torsade de Point

Rhythm: irregular
Rate: fast (200-250 bpm)
P wave: absent
QRS complex: wide and bizarre looking
Note: ECG strips copyright 2016 by MedEdu LLC. Used with permission.
H. Lymphatics
1. Retrieves excess fluid from tissue spaces and returns it to the bloodstream
a. conserves fluid and plasma proteins
b. is a major component of the immune system
c. absorbs lipids from the intestinal track
d. without lymphatic drainage, fluid remains in the interstitial spaces and produces edema
2. Two major trunks

a. right lymphatic duct empties into right subclavian vein
b. thoracic duct - drains remaining body
3. Lymph nodes
a. cervical - drains the head
b. axillary - drains the breast and upper arm
c. epitrochlear - in the antecubital fossa and drains the hand and lower arm
d. inguinal - in the groin and drains the lower extremities, external genitalia, and abdominal wall
4. Head and Neck

a. preauricular - in front of the ear
b. posterior auricular (mastoid)
c. occipital - base of skull
d. submental - midline, behind tip of mandible
e. submandibular - halfway between angle and tip of mandible
f. superficial cervical - overlying the sternomastoid muscle
g. deep cervical - deep under the sternomastoid muscle
h. posterior cervical - in posterior triangle along edge of trapezius
i. supraclavicular - just above and behind the clavicle
5. Related organs
a. tonsils
b. thymus
c. spleen
I. Lungs
1. History - smoking, infections, pain, discomfort, dyspnea, activity intolerance, fever
2. Inspection
a. general comfort and breathing pattern
i. breathing should be quiet and easy
ii. respiration involves ventilation, diffusion, and perfusion of gases
iii. factors influencing respirations

exercise: increases need for more oxygen
pain, anxiety or stress: increase respiratory rate
anemia: lack of cells to carry oxygen causes greater need for quantities of blood to be
circulated
posture
drugs: narcotics, amphetamines
iv. normal rates of respiration (at rest)

newborn: 35 to 40 breaths/minute
infant: 30 to 50 breaths/minute
toddler: 25 to 35 breaths/minute
school age: 20 to 30 breaths/minute

adolescent/adult: 14 to 20 breaths/minute
adult: 12 to 20 breaths/minute
v. depth: deep, normal, shallow
vi. rhythm: regular (normal finding) and irregular
b. appearance
i. skin color
ii. chest configuration: observe shape and symmetry of chest excursion from back and front;
normal chest contour is symmetrical
healthy adults: the ratio of the anteroposterior (AP) diameter to the lateral diameter is
approximately 1:2
deformities of the chest associated with respiratory disease: barrel chest (AP diameter is
equal to lateral diameter), funnel chest (pectus excavatum), pigeon chest (pectus
carinatum), and kyphoscoliosis
iii. posture
3. Palpation
a. feel for abnormalities such as masses, lesions, scars, swelling, crepitus, asymmetry
b. crepitus indicates air in subcutaneous space (in thoracic area, usually due to pneumothorax)
c. vocal fremitus: ask client to repeat "99"

i. vibration felt when patient speaks
ii. increased over areas of consolidation
4. Percussion - normal finding is resonance heard throughout lung fields
5. Auscultation - normal findings are quiet breathing throughout all lung fields
a. normal findings: clear breath throughout all lung fields
b. whispered pectoriloquy
i. client whispers "one, two, three"
ii. over normal areas of the lung, only muffled faint sounds are heard
iii. over consolidated areas, the words are more distinct
c. egophony
i. client says "E"
ii. over consolidated areas, the sound is a nasal "A"
Lung Sounds
For best sound quality, please make sure you have your headphones plugged in.
NORMAL LUNG SOUNDS
Download File
Normal Breath Sounds 1

Download File
Normal Breath Sounds 2

ADVENTITIOUS BREATH SOUNDS
1. Crackles (fine rales)
a. Brief, discontinuous, high-pitched sounds
i. heard in both phases of respiration
ii. sounds like hook & loop fasteners (Velcro) being pulled apart
b. Disease states
i. early inspiratory and expiratory crackles: chronic bronchitis
ii. late inspiratory and expiratory crackles: pneumonia, CHF or atelectasis
c. Listen using diaphragm of stethoscope with client in sitting position

Download File
Crackles (Fine Rales)

2. Crackles (coarse rales)
a. Brief discontinuous, popping lung sounds
i. similar to a bubbling sound
ii. louder and lower in pitch than fine crackles
b. Listen using diaphragm of stethoscope with client in sitting position
Download File
Crackles (Coarse Rales)

3. Grunting
a. Deep, guttural rumble sound due to forced expiration against a closed glottis
b. Disease states:
i. a sign of respiratory distress in newborns; also seen with nasal flaring, retractions, cyanosis
ii. pneumonia, pulmonary edema, airway obstruction, croup, epiglottitis

Download File
Grunting
4. Pleural rub
a. Discontinuous or continuous creaking or grating sounds
ii. sounds like someone walking on fresh snow
iii. coughing will not alter the sound
b. Caused by inflamed surfaces sliding by one another
c. Disease states: pleural effusion, pneumothorax
d. If rubbing sound continues even when client holds a breath, it may be a pericardial friction rub
e. Listen using diaphragm of stethoscope with client in sitting position

Download File
Pleural Rub
5. Rhonchi
a. Low pitched wheezes
ii. have a snoring, gurgling or rattle-like quality
iii. usually clear after coughing
iv. occur in the bronchi
b. Caused by blockages to main airways due to mucous, lesions or foreign bodies
c. Disease states: pneumonia, chronic bronchitis, cystic fibrosis
d. Listen using diaphragm of stethoscope with client in sitting position

Download File
Rhonchi
6. Stridor
a. Loud, high-pitched crowing breath sound usually heard during inspiration
b. Caused by foreign body obstruction of the larger airways and upper airway narrowing or
obstruction due to pertussis, croup in children

Download File
Stridor
7. Wheeze
a. Lung sounds with continuous musical quality
i. High pitched wheezes sound similar to squeaking
ii. Low pitched wheezes have a snoring or moaning quality
b. Caused by narrowing of the airways

Download File
Wheeze
8. Whispered pectoriloquy
a. Used to determine presence of consolidation
b. Ask client to whisper 1-2-3 or another short phrase several times

i. Sound will be unintelligible with healthy lungs
ii. Sound will be clear and loud with consolidation
6. Alterations in lung function

a. cough
b. expectoration: expelling sputum
c. dyspnea: difficulty breathing
d. bradypnea: slow breathing
e. tachypnea: fast breathing
f. hyperpnea: increased depth of breathing
g. apnea: no breathing
h. Cheyne-Stokes respiration: alternating between apnea and tachypnea
i. Kussmaul's breathing: deep labored breathing related to severe metabolic acidosis
j. Biot's respiration: groups of quick shallow respirations
k. retractions: physical sinking of the chest wall muscles with respiratory difficulty (especially in
children)
l. hemoptysis
m. pain
n. use of accessory muscles
o. cyanosis
p. adventitious breath sounds , including crackles, grunting, pleural rub, rhonchi, stridor,
wheeze
q. pursed-lip breathing: prolonged exhalation, breathing out through puckered lips
7.
Pediatric differences
a. increased risk of obstruction from mucus, edema, or foreign body due to the following:
i. smaller, shorter, more pliable airways
ii. underdeveloped supporting cartilage
b. flexible larynx more susceptible to spasm
c. immature immune system
d. incomplete myelinization
e. increased basal metabolic rate
f. decreased ability to mobilize secretions
g. less forceful cough
J. Breasts
1. Inspection (performed with client in lying, sitting, or standing position)
a. size - varies from convex to pendulous
b. symmetry (the left breast is commonly larger than the other)
c. skin - color, venous pattern, possibly a few hairs around areola
d. alterations
i. retraction: nipple does not protrude either during maturation or may be symptom of disease
ii. dimpling: skin appearance similar to an orange peel
iii. lesions
iv. edema: swelling
v. inflammation: red and warm to touch
vi. alterations with pregnancy and lactation

enlargement of breasts
soreness of nipples during lactation

possible striae
e. nipple and areola

i. size
ii. color - ranges from pink to brown
iii. shape
areola - round or oval
nipples - everted
iv. symmetry - normally symmetrical
v. direction - normally nipples point in same direction
vi. alterations
discharge
inverted nipples
bleeding
2. Palpation - breast
a. lymph nodes: normal findings - not palpable
b. breast tissue
i. client in supine position with hand placed behind neck
ii. methods of examining breast tissue

clockwise or counterclockwise circling breast from nipple outward
back and forth with fingers moving up and down each breast
cover entire thoracic area, including axillary area
iii. consistency
varies widely from person to person
normal findings: dense, firm and elastic
iv. alteration - fibrocystic disease of the breast
v. geriatric alterations
relaxed breasts
may appear elongated or pendulous
decrease in glandular tissue
K. Abdomen
1. History
a. pain, bowel habits, dietary problems, weight change, difficulty swallowing, flatulence,
belching, heartburn, nausea, vomiting, cramping
b. changes in micturition including: change in amount and color of urine, irritation of the lower
urinary tract, obstruction of the urinary tract, urinary incontinence, urinary tract pain
2. Inspection
a. landmarks
i. xiphoid process - marks upper boundary of abdomen
ii. symphysis pubis - marks lower boundary
iii. abdomen divided into four quadrants: RUQ, RLQ, LUQ, LLQ
b. normal findings
i. skin texture and color should be consistent with rest of body
ii. stria may be present
iii. umbilicus is normally flat or concave midway between xiphoid and symphysis pubis
iv. abdomen may be flat, concave or convex; all three are normal if there is symmetry
v. you may note peristalsis movement or aortic pulse
vi. voiding: steady, straight stream with no pain or post void dribble
3. Auscultation - important to auscultate first, before percussion and palpation, to obtain bowel sounds
a. bowel motility (normal findings) - bowel sounds audible in all quadrants, about 5 to 30 times per
minute
i. start in right lower quadrant (RLQ)
ii. if bowel sounds are present in the RLQ, indicates no obstruction above in the large intestine
b. vascular sounds - normal findings

i. no vascular sounds over aorta or femoral arteries
ii. renal artery bruit can be heard
4. Percussion
a. normal findings: tympany over stomach and intestines; dullness over liver, spleen, pancreas,
kidneys and distended (> 150 mL) bladder
b. liver border
i. usually noted in the 5th, 6th or 7th intercostal space
ii. distance between upper and lower borders should range between 6 to 12 centimeters at right
midclavicular line
c. spleen
i. left posterior midaxillary line: dullness at 6th to 10th rib
ii. left intercostal space in anterior axillary line: tympany
5. Palpation
a. normal findings: soft with no palpable masses, no tenderness or rigidity
b. techniques
i. light palpation - gently depress 1 centimeter, moving to each quadrant
ii. deep palpation - depress 5 to 8 centimeters; use one hand over another (bimanual) for obese
abdomen
c. bladder noted as a bulge in abdomen when filled with more than 500 mL of urine
d. deep palpation may produce tenderness - liver, kidneys, spleen inguinal nodes generally not
palpable
6. Alterations
a. distention
b. ascites: fluid filled belly associated with liver failure
c. paralytic ileus: no motility in bowel that can occur after abdominal surgery
d. borborygmus: stomach growling
e. guarding (muscles contract)
f. tenderness
g. pain
a. increased fat deposits over abdominal area
b. muscle tone more lax
L. Female reproductive system

1. History: sexually transmitted disease, menstrual history, obstetrical history, contraception
2. Inspection
a. external genitalia - normal findings
i. hair distribution variable; usually inverted triangle starting at symphysis pubis
ii. skin of perineum smooth, clean, slightly darker than other skin
iii. labia majora may be closed or gaping
iv. clitoris - about 2 centimeters in length and 0.5 centimeters in width
v. urethral orifice intact, pink without irritation
vi. vaginal orifice ranges from thin, vertical slit to large orifice with moist tissue
vii. anus moist and hairless; skin more darkly pigmented
b. internal genitalia
i. cervix - normal findings: pink; midline; usually about two to three cm in diameter; smooth,
firm, rounded or oval; odorless, creamy or clear secretions
ii. Papanicolaou (Pap) smear
iii. vagina pink throughout; clear or cloudy, odorless secretions; about 10 to 15 centimeters in
length
3. Palpation
a. ovaries may or may not be palpable; firm, slightly tender, oval, mobile; about 4 centimeters in
diameter
b. uterus mobile; rounded; palpable at level of pelvis
c. Skene's glands (located around the opening of the urethra) and Bartholin's glands (located in the
vulva on either side of the opening to the vagina) - normal findings are non-tender with no
discharge
a. labial folds flatten
b. skin paler, shiny
c. meatus usually more posterior
d. cervix decreases in size; may appear paler
e. scanty cervical discharge
f. vagina shortens with age
g. decreased vaginal secretions
h. uterus diminishes in size; may not be palpable
i. ovaries atrophy with age
M. Male reproductive system
1. History: sexual history, sexually transmitted disease, contraception, surgery, associated urinary
problems
2. Inspection
a. external genitalia
b. hair distribution varies; hair extends from base of penis over symphysis pubis; coarse and
curly
c. penis shaft, corona, prepuce, glans
d. urethral meatus is slit-like opening positioned on ventral surface; opening should be

glistening and pink
e. scrotum
i. skin more darkly pigmented; more wrinkled; usually loose
ii. symmetry - left testicle is lower than right
iii. size - changes with temperature
f. inguinal canal
i. normal finding: no bulging
ii. weakened area of abdominal wall allowing abdominal contents to protrude
iii. hernias are palpated as a mass when client bears down (increased abdominal pressure)
iv. can be a potentially emergency if abdominal contents become trapped
3. Palpation
a. penis
i. foreskin should retract easily
ii. small amount of thick white secretion between glans and foreskin is normal
iii. testicle - ovoid; ranges from 2 to 4 centimeters in diameter, smooth and rubbery; nontender
b. inguinal canal
c. normal finding: inguinal lymph nodes not palpable
a. increased bogginess of prostate gland
b. testes - softer, less firm and decrease in size
c. scrotal sac - pendulous
d. pubic hair - thinning, grey
e. penis - decrease in size
5. Rectum and anus

a. inspection of perianal areas
i. skin - smooth and uninterrupted
ii. anal tissues - normally moist and hairless
b. digital palpation
i. anal sphincter - note tone
ii. rectal walls - smooth and even
iii. prostate gland

palpate through anterior rectal wall
small walnut-sized, heart shaped structure
ranges from 2.5 to 4 centimeters in diameter
normal findings: firm, protrudes < 1 centimeter into rectum
c. alterations
i. hemorrhoids
Hemorrhoids
ii. fissures
iii. fistulas
iv. polyps
v. pain
N. Musculoskeletal
1. History: participation in sports, risk factors for osteoporosis, impact of current problem on
activities of daily living
2. Inspection - normal findings

a. gait - client walks with arms swinging freely at sides; coordinated and smooth; rhythmic with
push off and swing through
b. posture and balance
i. upright stance with parallel alignment of hips and shoulders
ii. feet aligned; toes pointing straight ahead
iii. convex curve to thoracic spine
iv. concave curve to lumbar spine
v. can stand still without swaying or tilting
c. extremities - bilateral symmetry in length, circumference, alignment, position and number of

skin folds
3. Palpation
a. all muscles, bones, joints
b. normal findings: muscles firm, non-tender
4. Range of motion (normal findings) - able to move joints through required range of motion
a. abduction: moving a limb away from midline
b. adduction: moving a limb toward the midline (adding)
c. dorsiflexion: decreases the angle between the foot and the leg
d. eversion: sole of foot faces laterally
e. inversion: sole of foot is turned medially
f. extension: increasing the angle of a joint
g. flexion: decreases the angle of a joint
h. hyperextension: bending of a joint beyond 180 degrees
i. plantar flexion: angle between the foot and leg is increased
j. pronation: palm of hand moves to face posterior
k. supination: palm of hand moves to face anterior
5. Muscle strength and symmetry (normal findings) - arm on dominant side generally stronger
6. Alterations
a. kyphosis: curving of the spine that causes bowing of the back leading to hump back
b. lordosis: sway back
c. scoliosis: curve of spine sideways (away from midline)

i. test by having client bend at waist and verify that both hips are the same height
ii. or note when standing that one shoulder is higher than the other
iii. if untreated can lead to decreased area for lungs or heart
d. pain
a. stance less upright with head and neck forward
b. lumbar curvature less pronounced
c. height decreased
d. gait slower to initiate and stop
e. steps may be shorter and more rapid
f. may need to hold onto furniture as age increases
g. muscles atrophy with disuse
h. weaker grip
i. active range of motion may be slower and limited in one or more joints
j. joints appear larger than surrounding tissue; may be stiff
O. Neurological system
1. History
2. Mental status: Mini-Mental State Examination (MMSE)
3. Emotional status (normal findings) - affect matches speech
4. Assessing cranial nerves
5. Assessing level of consciousness (LOC)

a. alert
b. orientation to time, person, place, situation
c. responds appropriately to visual, auditory, tactile and painful stimuli
d. able to carry out simple commands
e. Glasgow coma scale
f. alterations in LOC
There are a lot of mnemonics to remember the names of the 12 cranial nerves; here's one of the
"cleaner" versions: On Old Olympus Towering Tops A Fin And German ViewedSome Hops
Here's a version to help remember which of the cranial nerves carry sensory, motor, or both types of
impulses
(S=sensory, M=motor, B=both): Some Say Marry Money But My BrotherSays Big Business Makes Mon
ey
Cranial Nerves - Functions & Deviation from Normal

Nerve
Normal Function
Deviation
CN I: Olfactory
Identify smells
Inability to identify aroma
Visual acuity and full visual
Inability to identify full visual fields
fields
Total or partial blindness in one or
Fundoscopic exam reveals
both eyes
Recall Tip: Odor

= one (nose)
CN II: Optic
no pathology
CN III: Oculomotor
Follows up to six cardinal
One or both eyes will deviate from
positions of gaze
normal position
Pupils are unremarkable

Exhibits no nystagmus and
no ptosis
Nerve
Normal Function
Deviation
CN IV: Trochlear
Same as CN III: Oculomotor
CN V:Trigeminal
Clenches teeth with firm
Absent or one-sided blinking of
bilateral pressure
eyelids
No lateral jaw deviation with

mouth open
Differentiates sharp and dull
sensations on face
Corneal reflex: blinks when
cotton is touched to each
cornea
CN VI: Abducens
CN VII: Facial
Facial symmetry with and
Irregular and unequal facial
without smile
movements
Can raise eyebrows
Inability to taste or to identify salt,
symmetrically and grimace
sweet, sour, or bitter substances on

the anterior two-thirds of tongue
Can shut eyes tightly

Inability to smile symmetrically
Can identify sweet, sour, salt
or bitter on the anterior
tongue
CN VIII: Auditory
Can hear a whisper at 1 to 2
(Acoustic)
feet
Can hear a watch tick at 1 to
Recall Tip: Ear

= eighth
2 feet
Inability to hear spoken word
Nerve
Normal Function
Deviation
Does not lateralize the

Weber test
Can hear air conduction
better than bone conduction
in the Rinne test
CN IX:
Swallows and speaks
Unequal or absent rise of uvula and
Glossopharyngeal
without hoarseness
soft palate as client states: "ah"
Palate and uvula rise
Absent gag reflex
symmetrically when client

states: "ah"
Inability to taste or identify taste on

the posterior tongue
Bilateral gag reflex

Can identify taste on the
posterior tongue
CN X: Vagus
same as CN IX:
same as CN IX: Glossopharyngeal
Glossopharyngeal
CN XI: Spinal
Resists head turning
Accessory
Weak or absent should and neck

movement
Can shrug against

resistance
CN XII: Hypoglossal
Can stick tongue out and

move it from side to side
Can push tongue against
resistance
Assessing Level of Consciousness
Tongue deviates to side
Descriptor
Characteristics
Alert
Awake and aware of person, place, time, and situation

Responds appropriately to verbal stimuli
Lethargic
Sleeps but easily aroused

Speaks and responds slowly and appropriately
Obtunded
Difficult to arouse and returns to sleep quickly

May respond inappropriately
Stuporous
Aroused only through vigorous and repeated stimuli; will immediately

lapse back to unresponsive state when left undisturbed
No verbal response
Semicomatose Responds only to pain

Gag and blink reflexes intact
Comatose
No response to pain
No reflexes or muscle tone
Glasgow Coma Scale

The Glasgow Coma Scale (GCS) is used to objectively determine level of consciousness following
traumatic brain injury in the adult.
The total score is the sum of the scores from each of the three categories, i.e., eye opening, verbal
response and motor response
Coma is defined as
not opening eyes
not obeying commands
not uttering understandable words
The GCS was revised in 2014 and the focus is on reporting each of the three components of the scale,
rather than the total sum. Terms have been updated, but the number of steps in the scales have not
been changed.
To correctly assess the client:
check - for factors interfering with communication, ability to respond and other injuries
observe - eye opening, content of speech, movement of right and left sides
stimulate - spoken or shouted request (for sound) and pressure on finger tip; trapezius or supraorbital
notch (for physical)
rate - assign according to highest response observed
Eye Opening
Verbal Response
Motor Response
NT = non-testable
NT = non-testable
NT = non-testable
1 = no response
1 = no audible response
1 = no movement
2 = to (finger tip) pressure
2 = sounds (moans/groans)
2 = extension
3 = to sound
3 = (single) words
3 = abnormal flexion
4 = spontaneous
4 = confused
4 = normal flexion
5 = oriented
5 = localizing
6 = obeys commands
6. Sensory function assessment

a. visual - recognizes objects
b. auditory - identifies sounds
c. tactile - identifies objects through blind touch; perceives pain, hot and cold and vibration; twopoint discrimination
d. olfactory - identifies familiar smells
7. Motor function assessment (cerebellar function - position and balance)
8. Speech and language (normal findings)

a. smooth flowing speech
b. able to formulate words without difficulty
c. varied inflection
d. able to write letters and numbers to dictation
e. vocabulary appropriate to educational level
9. Intellectual (normal findings)

a. memory: immediate recall and remote recall
b. oriented to person, place and time
c. able to abstract
d. demonstrates consistent insight and perception of self
10.
Newborn reflexes assessment
11. Geriatric alterations in neurologic status

a. longer response time to sensory stimulation
b. may resist new ideas or change
c. thought patterns may become more concrete
d. kinesthesia diminishes
e. tactile sensation diminishes
f. superficial and deep reflexes may be diminished or absent
Assessing Sensory Nerve Function

Assessing sensory nerve function is done with the client's eyes closed.
Type of Assessment
Assessment Technique
Superficial pain
Prick with sterile needle

Have client identify whether the sensation is sharp or dull
Temperature
Fill two test tubes, one with hot water and the other with cold
water
Client identifies hot versus cold sensation and where it is felt
Light touch
Using cotton ball, nurse applies light wisp of cotton to different

surface points
Client identifies when touched
Vibration
Using low pitched tuning fork, nurse applies to distal

interphalangeal joint of finger and then toe
Client identifies when vibration stops
Position
Nurse grasps the client's finger or great toe, holding onto to it by

its sides
Client identifies if moving up or down
Two-point
Using two safety pins, nurse applies them lightly and
Type of Assessment
Assessment Technique
discrimination
simultaneously to two different places on skin's surface (usually

the nurse starts with the pads of the fingers)
Find minimal distance at which client can discriminate one from
two points (normally < 5 mm on finger pads)
Client identifies when can discriminate one from two points
Stereognosis
Use coin or paper clip or any familiar object with client's eyes
closed
Client identifies object to identify by touch and manipulation
Graphesthesia
Number is traced on the client's palm by a blunt object
(number identification)
Client identifies number
Extinction
Corresponding areas on both sides of body are simultaneously

stimulated
Client identifies where touched
Assessing Motor Nerve Function

Activity
Assessment Technique and Normal Findings
Romberg test
Tests position sense

Note client's ability to stand upright when standing with feet together and
eyes closed for 20-30 seconds
Hop in Place
Maintains balance while hopping on one foot
Knee Bends
Maintains balance while bending at knees
Tandem
Walks heel to toe in a straight line
Walking
Rapid Skills
Pronates and supinates hands rapidly with equal timing and purposeful
movement
Activity
Assessment Technique and Normal Findings
Touches alternate finger to nose rhythmically with eyes open and closed
Moves finger alternately from nose to examiner's finger in coordinated
fashion
Runs contralateral heel down shin with bilateral coordination
One-foot
Maintains balance on one foot for at least five seconds
Balance
Bilateral response with eyes open and closed
Newborn Reflexes
Reflexes are involuntary movements or actions.
They help transition newborns to life and to learn what they need to survive.
As a general rule, reflexes will stop or disappear cephalocaudally (from head-to-toe).
Body
Reflex
Area
Name
Eye
Blink
Nose
Glabellar
Action
Age
Eyes blink when strong light or object nears
Persists
baby.
throughout life
Tapping briskly on bridge of nose causes
Disappears
eyes to close tightly
around the fourth

month
Sneeze
Stimulated nasal passages result in sneezing
Persists
throughout life
Mouth
Gag
Stimulation of posterior pharynx causes
Persists
individual to gag
throughout life
Body
Reflex
Area
Name
Rooting
Action
Age
Touching or stroking cheek beside mouth
Usually stops at 3
causes baby to turn head to the side of the
to 4 months
stimulus and begin to suck

Extrusion
Sucking
Touch or depress the tongue, and it is forced
Usually stops by 4
outward
months of age
This occurs when something is placed in the
Slowly replaced
baby's mouth
by voluntary
sucking around 2
months of age
Hand
Grasp
Stroking palm of hand causes flexion of digits
Lessens by about
3 months of age
when it is
replaced by
voluntary grasp
Foot
Babinski or
Stroking outer sole of foot upward from heel
Usually
plantar
across ball of foot causes toes to fan and
disappears at 12
grasp
hyperextend with the big toe in dorsiflexion
to 18 months of
age
Body
Moro or
Sudden jarring (as when someone fails to
Usually
startle
support or hold the neck and head) causes
disappears at
reflex
extension and abduction of extremities and
about 2 months of
fanning of fingers, followed by flexion and
age
adduction of extremities; it is a bilateral

process
Dance or
Holding newborn so feet touch hard surface
Usually
stepping
causes flexion and extension of legs,
disappears at
reflex
simulating walking.
about 3 to 4
weeks of age
Body
Reflex
Area
Name
Crawl
Action
Age
Placing baby on abdomen causes crawling-
Usually
like movements of arms and legs
disappears at
about 6 weeks of
age
Parachute
When an infant is suspended in a horizontal
Found initially
prone position and suddenly thrust forward,
between 7 to 9
the hands and fingers extend forward. This
months and
reflex is protective; as the child learns to walk,
persists
the reflex helps protect him/her from falls.
indefinitely
Tonic neck
When the infant is supine and his/her head is
Usually
or fencing
turned to one side, the arm and leg extend on
disappears by 4 to
the side the head is turned and the arm and
9 months of age
leg flex on the opposite side. The reflex

protects the infant from rolling over before he
or she is neuromuscularly mature enough to
do so.
IX. Principles of Teaching/Learning

A. Adult learning theory
1. Self-directed
2. Reservoir of experience
3. Adults prefer mutual planning/goal setting
4. Internally motivated
5. Established orientation to learning
6. Educator is facilitator of learning
7. Experiential rather than didactic
8. Must be immediately applicable to life
B. Teaching/learning process
1. Assessment
2. Identification of learning needs
3. Outcome (goal) setting
4. Educational offerings
5. Evaluation of outcomes
C. Learning styles
1. Vary with individuals
2. Types of learning styles

a. visual
b. auditory
c. tactile (kinesthetic) - learn through touch and "hands on"
d. kinesthetic - learn through movement
D. Teaching strategies
1. Demonstration/return demonstration
2. Programmed instruction - self-paced
3. Role playing - group work
4. Simulation - group work
5. Case study analysis - individual or group work
6. May be individualized or in groups
7. May be computerized
8. May be media-based or print
E. Legal implications
1. American Hospital Association (AHA) issued the Patients' Bill of Rights (1973): guarantees a
person's right to information necessary to give informed consent before treatment begins
2. Patient Care Partnership (2008): describes the rights and responsibilities of individuals who are
hospitalized (replaced the Patients' Bill of Rights)
3. Individualized teaching must be documented in client's chart
4. Alterations for geriatric clients

a. make sure client has glasses or hearing aid
b. face the client and use a lower-pitched voice
c. supplement oral presentation with print materials
d. use large print
e. provide good lighting
f. some clients have a hard time seeing color; use black on white or yellow paper
g. keep sessions short and work with survival-level information initially
h. repeat often for clients prone to memory loss
i. break down learning into small steps
j. use specific, step-by-step directions and have the client redemonstrate them
k. get frequent feedback regarding client's level of understanding
5. Health Insurance Portability and Accountability Act (HIPAA)

a. signed into law in 1996
b. requires employer-sponsored group health plans, insurance companies, and health maintenance
organizations (HMOs) to
i. limit exclusions for preexisting conditions
ii. prohibit discrimination against employees and dependents based on their health status
iii. guarantee renewability of health coverage to certain employers and individuals
iv. protect many workers who lose health coverage by providing better access to individual
health insurance coverage
c. revised in 2003
i. provides patients with access to their medical records and more control over how their
personal health information is used and disclosed
ii. key provisions

access to medical records
notice of privacy practices
limits on use of personal medical information
prohibition on marketing
stronger state laws
confidential communications
complaints
Points to Remember - L & D

Before Birth
Early and regular antepartal (before-birth) care is critical since first trimester health directly influences
the development of embryonic organs.
To identify risks, nurses need both subjective (client's opinions and statements) and objective
(measurable) assessment data.
Prescribed medications, over-the-counter drugs, alcohol and tobacco may lead to problems for the
fetus and woman.
Pregnancy diet must include increased calcium, protein, iron and folic acid.
If the client's situation warrants, suggest ways to adapt activity, employment, and travel.
It is helpful if the woman can have the same support person throughout pregnancy and birthing
classes.
A doula gives prenatal, labor, birth and postpartum support for mothers and families.
Labor
Normal active labor progresses 1.2 centimeters per hour for primiparas and 1.5 centimeters per hour
for multiparas.
Maintain safety and medical asepsis through the labor and birth process to reduce risks to mother and
fetus/newborn.
Ideally, the same caregivers should stay through all stages of labor.
Reinforce the childbirth preparation techniques practiced by the couple during pregnancy but be
flexible since woman will have shorter attention span, increased discomfort, and experience a
fluctuation of emotions during labor.
Respect the cultural and religious beliefs of the woman and partner.
Involve the family in the birth process as noted in their birth plan or special requests.
Document ongoing assessments, changes in condition and care.
Pain and anxiety can impede progress of labor.
Safest time for the fetus is to administer analgesics is when the woman is dilated between 4 to 7
centimeters.
Be prepared to assist newborn transition to extrauterine environment.
Points to Remember - Postpartum
Postpartum
Teach (by demonstration and praise) self assessment and care, starting soon after birth.
Share your assessments and plans with parents; welcome their input.
Respect culture and religious beliefs of the family.
Praise the parent's skills.
Postpartum physical assessment can be remembered using the acronym: B.U.B.B.L.E. (for breasts,
uterus, bowels, bladder, lochia and episiotomy or C-section incision)
Perform Coombs' tests to detect antibodies after the birth of each Rh positive newborn
direct Coombs' test on newborn using neonatal cord blood
indirect Coombs' test and antibody screen on the mother
A normal (negative) indirect Coombs' test indicates that no antibodies are detected (there is no
clumping of the cells) and the woman is considered to be a candidate for RhoGAM.
Visits and Teachings
Mothers are discharged quickly (usually within 48 hours), so you must teach accordingly.
Home visits and follow-up telephone calls let the nurse and parents discuss adaptations, questions
and concerns.
Postpartum teaching should include women's health promotion.
The adolescent mother benefits from developmentally appropriate teaching and referral to community
resources, including parenting classes.
Points to Remember - G & D
General Concepts
Both growth and development normally proceed in a regular fashion from simple to complex and in a
cephalocaudal and proximodistal pattern.
Growth and development are impacted by genetics, environment, health status, nutrition, culture, and
family structures and practices.
Growth should be measured and evaluated at regular intervals throughout childhood; deviations from
normal growth and development should be thoroughly investigated and treated as quickly as possible.
Development occurs through conflict and adaptation.
Children
In the care of children, key concepts are anticipatory guidance and disease prevention.
Major developmental tasks of infancy include increase in mobility, separation, and establishment of
trusting relationships
In both toddlerhood and adolescence, hallmarks are development of independence and further
separation.
Children and adolescents have rapid growth patterns, so nurses must stress optimum nutrition and
give anticipatory guidance related to nutrition.
Leading causes of death:
Ages 0 to 1 year: developmental and genetic conditions that were present at birth, sudden infant
death syndrome (SIDS), all conditions associated with prematurity and low birth weight
Ages 1 to 4 years: accidents, developmental and genetic conditions present at birth, cancer
Ages 5 to 14 years: accidents, cancer, homicide
Ages 15 to 24 years: accidents, homicide, suicide

Points to Remember - G & D 2
Older Adults
Older adults must adjust to lessening physical and cognitive abilities; a majority of older adults have at
least one chronic disease.
When older adults experience cognitive changes, check for possible substance abuse or
polypharmacy.
Cognitive impairment may be either acute and reversible or chronic and irreversible; investigate all
changes in cognition.
Many older adults have some impairment in performance of activities of daily living.
Some physiologic changes are a normal part of the aging process and do not signal disease.
Older adults need more time to complete tasks.
Age is a weak predictor of survival in traumatic injury and critical illness.
Health Risks in Older Adults
Major health problems typically include cardiovascular, cerebrovascular, and respiratory diseases;
diabetes; and cancer.
The older adult will change social roles and these changes may affect their psychological health, e.g.,
depression.
Older adults need the same nutritional needs as other adults, but they need more bulk and fiber, and a
more nutrient dense diet containing fewer calories.
Older adults clear drugs from kidney and liver more slowly; so medications have longer half-lives, and
they can bring on side effects and toxicity at lower doses - remember "start low (dose), go slow
(gradually increase the dose)."
Older adults with low protein levels may have increased risks of drug toxicity for drugs that are proteinbinding.
Points to Remember - Health Assessment
Health Assessment
Measure vital signs when the client is at rest.
Compare both sides of the body for symmetry.
Assess the systems related to the client's major complaint first.
Offer rest periods if client becomes tired.
Culture and religious beliefs may play a role in observed differences.
Warm hands and equipment such as stethoscope before touching client.
Tell client what you are going to do before touching client.
Normal variations exist among clients and there is a range of normalcy for all physical findings.
Maintain the client's privacy throughout the examination.
Control for environmental factors which may distort findings.
Check equipment prior to exam for functioning.
Consider growth and developmental needs when assessing specific age groups.
Integrate client teaching throughout the exam.
Vasculature
Compare blood pressure in both arms.
Compare blood pressure with client lying, sitting and standing.
Points to Remember - Health Assessment 2
Lungs - Airway
Anemic patients may never become cyanotic (and are more commonly a dusky-ashen color when
hypoxic).
Polycythemic patients may be cyanotic, even when oxygenation is normal.
Cough results from stimulation of irritant receptors, with implications of either acute or chronic etiology.
Cyanosis indicates decreased available oxygen; etiology can be either peripheral or central in origin.
Wheezes indicates narrowing/inflammatory process of lower airways.
Stridor is a harsh sound produced near the larynx by vibration of structures in upper airway, producing
the classic "barky cough."
Crackles or rales are adventitious sounds, usually heard on inspiration, and can be described as
"moist", "dry," "fine," and "coarse."
Breasts
Breast tissue shrinks with menopause.
Teach client breast self examination.
Abdomen
Auscultation should be performed before palpation to prevent distortion of bowel sounds.
Tightening of abdominal muscles hinders accuracy of palpation and auscultation.
Warm hands before touching client's abdomen.
Men breathe abdominally; women breathe costally.
Auscultate all four quadrants for bowel sounds; start in the lower right quadrant.
Auscultate abdomen between meals.
Points to Remember - Health Assessment 3
Musculoskeletal
Older adults walk with smaller steps and need a wider base of support.
Adolescents should be screened for scoliosis.
Neurological
Glasgow Coma Score: assesses eye opening (possible scores range from 1 to 4), verbal response
(possible scores range from 1 to 5), and motor response (possible scores range from 1 to 6)
not valid in patients who have used alcohol or other mind-altering drugs.
possibly not valid in patients who are hypoglycemic, in shock, or hypothermic (below 93 F [34 C]).
should be compared to total of 10 when client is intubated.
Reflexes are normally less brisk or even absent in older clients.
Reflex response diminishes in the lower extremities before the upper extremities are affected.
Absent reflexes may indicate neuropathy or lower motor neuron disorder, resulting in flaccidity.
Hyperactive reflexes suggest an upper motor neuron disorder, resulting in spasticity.
Teaching client and family
Teaching-learning process mirrors the nursing process.
Select teaching strategies that are compatible with the client's learning style, age, culture, level of
education.
Client teaching should be multi-sensory - tell (auditory), show (visual), have them demonstrate (tactile).
Always confirm the client's understanding of the information presented.
Teaching must be geared to the level of the learner - most written materials are written at the sixth to
eighth grade level.
Repeat key information and summarize main points at intervals.
Explain medical terminology in lay terms.
Determine the client's learning style and gear teaching methods to using that style.
Sequence information the way the client will use it.
Be concrete and use the simplest words and the shortest sentences when teaching low literacy clients
or any client under stress.

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VII.