🌱 Unit 2

Health Promotion · 16 topics

My own notes. Rewritten from scratch — nothing here is copied from a review module.

Ch 16Health Promotion and Disease Prevention

Health promotion is about helping clients move toward wellness before illness happens, while disease prevention is organized into three levels based on where the client is in the disease process. Exams almost always test whether you can classify a nursing action as primary, secondary, or tertiary prevention, so learn the levels by the timing of the intervention rather than by memorizing examples.

Primary preventionActions taken before disease exists, aimed at keeping it from ever developing: immunizations, seat belt and helmet use, smoking cessation classes, folic acid before pregnancy, safe-sex education. The client is healthy and has no signs of the condition.

Secondary preventionEarly detection and prompt treatment in someone who is asymptomatic or in an early stage: mammography, Pap test, colonoscopy, blood pressure and cholesterol screening, tuberculin skin testing, vision and hearing screening, developmental screening.

Tertiary preventionLimiting disability and restoring function after disease is established: cardiac rehab after myocardial infarction, physical therapy after stroke, teaching foot care to a client who already has diabetes, support groups, prosthetic training.

Modifiable vs nonmodifiable riskNonmodifiable risk factors include age, sex, race, genetics, and family history. Modifiable factors include tobacco use, diet, activity level, weight, alcohol, stress, and sun exposure. Teaching targets only the modifiable ones, but nonmodifiable risk raises screening priority.

Stages of behavior changePrecontemplation (no intent within 6 months), contemplation (intends within 6 months), preparation (intends within 30 days, taking small steps), action (change made, under 6 months), maintenance (sustained over 6 months). Match the intervention to the stage: give information in precontemplation, not a detailed exercise plan.

Health belief modelA client acts only when perceived susceptibility and perceived seriousness outweigh perceived barriers, and when a cue to action exists. This is why a client who feels fine skips screening, and why cost, transportation, and time must be addressed before education will work.

Levels of health care servicePrimary care is first contact and prevention (clinics, health departments, provider offices); secondary care is diagnosis and treatment of acute problems (hospitals, emergency departments); tertiary care is highly specialized (burn centers, transplant, oncology centers, rehabilitation).

Wellness beyond absence of diseaseHealth promotion addresses physical, emotional, social, spiritual, intellectual, and occupational dimensions. A client with a chronic illness can still be assessed as having high-level wellness if functioning and self-management are optimized.

Screening priorities are age-drivenScreening recommendations shift by decade, so tie each test to the age it starts: cervical cancer screening in the early twenties, colorectal screening in the mid forties, bone density in the mid sixties. Family history moves the start date earlier.

Classify by timing, not by setting: if the client does not yet have the disease it is primary, if the disease is present but not yet detected or symptomatic it is secondary, and if the disease is already diagnosed and you are preventing complications or disability it is tertiary.

Never administer a live attenuated vaccine to a client who is pregnant or significantly immunocompromised.

Ch 17Client Education

Client education is a formal nursing responsibility with its own version of the nursing process: assess readiness, plan objectives, implement teaching, and evaluate learning. Exam items usually turn on two things, assessing readiness and motivation before teaching anything, and evaluating learning by what the client demonstrates rather than what the client says.

Three learning domainsCognitive is knowledge and understanding (evaluate by having the client explain or answer questions). Affective is attitudes, values, and feelings (evaluate by expressed willingness and behavior change). Psychomotor is hands-on skill (evaluate only by return demonstration).

Assess before you teachDetermine readiness, motivation, current knowledge, literacy level, language, sensory deficits, cultural beliefs, and support system first. Teaching a client who is in pain, sedated, anxious, in denial, or hypoxic wastes the session.

Relieve barriers firstMedicate for pain roughly 30 minutes before a teaching session, ensure hearing aids and glasses are in place, empty the bladder, and reduce environmental noise. Physical need and severe anxiety block learning entirely.

Teach-back is the standardAsk the client to explain the information back in their own words or to perform the skill, rather than asking do you understand. A yes answer is not evaluation of learning.

Health literacyWritten materials should be at roughly a fifth to sixth grade reading level, use plain words instead of medical terms, use short sentences, and include pictures. Low literacy is often hidden behind statements like I forgot my glasses.

Adult learning principlesAdults learn best when the content is immediately relevant and problem-centered, when their previous experience is used, and when they help set the goals. Prioritize what the client wants to know first, then fill gaps.

Session structureKeep sessions short (roughly 20 to 30 minutes or less), teach the most important content first and last because those are retained best, cover one main idea at a time, and reinforce with written material the client takes home.

Adapting by age and abilityFor children use play, dolls, and simple concrete words with a parent present. For older adults use larger print, a lower-pitched voice, good non-glare lighting, slower pacing, and more repetition, and do not assume cognitive decline.

InterpretersUse a trained medical interpreter for any client with limited English proficiency, speak directly to the client rather than to the interpreter, and use short sentences. Family members, especially children, are not acceptable interpreters.

Document the teachingRecord what was taught, who was present, the method and materials used, the client response, and the evidence of learning such as a successful return demonstration. Undocumented teaching is legally treated as teaching that did not occur.

Readiness to learn is assessed before any teaching begins, and learning is evaluated by demonstration or teach-back, never by the client stating that they understand.

Never use a family member, and especially never use a child, as the interpreter for medical information or consent.

Ch 18Newborns and Infants (Birth to 1 Year)

The first year is the fastest period of growth in the lifespan, and exam questions center on whether a milestone or measurement is on time, and on the safety rules that prevent the leading causes of infant death. Know the weight and length rules, the fontanels, the month-by-month motor milestones, and the sleep and feeding safety rules cold.

Growth benchmarksBirth weight doubles by about 6 months and triples by 12 months. Length increases by about 50 percent in the first year. An initial weight loss of up to 10 percent in the first few days is expected, with return to birth weight by about 2 weeks.

FontanelsThe posterior fontanel closes by about 2 to 3 months; the anterior fontanel closes between 12 and 18 months. A bulging fontanel suggests increased intracranial pressure and a sunken fontanel suggests dehydration; both are assessed with the infant upright and calm.

Gross motor milestonesHead control by 4 months, rolling both directions by about 6 months, sitting unsupported by 8 months, crawling by 9 months, pulling to stand by 9 to 10 months, cruising by 11 months, and walking alone by 12 to 15 months.

Fine motor and languagePalmar grasp fades by 4 to 6 months, transfers objects hand to hand at 7 months, crude pincer grasp at 9 months and neat pincer by 10 to 12 months. Cooing at 2 months, babbling at 4 to 6 months, mama and dada nonspecifically at 8 to 9 months, and 3 to 5 words with meaning by 12 months.

Psychosocial and cognitiveErikson stage is trust versus mistrust, built by consistently and promptly meeting needs. Piaget stage is sensorimotor; object permanence emerges around 9 months, which is why peekaboo and stranger anxiety both appear between 6 and 8 months.

Vital sign rangesNewborn heart rate is roughly 110 to 160 per minute and respirations 30 to 60, dropping toward roughly 90 to 150 and 25 to 40 by late infancy. Respirations are abdominal and irregular; count for a full minute. Use the apical site for the pulse under 1 year.

Feeding rulesBreast milk or iron-fortified formula only for the first 6 months, then introduce iron-fortified cereal and single-ingredient foods, waiting 5 to 7 days between each new food to identify allergies. No honey before 12 months due to botulism risk, and no whole cow milk before 12 months.

Sleep safetyPlace infants supine on a firm mattress in their own crib with no pillows, bumpers, blankets, or stuffed toys, and avoid bed sharing. Supervised tummy time while awake prevents positional plagiocephaly.

Injury preventionRear-facing car seat in the back seat, never in front of an active airbag. Never leave the infant unattended on an elevated surface or in water, keep small objects and cords out of reach, and set the water heater at or below about 49 C (120 F).

Teeth and immunizationsFirst teeth erupt around 6 months, with roughly 6 to 8 teeth by 12 months; wipe gums and avoid bottles in bed to prevent early childhood caries. The primary immunization series clusters at 2, 4, and 6 months, with MMR and varicella given at 12 to 15 months.

Supine sleep on a bare firm surface, with no soft objects and no bed sharing, is the single most tested infant safety rule.

Never prop a bottle, put an infant to bed with a bottle, place an infant prone to sleep, or give honey or cow milk before 12 months.

Ch 19Toddlers (1 to 3 Years)

Toddlerhood is defined by a drive for independence colliding with almost no judgment about danger, so the content splits into normal behaviors that parents mistake for problems and the injury prevention that matters most at this age. Expect questions on negativism, ritualism, physiologic anorexia, parallel play, toilet training readiness, and aspiration and drowning risk.

Growth slows sharplyWeight gain drops to about 1.8 to 2.7 kg (4 to 6 lb) per year and height increases about 7.5 cm (3 in) per year. Birth weight quadruples by about 2.5 years. The pot-bellied, lordotic, bowlegged stance is normal.

Motor milestonesWalks alone by 15 months, runs and walks up stairs with two feet per step by 2 years, and climbs stairs with alternating feet and pedals a tricycle by 3 years. Builds a tower of about 6 to 7 cubes at 2 years.

LanguageAbout 10 words at 18 months expanding to roughly 300 words at 2 years, with two-word phrases by 2 years and three-word sentences by 3 years. By 3 years speech should be understandable to strangers about 75 percent of the time.

Psychosocial and cognitiveErikson stage is autonomy versus shame and doubt. Piaget moves from late sensorimotor into preoperational thinking around age 2, marked by egocentrism, magical thinking, and no grasp of cause and effect.

Expected behaviorsNegativism (saying no reflexively), ritualism (needing the same cup, same routine), temper tantrums, and physiologic anorexia from slowed growth are all normal. Play is parallel: toddlers play alongside each other, not together.

Toilet training readinessPhysiologic readiness (voluntary sphincter control) appears around 18 to 24 months and must be paired with psychologic readiness: staying dry about 2 hours, recognizing the urge, communicating it, walking to the toilet, and willingness to please. Bowel control precedes bladder control, and daytime precedes nighttime.

Vital signsHeart rate roughly 80 to 130 per minute, respirations roughly 20 to 30, and blood pressure roughly 85 to 100 over 50 to 65. Blood pressure measurement becomes routine at age 3.

Nutrition specificsWhole milk until age 2, then reduced fat, and limit milk to about 480 to 720 mL (16 to 24 oz) daily to prevent milk-induced iron deficiency anemia. Serving size is about 1 tablespoon of each food per year of age.

Aspiration and chokingAvoid hot dogs, whole grapes, nuts, popcorn, raw carrots, hard candy, chunks of peanut butter, and marshmallows. Small toy parts, latex balloons, and coins are equally dangerous.

Other injury prioritiesDrowning is a leading cause of death and can occur in a toilet, bucket, or tub. Keep the child rear-facing in a car seat until at least 2 years or the seat maximum, lock up medications and cleaners in original containers, turn pot handles inward, and post the poison control number.

Physiologic anorexia, negativism, ritualism, and parallel play are normal toddler findings that require parent reassurance and teaching, not intervention.

Never leave a toddler unattended around any water, including a bathtub, toilet, bucket, or pool, even for a moment.

Ch 20Preschoolers (3 to 6 Years)

Preschoolers think magically and literally at the same time, which drives both their fears and the way you must communicate with them. High-yield content is the fine-motor drawing sequence, associative play, initiative versus guilt, fear of bodily mutilation, and how to prepare this age group for procedures.

GrowthGains about 2 to 3 kg (4 to 6 lb) and 6 to 7.5 cm (2.5 to 3 in) per year. Body proportions slim out and the pot belly disappears; birth length doubles by about age 4.

Gross motor sequenceRides a tricycle and alternates feet on stairs at 3 years, hops on one foot and throws overhand at 4 years, and skips, jumps rope, and balances on one foot for several seconds at 5 years.

Fine motor and drawingCopies a circle at 3 years, a cross and a square at 4 to 5 years, and a triangle at 5 years. Draws a person with 3 parts at 3 years and 6 or more parts by 5 years. Ties shoes and uses scissors well by 5 years.

Psychosocial and cognitiveErikson stage is initiative versus guilt, so let the child start and finish projects and make simple choices. Piaget preoperational thinking brings egocentrism, animism (objects are alive), magical thinking, and the belief that illness is punishment.

Play and imaginationPlay becomes associative: children play together at a shared activity without formal organization or assigned roles. Imaginary playmates and dramatic play are normal and healthy at 3 to 4 years.

Fears and communicationThe dominant fears are the dark, being alone, monsters, and bodily mutilation. Use adhesive bandages over any wound or injection site, avoid literal-sounding phrases such as put to sleep, take your vitals, or dye, and allow the child to handle safe equipment.

Procedure preparationPrepare a preschooler shortly before the event, roughly 1 hour to a few hours ahead rather than days ahead, using simple concrete words, play, and a doll. Explain that the procedure is not a punishment.

Vital signsHeart rate roughly 80 to 120 per minute, respirations roughly 20 to 25, and blood pressure roughly 95 to 110 over 55 to 70. Respirations shift from abdominal to thoracic during this period.

SafetyUse a forward-facing harness car seat and then a booster in the back seat, insist on a bicycle helmet, teach street and stranger safety, begin swimming lessons with constant supervision, and teach that no one may touch private areas.

Sleep and screeningRequires about 11 to 13 hours of sleep including possible naps. Nightmares occur late in the night and the child recalls them; night terrors occur early and the child does not recall them and should not be fully awakened. Vision and hearing screening at this age detects amblyopia in time to treat it.

Preschoolers fear bodily harm and mutilation and think magically, so use simple concrete language, cover every wound with a bandage, and reassure that illness and procedures are not punishment.

Never use figurative or ambiguous medical language such as put you to sleep, take your blood, or a little stick with a preschooler; they interpret it literally.

Ch 21School-Age Children (6 to 12 Years)

School age is the most stable growth period of childhood, and the developmental work is competence: producing something real and comparing it to peers. Test content clusters around industry versus inferiority, concrete operational thinking, cooperative play and rules, tooth loss, and the shift of safety risks toward bicycles, sports, and firearms.

Steady growthGains about 2 to 3 kg (4 to 6 lb) and 5 cm (2 in) per year. Girls typically begin the pubertal growth spurt around 10 years and boys around 12, so girls are often temporarily taller.

PsychosocialErikson stage is industry versus inferiority. Children need to complete tasks, earn recognition, and see real products of their effort. Repeated failure or excessive criticism produces a sense of inferiority.

Cognitive stagePiaget concrete operations brings conservation (mass and volume stay the same when shape changes), reversibility, classification, and serial ordering. Thinking is logical only about tangible things, so teaching must use real objects and models rather than abstractions.

Peers and playPlay becomes cooperative and rule-governed with assigned roles, teams, and collections. Same-sex best friends and clubs dominate, and rules are seen as absolute. Peer approval starts to rival parental approval.

TeethDeciduous teeth begin falling out around 6 years at roughly 4 teeth per year, and most of the permanent teeth other than the third molars are in by about 12 years. Emphasize brushing, flossing, dental sealants, and mouth guards for sports.

Vital signsHeart rate roughly 70 to 110 per minute, respirations roughly 18 to 22, and blood pressure roughly 100 to 120 over 60 to 75. Values move steadily toward adult ranges through this stage.

Moral developmentKohlberg conventional level: the child follows rules to please others and to maintain social order, and judges an act by the amount of damage rather than the intent. Concepts of fairness and taking turns become central.

ScreeningScreen for scoliosis around ages 10 to 12, especially in girls, by having the child bend forward at the waist with arms hanging and observing for rib hump and asymmetry. Continue annual vision, hearing, blood pressure, and body mass index screening.

Safety prioritiesBicycle, skateboard, and sports injuries plus motor vehicle crashes dominate. Require helmets, teach water safety and never swimming alone, secure firearms unloaded and locked with ammunition stored separately, and keep the child in a booster seat until the seat belt fits properly at about 145 cm (4 ft 9 in), and in the back seat until age 13.

Teaching approachExplain equipment and procedures with accurate simple terms and diagrams, allow the child privacy and modesty, and give real choices about timing or which arm. Include the child directly, not just the parent.

School-age children are in industry versus inferiority and think concretely, so teaching and coping strategies should involve real objects, clear rules, accomplishment, and praise for effort.

Never allow a school-age child to ride a bicycle, scooter, or skateboard without a properly fitted helmet, and never leave a firearm accessible or unlocked in the home.

Ch 22Adolescents (12 to 20 Years)

Adolescence combines rapid physical maturation with brand-new abstract thinking and a strong sense of invulnerability, which is why the leading causes of death are all preventable and behavioral. Know identity versus role confusion, formal operational thinking, the sequence of puberty, and the confidentiality rules for interviewing a teen.

PsychosocialErikson stage is identity versus role confusion. The adolescent experiments with roles, appearance, and values, and relies heavily on peer group for identity. Failure produces role confusion and a poorly defined sense of self.

Cognitive stagePiaget formal operations allows abstract reasoning, hypothetical thinking, and long-range planning. It also generates the personal fable (nothing bad will happen to me) and the imaginary audience (everyone is watching me), which underlie risk taking and self-consciousness.

Puberty in femalesThe first sign is breast budding, typically between 8 and 13 years, followed by pubic hair, the growth spurt, and then menarche roughly 2 to 2.5 years after breast budding, on average around 12 to 13 years. Cycles are often irregular for the first year or two.

Puberty in malesThe first sign is testicular and scrotal enlargement, typically between 9 and 14 years, followed by pubic hair, penile growth, the growth spurt, voice change, and nocturnal emissions. Boys mature about 2 years later than girls and their growth spurt peaks later.

Vital signs reach adult valuesHeart rate roughly 55 to 90 per minute, respirations roughly 12 to 20, and blood pressure roughly 110 to 125 over 65 to 80. Athletic adolescents may have resting heart rates in the 50s.

Leading causes of deathUnintentional injury, primarily motor vehicle crashes, is first, followed by suicide and homicide. Counsel about seat belts, no texting or impaired driving, limiting teen passengers, and helmet use, and screen for depression and suicidal ideation at every opportunity.

NutritionCaloric and protein needs peak during the growth spurt. Iron needs rise in both sexes, especially in menstruating females, and calcium requirement rises to about 1300 mg daily because peak bone mass is being laid down. Screen for disordered eating, skipped meals, and energy drink use.

Interview approachInterview the adolescent alone for part of the visit, explain the limits of confidentiality up front, ask open-ended nonjudgmental questions about sexual activity and substance use, and address body image and acne concerns seriously.

Screening and immunizationContinue scoliosis, vision, hearing, blood pressure, and body mass index screening; screen for sexually transmitted infections in sexually active teens. Adolescent immunizations include the tetanus-diphtheria-pertussis booster, meningococcal vaccine with a booster at 16, human papillomavirus series, and annual influenza.

Hospitalization needsPreserve privacy and control, allow personal clothing, music, and phone contact, encourage peer visits, and give choices about the plan of care. The greatest stressors are loss of independence, altered body image, and separation from peers.

Motor vehicle crashes are the leading cause of adolescent death and the personal fable explains why teens knowingly take those risks; anticipatory guidance targets driving, substance use, and firearm and suicide risk.

Never promise an adolescent unconditional confidentiality; disclosures involving suicide, homicide, or abuse must be reported.

HEADSSS interview: Home, Education and employment, Activities, Drugs, Sexuality, Suicide and depression, Safety.

Ch 23Young Adults (20 to 35 Years)

Young adulthood is the physical peak of the lifespan, which is exactly why this group underestimates risk and skips preventive care. Exam content focuses on intimacy versus isolation, the preventable causes of death, the screenings that begin in the twenties, and preconception and reproductive health teaching.

PsychosocialErikson stage is intimacy versus isolation. The task is forming committed relationships and a stable social network without losing personal identity; failure results in isolation and superficial relationships.

Physical statusMuscle strength, cardiac output, reaction time, and reproductive capacity peak in the twenties and begin a slow decline in the early thirties. Because the client feels well, prevention counseling is more important than treatment.

Leading causes of deathUnintentional injury (motor vehicle crashes, overdose), suicide, and homicide predominate over disease. Counsel on seat belts, impaired and distracted driving, substance use, firearm safety, and mental health access.

Routine screeningBlood pressure at least every 2 years when normal, lipid and glucose screening based on risk, body mass index at every visit, dental exams, skin checks, and screening for depression, intimate partner violence, and alcohol and tobacco use.

Reproductive screeningCervical cancer screening begins at age 21, typically every 3 years with cytology through age 29. Annual chlamydia and gonorrhea screening is recommended for sexually active women under 25, plus human immunodeficiency virus screening at least once.

Self-examination teachingTeach breast self-awareness and prompt reporting of any lump, dimpling, or nipple discharge, and teach monthly testicular self-examination, ideally after a warm shower, since testicular cancer peaks between roughly 15 and 35 years.

ImmunizationsAnnual influenza vaccine, a tetanus and diphtheria booster every 10 years with one dose containing pertussis, human papillomavirus series if not completed, and catch-up measles-mumps-rubella and varicella. Pertussis-containing vaccine is given during each pregnancy.

Preconception careAdvise 400 to 800 mcg of folic acid daily for any woman capable of becoming pregnant to prevent neural tube defects, review medications for teratogenicity, and counsel on complete abstinence from alcohol during pregnancy.

Lifestyle risksTarget the habits that set up midlife disease: tobacco and vaping, binge drinking, sedentary work, fast food and weight gain, tanning and unprotected sun exposure, and untreated stress. Recommend about 150 minutes of moderate activity weekly plus muscle strengthening twice weekly.

Common stressorsCareer establishment, higher education debt, partner selection, parenting, and moving away from the family of origin. Assess sleep, coping, and support system, since this is a common age of onset for anxiety, depression, and bipolar and psychotic disorders.

Young adults die of preventable injuries and behaviors rather than disease, so screening, injury prevention, and mental health assessment take priority even when the client reports feeling perfectly healthy.

Never prescribe, teach about, or administer a potentially teratogenic medication or a live vaccine to a woman of childbearing age without first determining pregnancy status.

Ch 24Middle Adults (35 to 65 Years)

Middle adulthood is when the effects of earlier lifestyle become measurable disease and when the major cancer and cardiovascular screenings start. High-yield content is generativity versus stagnation, the physical changes of midlife including menopause and presbyopia, and the ages at which specific screenings begin.

PsychosocialErikson stage is generativity versus stagnation. The task is contributing to the next generation through parenting, mentoring, community involvement, or meaningful work; failure produces self-absorption and a sense of stagnation.

Sensory changesPresbyopia, the loss of near focusing from decreased lens elasticity, typically becomes noticeable around age 40 and is why reading material is held at arm length. High-frequency hearing loss also begins in this period.

MenopausePerimenopausal changes usually begin in the mid to late forties, and menopause is defined retrospectively after 12 consecutive months without menses, occurring on average around age 51. Estrogen loss brings vasomotor symptoms, vaginal dryness, and accelerated bone loss.

Body composition and metabolismBasal metabolic rate declines and lean muscle mass is gradually lost, so weight accumulates centrally even with unchanged intake. Blood pressure and low-density lipoprotein tend to rise, and insulin resistance increases.

Cancer screening agesColorectal cancer screening now begins at age 45 for average-risk adults. Mammography is typically offered starting at age 40, with screening at least every 2 years from age 50 through 74. Earlier and more frequent screening applies with family history or genetic risk.

Cardiometabolic screeningLipid panel and blood pressure at regular intervals, with normal blood pressure defined as under 120 over 80. Screen for type 2 diabetes in adults with overweight or obesity beginning in the mid thirties, and calculate cardiovascular risk to guide statin discussion.

ImmunizationsRecombinant zoster vaccine is given as a two-dose series starting at age 50. Continue annual influenza, tetanus and diphtheria every 10 years, and add pneumococcal vaccination for those with chronic conditions or immunocompromise.

Leading causes of deathCancer and heart disease dominate this age group. Because women often present with atypical cardiac symptoms such as fatigue, jaw or back pain, nausea, and dyspnea rather than crushing chest pain, symptom reports require cardiac evaluation.

Psychosocial stressorsThe sandwich generation strain of raising children while caring for aging parents, launching adult children, divorce, caring for a spouse with illness, career plateau, and retirement planning. Assess caregiver burden and sleep quality.

Health promotion focusWeight-bearing and resistance exercise to preserve bone and muscle, calcium and vitamin D intake, smoking cessation with immediate cardiovascular benefit, alcohol limits, sleep hygiene, and skin cancer surveillance for changing moles.

Match the screening to the age it begins: colorectal screening at 45, mammography discussion at 40 with routine screening by 50, and shingles vaccination at 50.

Never attribute new fatigue, dyspnea, indigestion, or jaw or back pain in a middle-aged woman to stress or menopause without ruling out acute coronary syndrome.

Ch 25Older Adults (65 Years and Older)

The core skill in geriatric nursing is separating normal age-related change from pathology, because treating disease as normal aging delays care and treating normal change as disease causes harm. Expect questions on integrity versus despair, altered drug handling, atypical presentation of illness, delirium versus dementia, and fall prevention.

PsychosocialErikson stage is integrity versus despair. Life review and reminiscence are therapeutic and should be encouraged; despair appears as regret, bitterness, and fear of death. Losses of spouse, peers, role, and independence drive depression risk.

Normal aging changesExpected findings include decreased skin elasticity, thinner skin, gray hair, kyphosis and height loss, decreased muscle mass, slower reaction time, presbyopia, presbycusis with high-frequency loss, decreased thirst sensation, reduced bladder capacity, and slower gastric emptying.

Not normal agingConfusion, incontinence, depression, severe memory loss, falls, and significant functional decline are never normal aging and must be investigated. New-onset confusion is often the first sign of infection, hypoxia, dehydration, or medication toxicity.

Cardiovascular and vital sign shiftsArterial stiffening raises systolic pressure and widens the pulse pressure, and blunted baroreceptor response causes orthostatic hypotension. Baseline body temperature is lower, so a serious infection may occur without a classic fever, and maximum heart rate response to stress is reduced.

Medication safetyDecreased renal clearance, decreased hepatic metabolism, decreased serum albumin, and increased body fat prolong drug effects. Start low and go slow, review for polypharmacy and duplicate therapy at every visit, and be alert to high-risk drug classes such as benzodiazepines, anticholinergics, sedative hypnotics, and first-generation antihistamines.

Hydration assessmentSkin turgor over the hand or forearm is unreliable because of decreased elasticity. Assess hydration using oral mucous membranes, tongue furrows, urine output and concentration, daily weight, and mentation, and offer fluids on a schedule since thirst is diminished.

Delirium versus dementiaDelirium is acute in onset over hours to days, fluctuates, impairs attention, is often accompanied by altered consciousness, and is reversible when the cause is treated. Dementia is gradual over months to years, progressive, and irreversible, with consciousness preserved until late. Depression can mimic both and typically features an I do not know response pattern.

Fall preventionFalls are the leading cause of injury and injury death in this population. Interventions include removing throw rugs and clutter, adequate non-glare lighting, grab bars and raised toilet seats, non-skid footwear, keeping the bed low with the call light in reach, rising slowly in stages, vision correction, and reviewing sedating medications.

Communication techniqueFace the client, ensure hearing aids and glasses are in place, speak at a normal pace in a lower pitch rather than shouting, reduce background noise, allow extra response time, and address the client directly rather than the family member.

Immunizations and screeningAnnual influenza, pneumococcal vaccination, recombinant zoster series, respiratory syncytial virus vaccine per current recommendations, and tetanus and diphtheria every 10 years. Screen for depression, cognition, functional status in activities of daily living, elder mistreatment, and bone density in women at 65.

In an older adult, an acute change in mental status is a medical emergency and a common first sign of infection, hypoxia, dehydration, or drug toxicity; it is never dismissed as normal aging.

Never assess an older adult for dehydration using skin turgor alone, and never assume new confusion, incontinence, or a fall is simply part of getting old.

SPICES screening: Sleep disorders, Problems with eating or feeding, Incontinence, Confusion, Evidence of falls, Skin breakdown.

Ch 26Data Collection and General Survey

This topic covers where assessment data comes from, how it is classified, and the physical techniques used to gather it. The two things most reliably tested are distinguishing subjective from objective data and knowing the order of examination techniques, including the abdominal exception.

Subjective versus objectiveSubjective data are what the client reports and cannot be verified by the nurse: pain, nausea, dizziness, itching, anxiety. Objective data are observed or measured: blood pressure, a rash, guarding, a wound measurement, laboratory values. Document subjective data in the client's own words with quotation marks.

Data sourcesThe client is the primary source. Family, medical records, other providers, and diagnostic results are secondary sources. Use secondary sources when the client is an infant, unresponsive, confused, or unable to communicate.

Types of assessmentA comprehensive assessment is a full head-to-toe database completed on admission. A focused assessment targets a specific problem or body system. An emergency assessment is a rapid airway, breathing, circulation evaluation. Ongoing assessment compares current findings to the baseline.

Order of techniquesInspection, then palpation, then percussion, then auscultation for every region except the abdomen. For the abdomen, auscultate before percussing or palpating because touching the abdomen alters bowel sounds.

Palpation depthLight palpation depresses about 1 to 2 cm and assesses surface texture, temperature, moisture, and tenderness; use it first and everywhere. Deep palpation depresses about 4 to 5 cm to assess organs and masses; use the palmar surface of the fingers for texture and the dorsum of the hand for temperature.

Percussion tonesFlatness over bone and muscle, dullness over dense organs such as the liver or a full bladder, resonance over normal lung, hyperresonance over hyperinflated lung as in emphysema or pneumothorax, and tympany over air-filled structures such as the gastric bubble and intestine.

Stethoscope selectionUse the diaphragm, pressed firmly, for high-pitched sounds: normal breath sounds, bowel sounds, and normal heart sounds S1 and S2. Use the bell, held lightly, for low-pitched sounds: S3, S4, murmurs, and bruits. Warm the stethoscope and place it on bare skin.

General survey componentsFormed within the first moments of contact: overall physical appearance and apparent versus stated age, body structure and nutritional status, mobility and gait, posture, behavior including facial expression, mood, speech, hygiene and dress, level of consciousness, and any odors. Include height, weight, body mass index, and vital signs.

Body mass index interpretationUnder 18.5 is underweight, 18.5 to 24.9 is normal, 25 to 29.9 is overweight, and 30 or above is obese. Waist circumference and unintentional weight change over time carry additional risk meaning.

Examination sequence rulesCompare bilaterally and symmetrically, assess the unaffected side before the affected side, examine painful or tender areas last, use standard precautions and hand hygiene, provide privacy and warmth with only the area being examined exposed, and organize the exam to limit position changes for the client.

Inspection always comes first, and the abdomen is the one region assessed as inspection, auscultation, percussion, palpation because palpating or percussing first changes bowel sounds.

Never palpate or percuss the abdomen before auscultating it, and never deeply palpate a pulsating midline abdominal mass or a Wilms tumor.

IPPA for every region; the abdomen flips to IAPP (Inspect, Auscultate, Percuss, Palpate).

Ch 27Vital Signs

Vital signs are the fastest objective indicator of a change in condition, and the exam expects you to know normal adult ranges, how those ranges shift by age, and the technique errors that produce false readings. Interpretation matters more than measurement: an abnormal value is compared to the client's own baseline and trend before any action is taken.

Normal adult rangesTemperature about 36.5 to 37.5 C (97.6 to 99.6 F) with an average of 37 C (98.6 F); heart rate 60 to 100 per minute; respirations 12 to 20 per minute; blood pressure under 120 over 80; oxygen saturation 95 to 100 percent.

Blood pressure categoriesNormal is under 120 over 80, elevated is 120 to 129 systolic with diastolic under 80, stage 1 hypertension is 130 to 139 or 80 to 89, and stage 2 is 140 or higher or 90 or higher. Confirm an abnormal reading with repeat measurements on separate occasions.

Temperature route differencesRectal readings run about 0.5 C (roughly 1 F) higher than oral and axillary readings run about 0.5 C lower than oral. Fever is generally defined as 38 C (100.4 F) or higher. Wait 15 to 30 minutes after hot or cold intake or smoking before an oral reading.

Age variations in heart rateNewborn about 110 to 160, infant about 90 to 150, toddler about 80 to 130, preschooler about 80 to 120, school-age about 70 to 110, adolescent about 55 to 90, adult 60 to 100. Rates fall and blood pressure rises steadily with age.

Age variations in respirationsNewborn 30 to 60, infant 25 to 40, toddler 20 to 30, preschooler 20 to 25, school-age 18 to 22, adolescent and adult 12 to 20. Infants and young children breathe abdominally and irregularly, so count for a full minute.

Pulse techniqueCount a regular radial pulse for 30 seconds and double it; count for a full minute if it is irregular, if the client is under 1 year, or before giving digoxin. Use the apical site at the fifth intercostal space, left midclavicular line. A pulse deficit is the apical rate minus the radial rate, counted simultaneously by two nurses.

Pulse amplitude scale0 is absent, 1 plus is weak or thready, 2 plus is normal, 3 plus is increased or full, and 4 plus is bounding. Always compare the same pulse bilaterally, and check capillary refill of under 3 seconds alongside it.

Blood pressure cuff errorsThe bladder width should be about 40 percent of the arm circumference and the bladder should encircle about 80 percent of the arm. A cuff that is too narrow or applied too loosely gives a falsely high reading; a cuff that is too wide gives a falsely low reading. The arm positioned above heart level reads falsely low and below heart level reads falsely high, and crossed legs or a full bladder raise the reading.

Orthostatic hypotensionMeasure blood pressure and heart rate supine, then sitting, then standing, waiting 1 to 3 minutes between positions. A drop of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within 3 minutes of standing, often with a compensatory heart rate rise, is positive. Return the client to a safe position immediately if dizziness occurs.

Respiration and pulse oximetry pitfallsCount respirations without telling the client, ideally while appearing to still hold the pulse, because awareness alters the rate. Pulse oximetry is unreliable with poor perfusion, hypothermia, vasoconstriction, motion, dark nail polish or artificial nails, and gives falsely normal readings in carbon monoxide poisoning.

An abnormal vital sign is interpreted against the client's own baseline and trend, and any measurement outside the expected range is rechecked with correct technique and equipment before it is acted on or reported.

Never take a rectal temperature in a client who is neutropenic, thrombocytopenic, has diarrhea, or has had rectal or perineal surgery, and never take blood pressure in an arm with a dialysis access, an intravenous line, or a mastectomy with node dissection.

Ch 28Head and Neck

This is the systematic inspection and palpation of the skull, face, eyes, ears, nose, sinuses, mouth, lymph nodes, thyroid, and trachea. Exam items almost always hinge on one thing: knowing which finding is expected and which one demands a call to the provider. Master the paired hearing and vision tests, because they separate types of deficit rather than just detecting them.

Sequence and toolsMove head to toe, inspect before you palpate, and compare side to side for symmetry at every step. Use the ophthalmoscope in a darkened room and the otoscope with the adult pinna pulled up and back, the child's (under 3) pulled down and back.

Pupil assessmentExpected pupils are round, equal, roughly 2 to 6 mm, and briskly constrict to light both directly and consensually while accommodating to a near object. A newly unequal, sluggish, or fixed dilated pupil suggests rising intracranial pressure and is an emergency, though about one in five people have benign lifelong slight inequality.

Extraocular movementHold the patient's chin, move a target through the six cardinal fields of gaze, and watch both eyes track together; this screens cranial nerves III, IV, and VI. A few beats of end-point nystagmus at extreme lateral gaze are normal, but sustained nystagmus, lid lag, or one eye that fails to track is abnormal.

Weber and RinneWeber places a vibrating tuning fork on the skull midline; normally sound is heard equally in both ears. Conductive loss makes sound lateralize toward the bad ear, sensorineural loss lateralizes it toward the good ear. Rinne compares air to bone conduction at the mastoid: air conduction lasting about twice as long as bone is normal, while bone equal to or longer than air signals conductive loss.

Lymph node red flagsPalpate with the finger pads in gentle circles down the chain. Nodes that are small, soft, mobile, and either nontender or mildly tender suggest infection or are simply normal residual nodes; nodes that are hard, fixed to underlying tissue, irregular, and painless raise concern for malignancy.

Thyroid techniqueStand behind or in front of the patient, locate the isthmus below the cricoid, and have the patient sip and swallow water so the gland rises under your fingers. A normal thyroid is often not palpable at all; if it is enlarged, auscultate for a bruit, which reflects the increased vascularity of hyperthyroidism.

Trachea and neck vesselsThe trachea should sit midline in the suprasternal notch. Deviation toward one side points to a mass, atelectasis, or a tension pneumothorax pushing structures away from the affected lung, and it is an urgent finding.

Mouth lesions that matterWhite curd-like patches that wipe away and leave a reddened, sometimes bleeding base indicate candidiasis. Thick white plaques that will not scrape off are leukoplakia, which is considered precancerous and must be referred; so must any oral ulcer persisting beyond about two weeks.

Infant head findingsThe posterior fontanel typically closes by around two months and the anterior by roughly 12 to 18 months. A bulging, tense fontanel in a quiet infant suggests increased intracranial pressure, while a sunken one suggests dehydration; both need reporting.

Vision screeningSnellen testing at 20 feet records the smallest line read with each eye and both; 20/40 means the patient sees at 20 feet what a normal eye sees at 40. Always test with corrective lenses in place and document that they were worn.

Weber lateralizes to the impaired ear in conductive loss and to the better ear in sensorineural loss; if you remember only one head-and-neck rule, remember that one.

Never palpate both carotid arteries at the same time, and never palpate a carotid vigorously, because you can drop cerebral perfusion or trigger a reflex bradycardia.

PERRLA: Pupils Equal, Round, Reactive to Light, and Accommodation.

Ch 29Thorax, Heart, and Abdomen

These three regions share one exam skill set but not one order of operations, and that difference is a classic test point. You need the auscultation landmarks, the meaning of each adventitious sound, and the abnormal findings that stop the exam entirely. Think of every finding as a question: fluid, air, or tissue?

Order of techniquesChest and heart follow inspect, palpate, percuss, auscultate. The abdomen changes the order to inspect, auscultate, percuss, palpate, because touching the belly first can artificially change bowel sound activity.

Normal breath soundsVesicular sounds are soft and breezy over most peripheral lung fields with a longer inspiration. Bronchovesicular sounds are medium pitched with equal phases over the main bronchi and between the scapulae, and bronchial sounds are loud and harsh with a longer expiration over the trachea. Hearing bronchial sounds out in the periphery indicates consolidation.

Adventitious soundsFine crackles are brief popping sounds from alveoli reopening in fluid or atelectasis and do not clear with coughing. Wheezes are musical and reflect narrowed airways, rhonchi are low and snoring and often clear after a cough, a pleural friction rub grates like leather, and stridor is a high crowing sound over the upper airway that signals an emergency.

Fremitus and percussionHave the patient repeat a resonant phrase such as ninety-nine while you feel with the ball of your hand; vibration increases over consolidated lung and decreases over pleural effusion, pneumothorax, or hyperinflated emphysematous lung. Percussion is resonant over normal lung, dull over fluid or solid tissue, and hyperresonant when air is trapped.

Cardiac landmarksAortic is the second right intercostal space, pulmonic the second left, Erb's point the third left, tricuspid the fourth to fifth left sternal border, and mitral the fifth intercostal space at the midclavicular line, which is also where you find the apical impulse.

Heart soundsS1 is closure of the mitral and tricuspid valves and is loudest at the apex; S2 is closure of the aortic and pulmonic valves and is loudest at the base. An S3 gallop just after S2 suggests volume overload or heart failure in adults, though it can be normal in children and pregnancy, while an S4 before S1 reflects a stiff, noncompliant ventricle.

Apical pulse ruleCount the apical pulse for a full minute whenever the rhythm is irregular, the patient is an infant or child, or you are about to give digoxin. Withhold digoxin and notify the provider for an adult apical rate under 60.

Bowel soundsUse the diaphragm and listen in all four quadrants; normal sounds are irregular gurgles roughly 5 to 30 times per minute. Hyperactive high-pitched rushes suggest early mechanical obstruction or gastroenteritis; you must listen a full 5 minutes in a quadrant before charting absent sounds, which suggest ileus or late obstruction.

Abdominal palpation setupHave the patient empty the bladder, lie supine with knees flexed and arms at the sides, and warm your hands. Palpate lightly about 1 cm first, then deeper if indicated, and always save the area the patient identifies as painful for last.

Peritoneal irritationRebound tenderness, meaning pain that is worse when you release pressure than when you apply it, indicates peritoneal inflammation. Point tenderness at McBurney's point in the right lower quadrant, with guarding and a rigid boardlike abdomen, points toward appendicitis and possible perforation.

Auscultate the abdomen before you percuss or palpate it, and count the apical pulse for a full minute before giving digoxin, holding the dose if it is below 60 in an adult.

Never deeply palpate an abdomen with a visibly pulsating mass or an audible aortic bruit, and never deeply or repeatedly palpate a suspected appendicitis or a child's suspected Wilms tumor; you can cause rupture.

APE To Man for auscultation sites: Aortic, Pulmonic, Erb's point, Tricuspid, Mitral.

Ch 30Integumentary and Peripheral Vascular Systems

Skin and circulation are assessed together because most skin findings are really perfusion findings. Exams focus on pressure injury staging, telling arterial from venous disease, and recognizing color changes in patients with darker skin. The interventions reverse between arterial and venous problems, which is exactly why it gets tested.

Basic techniqueInspect in good, preferably natural light and use the dorsum of your hand to judge temperature because it is more heat sensitive. Check turgor over the sternum or clavicle rather than the hand in older adults, since loss of elasticity there gives a false positive for dehydration.

Color in darker skinAssess cyanosis in the conjunctivae, oral mucosa, palms, soles, and nail beds rather than by overall skin tone. Jaundice shows earliest in the sclera and hard palate, pallor in the mucous membranes and conjunctivae, and erythema is often better detected by warmth and induration than by redness.

Lesion screeningAny lesion that is asymmetric, has an irregular or notched border, contains more than one color, exceeds about 6 mm, or has changed in size, shape, sensation, or bleeding warrants urgent referral. Change over time is the most significant single feature.

Pressure injury stagesStage 1 is intact skin with nonblanchable erythema. Stage 2 is partial thickness loss with a shallow pink wound bed or an intact or ruptured serum-filled blister. Stage 3 exposes subcutaneous fat but not deeper structures, and Stage 4 exposes muscle, tendon, cartilage, or bone.

Unstageable and deep tissueA wound whose base is obscured by slough or eschar is unstageable until the base is visible. A deep tissue pressure injury is intact or blistered skin with persistent nonblanchable deep red, maroon, or purple discoloration, and it can deteriorate rapidly even with treatment.

Prevention specificsReposition patients in bed at least every 2 hours and seated patients about every hour, keep the head of bed at 30 degrees or lower when tolerated to limit shear, and lift rather than drag. Screen risk with the Braden Scale, where a lower total score means higher risk.

Pulse gradingGrade pulses 0 for absent, 1+ for weak or thready, 2+ for normal, 3+ for increased, and 4+ for bounding. If a pulse is not palpable, use a Doppler before concluding it is absent, and mark the site with an indelible pen so subsequent checks compare the same spot.

Arterial insufficiencyLook for intermittent claudication relieved by rest, pain that worsens with elevation and eases with dangling, cool and shiny hairless skin, thickened nails, weak or absent pulses, and pale elevation with dependent rubor. Ulcers are on the toes, heels, or lateral malleolus, round and punched out with minimal drainage.

Venous insufficiencyLook for a dull aching heaviness relieved by elevation, warm skin, dependent edema, and brownish hemosiderin staining around the ankles. Ulcers sit near the medial malleolus with irregular borders and heavy exudate; treatment is elevation and graduated compression.

DVT and compartment cluesSuspect deep vein thrombosis with unilateral calf swelling, warmth, redness, and tenderness; measure and compare calf circumferences bilaterally. The classic six warning signs of acute arterial or compartment compromise are pain out of proportion, pallor, pulselessness, paresthesia, paralysis, and poikilothermia.

Elevate the legs for venous insufficiency and keep them dependent for arterial insufficiency, and never apply compression stockings to a limb with arterial disease.

Never massage a reddened bony prominence or a calf suspected of harboring a deep vein thrombosis; massage worsens tissue damage and can dislodge a clot.

ABCDE for suspicious lesions: Asymmetry, Border, Color, Diameter, Evolving.

Ch 31Musculoskeletal and Neurologic Systems

This pairing is about grading: strength, reflexes, and level of consciousness all use numeric scales you must be able to apply. The second theme is localization, meaning whether a deficit is cortical, cerebellar, or peripheral. A change from the patient's own baseline outranks any single number.

Muscle strength scaleScore 0 for no contraction, 1 for a flicker, 2 for movement only with gravity eliminated, 3 for movement against gravity alone, 4 for movement against some resistance, and 5 for full strength against full resistance. Always compare right to left.

Range of motion rulesAssess active range first and only move to passive if the patient cannot move the joint independently. Stop at the point of pain or resistance, support the joint above and below, and never force a joint past its limit.

Reflex gradingDeep tendon reflexes run 0 for absent, 1+ diminished, 2+ normal, 3+ brisker than average, and 4+ hyperactive with clonus. Exaggerated reflexes suggest an upper motor neuron problem, while diminished or absent reflexes suggest lower motor neuron or peripheral nerve involvement.

Glasgow Coma ScaleScore eye opening out of 4, verbal response out of 5, and motor response out of 6, for a range of 3 to 15. A total of 8 or less generally means the patient cannot protect the airway and needs intubation.

Abnormal posturingDecorticate posturing is flexion of the arms in toward the core with extended legs and indicates cerebral hemisphere injury. Decerebrate posturing is rigid extension and inward rotation of all extremities, indicates brainstem injury, and is the more ominous of the two; progression from decorticate to decerebrate signals deterioration.

Cerebellar testingUse finger-to-nose, heel-to-shin, rapid alternating movements, and tandem heel-to-toe walking. In the Romberg test the patient stands with feet together and eyes closed; minimal sway is normal, but losing balance is a positive, abnormal result, so stand close enough to catch them.

Sensory testingTest with the patient's eyes closed, compare sides symmetrically, and move from distal to proximal in a random pattern so the patient cannot anticipate. Include light touch, sharp versus dull, vibration, position sense, and cortical functions such as stereognosis and graphesthesia.

Expected aging changesDecreased muscle mass and grip strength, slowed reaction time, mild kyphosis, reduced vibratory sensation in the feet, and a diminished Achilles reflex are all expected with age. New confusion, disorientation, or a change in level of consciousness is never a normal aging change and must be investigated.

Rising intracranial pressureThe earliest and most sensitive sign of neurologic deterioration is a change in level of consciousness, often subtle restlessness or difficulty rousing. The triad of widening pulse pressure with rising systolic, bradycardia, and irregular respirations is a very late finding of brainstem compression.

Stroke recognitionScreen with sudden facial droop, unilateral arm drift, slurred or garbled speech, and note the exact time the patient was last known well, because that time determines eligibility for thrombolytics. Keep the patient NPO until a swallow screen is passed.

A change in level of consciousness from the patient's own baseline is the earliest neurologic warning sign; do not wait for vital sign changes, which come late.

Never move the neck or perform range of motion on a patient with a suspected spinal injury, and never force any joint through motion it resists.

Glasgow Coma Scale is Eyes 4, Verbal 5, Motor 6, totaling 15.