Health Promotion and Maintenance

I.
Family Planning
A. Contraception - the voluntary prevention of pregnancy
1. Attitudes toward contraception
a. shaped by religion and culture
b. influenced by family's attitudes
c. affected by socioeconomic status
2. Contraception only works if the user
a. accepts the method
b. understands it
c. is motivated to use it correctly
3. Nurse's role in family planning
a. explain all available methods
b. discuss effectiveness, benefits, and drawbacks of each
method
c. discuss how the user feels about contraception
d. have user explain chosen method ("say back")
e. clarify any misunderstandings
Methods of Contraception
A. Fertility awareness methods:
1. Calendar - estimate date of ovulation based on length of cycle
(rhythm method)
2. Basal body temperature - identifies ovulation by drop and rise in
temperature
3. Cervical musus method- identifies ovulation by increase in mucus

amount and stretchability.
B. Chemical agents, that destroy or immobilize sperm- creams, foams, jellies,
or suppositories
C. Mechanical barrier methods
1. Diaphragm- covers the external os
Disadvantage: must be fitted, provides no protection against
STD's and risk of TSS (toxic shock syndrome)
Most effective when used with a chemical agent
2. Condom:
Disadvanteage: decreases penile sensation and spontaneity
Advantage: inexpensive, accessible, and reduces spread of
STD's
D. Oral Contraceptives- hormones suppress ovulation
1. Single-hormone therapy - Estrogen given two weeks to suppress
LH and FSH. Progesterone given daily to make cervical mucus
impervious to sperm.
2. Combined-hormone therapy - combination of estrogen and
progesterone on a 25-day cycle.
Bleeding starts one to four days after the last pill.
Contraindications: family history of stroke, migraines,
hypertension, diabetes, chronic renal disease,
thrombophlebitis, tobacco use- smoking
Side effects: nausea and vomiting, edema and weight gain,
breakthrough bleeding, thrombophlebitis, pulmonary
embolism, stroke
E. Intrauterine devices - thought to prevent implantation
1. Side effects: heavy menstrual bleeding, severe cramping, bleeding
between periods
2. Complications: uterine perforation, infections
F. Long-acting methods
1. Implantable progestin (Norplant) - five years
2. Injectable progestin (Depo Provera) - one to three months
G. Permanent contraception
1. Male sterilization- vasectomy
2. Female steriization- tubal ligation, hypterectomy (removal of uterus)
Nurses Role in Family Planning

A. Ideally extends from pregnancy through follow-up
B. The nurse works with the woman, her partner, provider of care -
reinforcement of education
C. Address use, questions, and concerns about birth control methods
1. Build trust; acknowledge cultural and religious factors
2. Ask about prior use and knowledge
3. Address lifestyle and desire for more children
4. Include safe-sex practices and abstinence
5. If indicated, refer client to a class on a specific method of
contraception such as natural family planning
6. Refer to MD, CNM, or Nurse Practitioner for methods that require a
prescription or special fit (oral contraceptives, Norplant, diaphragm,
IUD)
7. Refer client to MD for sterilization
B. Interruption of pregnancy (abortion)

1. Voluntary interruption of pregnancy
a. indications medical - physical, mental reasons; called
"therapeutic"
b. indications nonmedical - personal reasons; called
"voluntary" or "elective"
2. Methods
a. first trimester - menstrual extraction, dilation and currettage
(D&C), suction or vacuum aspiration, Mifepristone
b. second trimester - dilation and evacuation (D&E), saline
injection, prostaglandins
3. Possible complications
a. most common: infection, retained products of conception or
intrauterine blood clots, continuing pregnancy, cervical or
uterine trauma, and excessive bleeding
b. D&C: may perforate uterus
c. suction or vacuum: may invert uterus
d. saline injection: fluid and electrolyte imbalance and cardiac
arrhythmias
4. Legal
a. refer to laws regarding abortion in state of practice
C. Sterilization
1. Surgical procedures intended to render the person infertile
2. Most states bar sterilizing minors or mentally incompetent persons
3. Methods
a. male: vasectomy
b. female: removal of ovaries or uterus, tubal ligation
4. Informed consent must include:
a. explanation of risks, benefits, and alternatives
b. description that sterilization is permanent and irreversible
c. mandatory 30 day waiting period
d. wording in person's native language or interpreter must be
provided
II. Uncomplicated Pregnancy
Preconception Health
A. Teach about
1. Lifestyle for optimal health
2. Balanced diet including folic acid
3. Fertility awareness
4. Stress management
5. Avoidance of harmful or teratogenic substances
6. Safe sex
7. Risk awareness
8. Parenting responsibilities
B. Conception (illustration )
1. Factors influencing conception
a. hormone cycles
b. cervical mucus
c. sperm motility
d. ovulation
2. Occurs when ovum is penetrated by sperm resulting in fertilization
3. Male gamete determines sex of child at fertilization
4. Fertilization typically occurs in outer third of the fallopian tube
5. Single or multiple fertilizations are possible
Conception
1. The mental process of forming an idea. 2. The onset of pregnancy marked by implantation
of a fertilized ovum in the uterine wall. SEE: contraception; fertilization; implantation.
ovum
pl. ova 1. The female reproductive or germ cell. 2. A cell that is capable of developing into a
new organism of the same species. Usually fertilization by a spermatozoon is necessary,
although in some lower animals ova develop without fertilization (parthenogenesis). SEE:
conception; fertilization; menstrual cycle; menstruation
gamete
mature male or female reproductive cell; the spermatozoon or ovum.
fallopian tube
The hollow, cylindrical structure that extends laterally from the lateral angle of the fundal end
of the uterus and terminates near the ovary. It conveys the ovum from the ovary to the uterus
and spermatozoa from the uterus toward the ovary. Each lies in the superior border of the
broad ligament of the uterus. SYN: oviduct; uterine tube. SEE: female genitalia for illus;
uterus.
C. Implantation
1. Usually occurs seven - ten days after fertilization
2. Trophoblast secretes enzymes which enable it to burrow into endometrium
3. Trophoblast develops chorionic villi which secrete human chorionic
gonadotropin (HCG)
4. HCG inhibits further ovulation by stimulating secretion of estrogen and
progesterone
5. HCG is detected by lab tests for pregnancy as early as six days after
conception in blood and 26 days after conception in urine
D. Fetal Development (illustration )
1. Embryo
a. most critical developmental period
b. developing areas most vulnerable to teratogens
2. Fetus
3. Fetal-placental unit (illustration 1 and illustration 2 )
a. oxygenation
b. nutrition
c. HCG levels
d. screening for fetal problems
i. daily count of fetal movements
ii. non stress test
iii. basic ultrasound screening
trophoblast
The outermost layer of the developing blastocyst (blastodermic vesicle) of a mammal. It
differentiates into two layers, the cytotrophoblast and syntrophoblast, the latter coming into
intimate relationship with the uterine endometrium, with which it establishes nutrient
relationships. SEE: fertilization for illus. trophoblastic, adj.
endometrium
The mucous membrane that lines the uterus. It consists of two highly vascular layers of
areolar connective tissue; the basilar layer is adjacent to the myometrium, and the functional
layer is adjacent to the uterine cavity. Simple columnar epithelium forms the surface of the
functional layer and the simple tubular uterine glands. Straight arteries supply blood to the
basilar layer; spiral arteries supply the functional layer. Both estrogen and progesterone
stimulate the growth of endometrial blood vessels.
chorionic villi
The vascular projections from the chorion, which will form the fetal portion of the placenta.
SEE: embryo for illus.
estrogen
Any natural or artificial substance that induces estrus and the development of female sex
characteristics; more specifically, the estrogenic hormones produced by the ovary; the female
sex hormones. Estrogens are responsible for cyclic changes in the vaginal epithelium and
endometrium of the uterus. Natural estrogens include estradiol, estrone, and their metabolic
product, estriol. When used therapeutically, estrogens are usually given in the form of a
conjugate such as ethinyl estradiol, conjugated estrogens, or the synthetic estrogenic
substance diethylstilbestrol. These preparations are effective when given by mouth.
progesterone
A steroid hormone, C21H30O2, obtained from the corpus luteum and placenta. It is responsible
for changes in the endometrium in the second half of the menstrual cycle preparatory to
implantation of the blastocyst. It facilitates implantation by inhibiting uterine motility and
stimulates the development of the mammary glands. Progesterone is used to treat patients
with menstrual disorders (secondary amenorrhea, abnormal uterine bleeding, luteal phase
deficiency) and to manage renal or endometrial carcinoma. In combination with estrogen, it is
used for contraception and postmenopausal hormone replacement therapy. SYN: progestin
(1).
Embryo
1. The young of any organism in an early stage of development. 2. In mammals, the stage of
prenatal development between fertilized ovum and fetus. In humans, this stage begins on day
4 after fertilization and continues through gestational week 8.
teratogen
Anything that adversely affects normal cellular development in the embryo or fetus. Certain
chemicals, some therapeutic and illicit drugs, radiation, and intrauterine viral infections are
known to adversely alter cellular development in the embryo or fetus.
Fetal Development Stages and Circulation
By 8 weeks: Head and heart grow rapidly. Head is larger than trunk. Central
hemispheres appear, face elongates and eyelid folds have developed but eyes
are still far apart. Flat nose and recognizable mouth are evident. External ears
look similar to final appearance. Arms, legs, fingers and toes are distinct. Heart
and liver are prominent. Length: approximately 2.5 cm. Weight: approximately 2
gm.
By 12 weeks: Intestinal villi form. Bladder and urethra separate from rectum.
Kidneys begin to secrete urine. Bronchioles branch and pleural and pericardial
cavities appear. Lungs assume definitive shape. Thyroid and pancreas begin to
secrete hormones. Sex distinguishable. Bone ossification occurs. Able to suck
and swallow. Length: approximately 7cm. Weight: approximately 28 gm.
By 16 weeks: Joint cavities are present. Bile is secreted. Intestines assume

normal position, meconium present. Kidneys in proper position. Testes begin to
descend into inguinal canal. More human-like appearance. Length:
approximately 10-17 cm. Weight: approximately 55-120 gm.
By 20 weeks: Brain grossly formed. Spinal cord myelinization begins. Lanugo

and vernix caseosa begin to form. Able to hear heart beat. Length: approximately
16-25 cm. Weight: approximately 225-300 gm.
By 24 weeks: External genitalia discernible. Skin red and wrinkled. Lungs begin
to produce surfactant. Meconium present in rectum. Eyes are structurally
complete. Length: approximately 24-28 cm. Weight: approximately 680-1000 gm.
By 28 weeks: Face matures. Eyelashes and eyebrows form. Viable as a

neonate with intensive care. Length: approximately 35-38 cm. Weight:
approximately 1000-1200 gm.
By 32 weeks: Increase in subcutaneous fat. Hair evident. Still covered with

vernix caseosa. Can turn head side to side. Skin begins to smooth out. Chances
of survival outside utero increase. Length: approximately 38-43 cm. Weight:
approximately 1200-2400 gm.
By 36 weeks: Lanugo begins to disappear. Subcutaneous fat continues to
increase. Elongation of spinal cord almost complete. Good chance of survival.
Length: approximately 43-48 cm. Weight: approximately 2400-2800 gm.
By 40 weeks: Baby is full term. Both testes have descended in the male. Lanugo
has disappeared. All organ systems have developed. Lecithin-sphingomyelin (L-
S) ratio is 2:1. Length: approximately 48-52 cm. Weight: approximately 2800 gm
or over.
Fetal circulation (illustration )
Normally ceases to exist after birth

Fetal lungs do not function
Human Chorionic Gonadotropin
A hormone produced by the chorionic villi and found in the urine of pregnant women. Also
called prolan
Screenings for Fetal Problems in Uncomplicated

Pregnancy
A. Daily fetal movement count
1. Same time every day
2. Mother records how often fetus moves
3. If fetus is quiet, mother is to drinks a glass of juice and
repeats the count of movements
4. If the fetus does not move at least three times in an hour,
mother should notify the care provider immediately
5. An active fetus reflects adequate oxygenation
B. Nonstress Test
1. Electronic monitor on mother's abdomen for 20-30 minutes
2. Records fetal heart rate during the period
3. Each time fetus moves, fetal heart rate should speed up at
least 15 beats/minute
4. A reactive (good) outcome shows two or more such
speedups per session
C. Basic ultrasound screening
1. Noninvasive test
2. Can be performed in an outpatient or inpatient setting.
3. A full bladder enhances visualization
4. Can confirm viability
5. Shows presentation of the fetus
6. Shows if more than one fetus
7. Identifies of placenta location
8. Suggests gestational age
Maternal Health in Pregnancy

A. Physical systems that must adapt
1. Reproductive
2. Respiratory
3. Cardiovascular
4. Endocrine
5. Metabolic
6. Gastrointestinal
7. Renal
8. Integumentary
9. Musculo-skeletal
B. Psychologic adaptations
1. Maternal responses
2. Paternal responses
3. Adaptation to tasks of pregnancy
4. Factors in family dynamics that affect adaptation
a. support systems: grandparents, siblings
b. cultural influence
c. religious influence
d. developmental needs
e. previous experience with pregnancy
f. health beliefs
g. economic factors
h. stress management
Maternal Physical Changes

A. Menses ceases
B. Braxton-Hicks contractions
C. Breast changes: areola and nipples darken, colostrum is produced
D. Blood volume, stroke volume and cardiac output increases to meet
demand of enlarging uterus and fetal oxygenation
E. Enlargement of uterus causes urinary frequency
F. As pregnancy progresses, body retains more water, resulting in
dependent edema
G. Melasma- brownish "mask of pregnancy" (formerly called
chloasma)
H. Linea nigra- darkened vertical line on mid abdomen
I. Striae- gravidarum- stretch marks on abdomen, upper arms and
legs
J. Center of gravity shifts, so gait and posture change and low back
pain may occur; posture described as lordosis
K. Ovarian hormone relaxin causes connective tissue of joints to relax,
so risk of falls increases.
L. Potential for nausea and vomiting is greatest in first trimester from
increased levels of HCG
M. Digestive system is cramped, decreased perestalsis from increased
progestion levels
N. Pressure of uterus on the diaphragm may lead to dyspnea
especially in third trimester
First Trimester
Assessment Based on Adaptations
A. Initial history
1. General health
2. Family health/partner's health history
3. Current health status
4. Reproductive summary (gravida, parity)
a. past pregnancies
b. current pregnancy (subjective symptoms)
5. Social factors
6. Lifestyle
7. Diet history
8. Cultural and religious practices
9. Risk Factors
B. Initial physical exam
1. Baseline vital signs and weight/height
2. Head-to-toe assessment/general well being assessment
3. Breast examination
4. Abdominal examination
5. Pelvic exam
6. Signs of pregnancy
a. presumptive: subjective symptoms and objective signs
reported by woman (amenorrhea, fatigue, nausea and
vomiting, breast changes, elevation of basal body
temperature (BBT), skin changes). These may be caused by
conditions other than pregnancy
b. probable: changes observed by examiner
i. Chadwick's Sign: Increased vaginal vascularity
ii. Hegar's Sign: Increased vascularity and softening of
uterine isthmus
iii. Goodell's Sign
iv. ballottement
c. positive: signs attributed only to presence of fetus (fetal
heart tones, visualization of fetus, palpating fetal
movements)
High Risk Pregnancy Charactersitics

A. Age under 17 or over 35
B. Grand multiparity
C. Hereditary conditions
D. Chronic health problems
E. Complications in past pregnancies
F. Nutritional alterations
G. Substance abuse
H. Domestic violence
I. Poverty
J. Disability
K. Infection
L. Exposure to potential teratogens
M. Autoimmune diseases such as Lupus or Multiple Sclerosis
Chadwick's sign
[James R. Chadwick, U.S. gynecologist, 1844-1905] A deep blue-violet color of the cervix and
vagina caused by increased vascularity; a probable sign of pregnancy that becomes evident
around the fourth week of gestation.
Hegar's sign
[Alfred Hegar, Ger. gynecologist, 1830-1914] Softening of the lower uterine segment; a
probable sign of pregnancy that may be present during the second and third months of
gestation. On bimanual examination, the lower part of the uterus is easily compressed
between the fingers placed in the vagina and those of the other hand over the pelvic area.
This is due to the overall softening of the uterus related to increasing vascularity and edema
and because the fetus does not fill the uterine cavity at this point, so the space is empty and
compressible.
Goodell's sign
[William Goodell, U.S. gynecologist, 1829-1894] Softening of the cervix; a probable sign of
pregnancy that may be present during the second and third months of gestation. Palpation
reveals the cervix has altered from a nonpregnant firmness similar to the tip of the nose to a
softness similar to the lips. This change is due to increasing uterine vascularity and edema.
Waist Roll Exercise
Instructions
Start by bringing your hands to your hips. Stand with a slight bend at
the knees, this will help to keep the lower half of the body still.
Press your chest just slightly forward, then pull it back to the side of
the hip, then continue around to the back pressing out only slightly at
first. Bring the chest back to the other side of the hip for completion of
the first circle. Progress out further with the chest if you are able until
you can eventually drop the chest all the way forward and backward
for each revolution. INHALE as you go backward and EXHALE as you
go forward. Breathe through the nose.
Do several non stop revolutions in each direction.
o Laboratory tests
Urinalysis for protein and glucose
Urine or blood HCG level
Complete blood count
Blood type and Rh factor
Rubella titer
Screening for sexually transmitted diseases
Cervical culture
Hepatitis B surface antigen (HBsAG)
Hepatitis B surface antibody (HBsAB)
Tuberculin skin test
HIV antibody (with client permission)
o Psychological assessment
Emotional response to pregnancy
Family relationships
Support systems
Developmental tasks/maternal tasks
Expressed feelings
Learning needs
Rh(D) Immune Globulin or RHoGAM

A. Reasons
1. Rh negative mother, Rh positive father: fetus may be Rh positive
2. Rh antigens may leak at the placental site
3. To these antigens, mother's body forms antibodies
4. More Rh antigens may leak at delivery and invade mother's
bloodstream
B. Prophylaxis for Rh negative mother with a Rh positive baby
1. Give Rh immune globulin during pregnancy (at 28-30 weeks)
2. After birth of each Rh positive newborn, perform Coomb's Test
3. Coomb's test detects antibodies
a. mother- indirect Coombs
b. neonatal cord blood- direct Coombs
4. If no antibodies are identified, the woman is considered to be a
candidate for RhoGAM
5. Give RhoGAM within 72 hours of delivery
6. RhoGAM is an immune globulin (Ig)
7. RhoGAM blocks formation of antibodies
8. RhoGam suppresses the immune response of the nonsensitized
Rh negative woman who has been exposed to Rh positive antigens
9. Give RhoGAM after each ectopic pregnancy, miscarriage, or
abortion (8 weeks)
10. Administration of Rh immune globulin prevents Rh sensitization in
mother and resulting hemolytic anemia called erythroblastosis or
hydrops fetalis of the newborn if antibodies cross the placenta
C. Nursing care: first trimester
1. Build rapport
2. Discuss pregnancy confirmation
3. Calculate due date - Naegele's Rule: If last normal period's first day=N,
then due date is N + seven days, minus three months, plus one year.
Example: June 10, 2001 first day of last menstrual period

6 10 2001
-3 +7 +1
3 17 2002
Estimate date of birth (EDB): March 17, 2002

4. Discuss maternal physical changes
5. Review development of embryo and fetus
6. Return Scheduling: plan antepartal schedule of visits
7. Review and teach: identify learning needs
8. Risk assessment
9. Recommend vitamins, folic acid and iron supplements
10. Offer anticipatory guidance
4.
a. discomforts and remedies
b. rest and exercise (including Kegel exercise)
c. diet and fluid intake
d. medications, tobacco, other substances
e. safety: avoid hot tubs, virus exposure, etc.
f. refer (for example, to childbirth classes)
g. warning signs
G. Role of expectant woman and partner
4. Keep appointment schedule (monthly visits)

5. Maintain healthy lifestyle
6. Follow diet and take vitamins
7. Cope safely with discomforts (such as dry toast for
morning sickness)
8. Discuss sexual feelings and needs
9. Report warning signs
Maternal Physical Changes

A. Menses ceases
B. Braxton-Hicks contractions
C. Breast changes: areola and nipples darken, colostrum is produced
D. Blood volume, stroke volume and cardiac output increases to meet
demand of enlarging uterus and fetal oxygenation
E. Enlargement of uterus causes urinary frequency
F. As pregnancy progresses, body retains more water, resulting in
dependent edema
G. Melasma- brownish "mask of pregnancy" (formerly called
chloasma)
H. Linea nigra- darkened vertical line on mid abdomen
I. Striae- gravidarum- stretch marks on abdomen, upper arms and
legs
J. Center of gravity shifts, so gait and posture change and low back
pain may occur; posture described as lordosis
K. Ovarian hormone relaxin causes connective tissue of joints to relax,
so risk of falls increases.
L. Potential for nausea and vomiting is greatest in first trimester from
increased levels of HCG
M. Digestive system is cramped, decreased perestalsis from increased
progestion levels
N. Pressure of uterus on the diaphragm may lead to dyspnea
especially in third trimester
antepartal
Before the onset of labor, used with reference to the mother.
Warning Signs in Pregnancy

A. First trimester
1. Excessive vomiting
2. Lower abdomial cramping
3. Vaginal bleeding
4. Elevated temperature- greater than 101 F persistent temperature
5. Vaginal discharge
6. Dysuria
7. Exposure to infections including childhood diseases
B. Second trimester
1. Absence of quickening
2. Change in fetal activity
3. Leaking vaginal fluid- water type consistency
4. Vaginal bleeding
5. Fever, chills
6. Vaginal discharge
7. Uterine contractions or low backache
8. Persistent vomiting
9. Dysuria
10. Edema of hands, face
11. Signs of preterm labor
12. Sudden weight gain, greater than four lbs. in one week
C. Third trimester
1. Decreased or absent fetal movement
2. Vaginal Bleeding
3. Abdominal pain especially sudden severe epigastric pain
4. Headaches with or without visual distrubances
5. Leaking fluid from vaginal orfice
6. Edema- generalized anasarca
7. Signs of preterm labor
8. Sudden weight gain of greater than four pounds in one week
Second Trimester
Regular Monthly Assessments, Based on Adaptations
A. Current signs and symptoms

B. Visualize or palpate fetal outline
C. Fetus:
1. Activity
2. Heart rate
D. Gestational age assessment
1. Estimated after duration of pregnancy and EDB are determined
2. Determined by
a. first uterine size estimate
b. fetal heart first heard
c. date of quickening
d. current fundal height
e. current week of gestation
f. ultrasound
g. reliability of dates
E. Physical exam
1. Compare weight, vital signs to baseline
2. Fundal height:
a. uterus becomes an abdominal organ
b. height of fundus in cm is approximately same as number of
weeks gestation
F. Lab tests
1. Urinalysis for protein and glucose
2. AFP - Alpha fetoprotein (16 to 18 weeks)
3. 1 Hour 50 g or 100 g Glucose Test (24 to 28 weeks)
4. Viral screening (for HIV, Hepatitis, etc.)
5. Tuberculin test (can be done in first or second trimester)
G. Managing care, trimester two: role of nurse on team with physician or
CNM
1. The seven R's
2. Discuss birth plan
3. Offer anticipatory guidance:
a. adapting employment to motherhood
b. safety
c. discomforts and remedies
d. travel, exercise, nutrition
e. sexual relations
f. childbirth education
g. body image changes
H. Role of expectant woman and partner
1. Keep appointments (monthly)
2. Verbalize concerns
3. Modify lifestyle as needed; eat balanced diet
4. Use safe remedies, such as small, low-fat meals for heartburn
5. Discuss emotional responses and birth plan
6. Enroll in childbirth education
7. Develop prenatal attachment, prepare other children for new
siblings
quickening
A woman's initial awareness of the movement of the fetus within her womb (uterus). Most
commonly, fetal activity is first reported between 18 and 20 weeks' gestation.
alpha-fetoprotein
ABBR: AFP. An antigen present in the human fetus and in certain pathological conditions in
the adult. The maternal serum level should be evaluated at 15 to 22 weeks' gestation. During
pregnancy, elevated levels are associated with open neural tube defects, anencephaly,
omphalocele, gastroschisis, and fetal death. Decreased levels may indicate an increased risk
of having a baby with Down syndrome. If an abnormal level of AFP is found, further tests such
as ultrasound or amniocentesis need to be done. Elevated serum levels are found in adults
with certain hepatic carcinomas or chemical injuries. Test results also may be abnormal in
persons with diabetes, multiple pregnancies, or obesity.
glucose tolerance test
ABBR: OGTT. A screening test for diabetes mellitus (DM), in which plasma glucose levels are
measured after the patient consumes an oral glucose load.
tuberculin test
A test to determine the presence of a tuberculosis infection based on a positive reaction of the
subject to tuberculin
The Seven R's
In OB nursing, many interventions fall into these Seven R's categories.
1. Relationship (caring)
2. Respond (to questions and concerns)
3. Review and reinforce (including anticipatory guidance)
4. Recommend (diet, vitamins, Kegel exercises, etc.
5. Risk data
6. Return scheduling
7. Referral resources
Third Trimester
Assessments Based on Adaptations
A. Current health status

B. Findings
C. Comfort and mobility
D. Physical examination
1. Comparison to baseline:
a. weight gain pattern
b. vital signs
2. Fundal growth
3. Fetal assessment
a. activity
b. fetal heart rate
c. position
d. presentation (illustration )
e. lie: baby's spine in relation to mother's spine; longitudinal,
vertical, transverse
The fetus is described in documentation according to its:
-Position
-Lie
-Presentation
-Attitude
-and during the process, the Stations it passes.

Screenings for Fetal Problems in Uncomplicated
Pregnancy
A. Daily fetal movement count
1. Same time every day
2. Mother records how often fetus moves
3. If fetus is quiet, mother is to drinks a glass of juice and
repeats the count of movements
4. If the fetus does not move at least three times in an hour,
mother should notify the care provider immediately
5. An active fetus reflects adequate oxygenation
B. Nonstress Test
1. Electronic monitor on mother's abdomen for 20-30 minutes
2. Records fetal heart rate during the period
3. Each time fetus moves, fetal heart rate should speed up at
least 15 beats/minute
4. A reactive (good) outcome shows two or more such
speedups per session
C. Basic ultrasound screening
1. Noninvasive test
2. Can be performed in an outpatient or inpatient setting.
3. A full bladder enhances visualization
4. Can confirm viability
5. Shows presentation of the fetus
6. Shows if more than one fetus
7. Identifies of placenta location
8. Suggests gestational age
Presentation (illustration )
A. Cephalic: Head alone is presenting part
1. Vertex
2. Brow
3. Sinciput
4. Face
B. Breech: head alone is not presenting part
1. Frank: buttocks presents, legs are usually flexed up on body
2. Complete: buttocks and feet present, legs are usually crossed with knees
flexed
3. Kneeling: knees present
4. Footling: foot or feet present
5. Shoulder: shoulder presents. transverse lie
6. Compound: two presenting parts, such as head and hand
E. Lab tests
1. Urinalysis for protein
2. Indirect Coombs test (if client is Rh negative)
3. Cervical culture for strep
4. Hemoglobin and hematocrit
F. Managing care, trimester three: role of nurse on team with physician or
CNM
1. The seven r's
2. Administer Rh immune globulin to Rh-negative woman (24 to 28
weeks)
3. Offer anticipatory guidance
a. discomforts and remedies
b. body mechanics and safety
c. birth options, feeding choices, plans for newborn care
d. recognizing onset of labor
e. reportable signs
G. Role of expectant woman and partner
1. Keep appointments-visits every two weeks or weekly
2. Prepare for role change; support each other; discuss sexual needs
3. Use safe remedies for discomforts (such as lateral posture for
sleep)
4. Practice relaxation and breathing techniques; perform fetal
movement count daily
5. Follow dietary and fluid advice
6. Maintain safety in daily activities
7. Meet psychological tasks
8. Arrange hospital or home birth, plan newborn feeding; learn
newborn needs
9. Recognize signs of labor

A. Reasons
bloodstream
abortion (8 weeks)
hemoglobin
The iron-containing pigment of the red blood cells which carries oxygen from the lungs to the
tissues.
hematocrit
1. An obsolete term for a centrifuge for separating solids from plasma in the blood. 2. The
volume of erythrocytes packed by centrifugation in a given volume of blood. The hematocrit is
expressed as the percentage of total blood volume that consists of erythrocytes or as the
volume in cubic centimeters of erythrocytes packed by centrifugation of blood. Approximate
normal values at sea level: men, average 47%, range 40% to 54%; women, average 42%,
range 37% to 47%; children, varies with age from 35% to 49%; newborn, 49% to 54%. SEE:
blood.
III. Uncomplicated Labor and Birth
Processes of Labor
A. Factors affecting labor include the five P's: passageway, passenger,

powers, position and psyche
1. Passageway (bony elvis and soft tissues of cervix, pelvic floor,
vagina, and introitus)
a. inlet
b. outlet
c. size
d. types
2. Passenger (fetus)
a. fetal head diameters
b. position
c. presentation
d. lie
e. station
f. attitude
g. amniotic Fluid
h. placenta
3. Powers
a. primary powers
i. uterine contractions
frequency
duration
intensity
rest phase
ii. responsible for effacement and dilation of cervix
b. secondary powers (bearing down efforts)
i. aids in expelling fetus
ii. diaphragm and abdominal muscles
4. Position of laboring woman
a. for comfort and safety
b. fetus gets more air if mother lies on her side
c. determined by woman's preference
d. constrained by condition of woman and fetus, environment,
and health provider's confidence in assisting birth in a
specific condition
5. Psyche (person)/psychology of birth (See section "E" on page 16
of this lesson)
Stations of Fetal Descent
"Stations" describe numerically the relationship of fetus's presenting part to the mother's ischial
spines
1. Ischial spines form narrowest slot through which the newborn's head
must pass
2. The head floats until it descends into the mother's pelvis (engagement)
a. In primipara, usually about two weeks before birth
b. In multipara, varies from several weeks prior to onset of
labor to during the labor process
3. At station zero, largest portion of the head (biparietal diameter) is level
with ischial spines
4. When the head is above the ischial spines the station is recorded as a
negative number (-1, -2)
5. When the head is below the ischial spines the station is recorded as a
positive number (+1, +2)
6. If the fetus stops descending, possible cephalopelvic disproportion may
call for cesarean section
B. Early signs of labor versus true labor
C. Duration of stages and phases varies with parity, fetal presentation,
position and station.
D. Maternal systems adaptations
1. Reproductive
1. effacement
a. vaginal part of cervix progressively shortens and its
walls thin
b. effacement is noted as a percentage from 0% (non-
effaced) to 100% (fully effaced)
2. cervical dilation
a. progressive enlargement of the cervical os from less
than one cm to ten cm
2. Cardiovascular
1. as labor progresses, cardiac output increases between
contractions
2. BP rises with contractions and with voluntary bearing down
3. BP can vary with mother's position, anxiety and pain
4. pulse rate rises slowly and progressively
3. Respiratory
1. mother consumes more oxygen
2. pain, anxiety can cause hyperventilation
3. respiratory alkalosis, hypoxia or hypocapnia can occur
4. Renal
1. uterus may squeeze ureters and impede urine flow
2. trace amounts of protein in urine are common
5. Gastrointestinal
1. decreased peristalsis and absorption
2. stomach is slower to empty (gastric emptying time)
3. nausea and vomiting common
6. Musculo-skeletal
1. diaphoresis, fatigue, proteinuria and possible increased
temperature cause marked increase in muscle activity
2. backache, joint aches
3. leg cramps
7. Endocrine - progestin levels drop and as a result the labor process
begins
Reframe your thoughts from I should or have to do 3000 to 5000 practice

questions to I will do what ever number of practice questions I have time to do
and I will be successful on the NCLEX-RN. Be realistic. Make a calendar of the
must dos in your life. Then look to see how much time is left in your schedule to
do test questions.
Early Signs of Labor Versus True Labor Signs

A. Early labor
1. Lightening
2. Bloody show
3. Braxton-Hicks contractions
4. Burst of energy
5. Low backache
6. Weight loss
7. Diarrhea
B. True labor
1. Cervical changes
2. Effacement
3. Cervical dilation
4. Contraction frequency increases
5. Intensity of contractions persists despite changes in position
6. Membranes may be intact or ruptured
effacement
In obstetrics, the thinning of the cervix as the internal os is slowly pulled up into the lower
uterine segment.
hyperventilation
Increased minute volume ventilation, which results in a lowered carbon dioxide (CO 2) level
(hypocapnia). It is a frequent finding in many disease processes such as asthma, metabolic
acidosis, pulmonary embolism, and pulmonary edema, and also in anxiety-induced states.
respiratory alkalosis
Alkalosis with an acute reduction of carbon dioxide followed by a proportionate reduction in
plasma bicarbonate.
hypoxia
1. An oxygen deficiency in body tissues. 2. A decreased concentration of oxygen in inspired
air. SEE: anoxia; hypoxemia; posthypoxia syndrome.
hypocapnia
A decreased amount of carbon dioxide in the blood. An excessively rapid rate of respiration
("hyperventilation") is usually responsible.
E. Mother's behavioral changes are affected by
1. Stage and phase of labor
2. Psychological responses to pain
3. Preparation for labor
4. Presence of support person
5. Coping style
6. Culture
7. Previous childbirth experience
8. Feelings about this pregnancy
F. Fetal adaptations
1. Mechanisms of labor (cardinal movements) (illustration )
a. engagement, descent, flexion
b. internal Rotation
c. extension
d. external Rotation
e. expulsion
2. Fetal circulation
a. changes when uterus contracts
b. maximum oxygenation during rest phase
Mechanisms of Labor
(illustration )
Tabor's Figure "labor" shows membranes intact, membranes ruptured, effacement, rotated,
extended, presents, and placenta.
Engagement, descent, flexion: the widest part of the head passes the ischial spines as the
head is flexed onto the chest
Internal rotation: the anteroposterior diameter of the head lines up with the anteroposterior
diameter of the pelvis
Extension: the head passes the symphysis pubis and extends from the perineum
External rotation: the baby's rotates back to its position during engagement and then an
additional 45 degrees to align the shoulders with the anteroposterior diameter of the pelvis. The
anterior shoulder passes under the symphysis pubis followed by the posterior shoulder
Expulsion: the rest of the body passes under the symphysis pubis and is expelled
Labor and Birth (Intrapartum)
Brief Overview: Stages of Labor (illustration )
first stage: onset until complete dilation

o latent phase: one to three cm
o active phase: four to seven cm
o transition: eight to ten cm
second stage: complete dilation through birth
third stage: placental separation and delivery
fourth stage: maternal adaptation
A. First stage of labor: latent phase

1. Assessments
a. history
i. critical admission
due date
onset, frequency and duration of contractions
membranes intact or leaking
gravida and parity
ii. general health history
iii. reproductive history
iv. prenatal care
v. antepartal health
vi. social history
vii. lifestyle
viii. allergies
ix. family history
x. childbirth preparation
xi. risk factors including:
problems identified on antepartal record
preterm labor
reduced or absent fetal activity
prolonged ruptured membranes
acute health problems
infection
bleeding with or without pain
substance abuse
xii. physical examination
baseline vital signs compared to antepartal chart
weight
intake and output
contractions: mild and irregular
Leopold's Maneuvers
fetal activity and heart rate
pelvic exam
A. confirm true labor
B. identify fetal position, presentation, station
C. membranes: intact or ruptured
head-to-toe assessment
xiii. laboratory tests
values compared to antepartal records
complete blood count
blood type and Rh
urinalysis for protein
xiv. psychological assessment
how does she respond to mild irregular
contractions?
what does she expect and know about birth and
labor process?
learning needs
developmental level
support systems available during labor
cultural influences on labor and care
behavioral responses (such as, excited or talkative)
what strategies does she use to cope with labor
pain?
Early Signs of Labor Versus True Labor Signs

A. Early labor
1. Lightening
2. Bloody show
3. Braxton-Hicks contractions
4. Burst of energy
5. Low backache
6. Weight loss
7. Diarrhea
B. True labor
1. Cervical changes
2. Effacement
3. Cervical dilation
4. Contraction frequency increases
5. Intensity of contractions persists despite changes in position
6. Membranes may be intact or ruptured
7. Managing care: stage one latent phase: role of nurse on team with
physician or CNM
3. In addition:
a. promote comfort through ambulation, position changes,
shower, whirlpool
b. identify learning needs for labor and birth
c. review birth plan, analgesic and anesthetic options
d. explain intermittent/continuous fetal monitoring
4. Role of woman and support person
a. discuss questions and concerns
b. use appropriate relaxation methods for early labor
c. adapt the environment to cultural beliefs
d. empty bladder frequently
e. report physical changes to caregivers
Try to answer the question before looking at the options.
Electronic Fetal Monitoring

A. Can identify fetal-placental problems early, even during contractions.
B. Fetal heart rate may be measured externally or via internal electrode.
C. Timing
1. Intermittent
2. For 30-minute periods
3. Continuous
4. When membranes rupture, monitor the fetal heart rate at once. At this time, the
fetus may be stressed.
D. Measures - Baseline heart rate usual range 120-160 bpm in the full term fetus.
1. Less than 120 bpm - bradycardia
2. More than 160 bpm - tachycardia
3. May signal hypoxia, maternal infection or other factors. Notify provider of care.
E. Variability, or rhythm irregularity, of at least six to ten beats per minute. This variability is
affected by medications or by hypoxia. If fetal heart rhythm does not vary with
contractions, report this fact immediately to provider of care.
1. Accelerations: heart rate increases during fetal movements; and
2. Decelerations: heart rate slows in relation to contractions.
3. Early decelerations: mirror the contraction pattern and return quickly to the
baseline. These are very common, and caused by fetal head compressure. No
intervention is needed.
4. Late decelerations: heart rate slows after contraction ends. They signal placental
insufficiency. Action required:
a. Immediately turn the woman to the side
b. Administer oxygen
c. Notify the physician or midwife.
5. Variable decelerations: heart rate slows, but in inconsistent pattern, during a
series of contractions. Variable decelerations usually signal umbilical cord
compression. Action required:
a. Turn the woman to the side
b. Give oxygen, and
c. Notify the provider of care immediately
NOTE:
Electronic fetal monitoring requires advanced skills. PN role is one of assisting the RN or
healthcare provider with safety.
6. RN notices abnormal patterns such as decelerations

7. RN to act appropriately and immediately
8. Let the advanced practitioner interpret the changes
9. All caregivers are responsible to be aware of safety issues
10. Document promptly and accurately, both on the monitoring strip and the chart by
the RN or healthcare provider
11. First stage of labor: active phase
a. Assessments
A. physical examination
A. compare present vital signs compared to baseline
B. monitor contractions: increased frequency and
duration, moderate to strong, more regular
C. observe membranes: intact or ruptured
D. measure fetal heart rate
B. psychological assessment: emotional response to increasing
frequency, duration and intensity of contractions
C. behavioral changes (self focus; concentration)
b. Managing care, stage one active phase: role of nurse on team with
physician or CNM
A. intrapartum care: RAFAP eleven
B. encourage ambulation or position changes until membranes
rupture
C. promote drugless comfort measures (such as effleurage,
relaxation and paced breathing, massage, hydrotherapy,
labor support)
D. offer analgesia
A. safest time for fetus is four to seven cm dilation
B. safety measures for woman may include siderails
E. discuss regional anesthesia such as epidural block
c. Role of woman and support person
A. continue effective breathing and relaxation techniques
B. alter position for comfort
C. maintain bedrest (lateral position preferred) after
membranes rupture. Lateral position promotes optimal
uteroplacental and renal blood flow and increases oxygen
saturation.
D. communicate questions and concerns
E. report physical changes
perineum
1. The structures occupying the pelvic outlet and constituting the pelvic floor. 2. The external
region between the vulva and anus in a female or between the scrotum and anus in a male. It
is made up of skin, muscle, and fasciae. The muscles of the perineum are the anterior portion
of the intact levator ani muscle and the transverse perineal muscle.
D. Second stage of labor: complete dilation through birth
1. Assessment
a. physical examination
i. fetal crowning
ii. increased bloody show
iii. mother pushes involuntarily
iv. fetal heart rate response to contractions and pushing
2. Psychological assessment
a. emotional response to perineal pressure
b. relief at labor's end
3. Managing care, stage two: role of nurse on team with physician or
CNM
a. the RAFAP eleven
b. help the woman to push with contractions
c. deliver the newborn safely; clear newborn airway
d. dry newborn skin
e. inform the couple of the newborn's gender and condition
f. explain repair of episiotomy or lacerations
g. monitor uterine contraction after birth
h. follow Standard Precautions
a. breathe effectively
b. push with contractions
c. relax after contractions
d. follow directions to stop pushing
e. hold and bond with newborn
crowning
Visible presentation of the fetal head at the vaginal introitus. It occurs when the largest
diameter of the infant's head comes through the vulvar opening.
E. Third stage of labor: placental separation and expulsion
1. Assessment
i. increased bleeding
ii. umbilical cord lengthens
iii. uterine contractions
b. psychological assessment
i. emotional response to newborn's birth: excitement and
fatigue
2. Managing care, stage three: role of nurse on team with physician or CNM
a. inform couple of placental separation
b. observe for intact placenta
c. analyze blood loss
d. monitor maternal vital signs
e. administer oxytocic drugs
f. document promptly and accurately
a. refraining from pushing during placental stage
b. holding newborn
c. initiating lactation
oxytocic
1. Agent that stimulates uterine contractions. 2. Accelerating childbirth.
lactation
1. The production and release of milk by mammary glands. 2. The period of breastfeeding
after childbirth, beginning with the release of colostrum (the nutrient-rich substance that
precedes milk production) and continuing until the infant is weaned. Many hormonal factors
are involved in lactation. The process depends on secretion of the hormone prolactin by the
pituitary gland, but it begins only after the marked decreases in estrogen and progesterone
that follow childbirth. Nursing by the infant stimulates pulsatile increases in prolactin secretion.
Oxytocin, secreted by the hypothalamus, also contributes to the release of milk by stimulating
the contraction of muscular cells in the milk ducts and mammary glands.
F. Fourth stage of labor: maternal adaptation (one to two hours after birth)
1. Assessment
i. monitor vital signs (every 15 minutes) compared to
intrapartal data
ii. observe for:
uterine contraction
vaginal bleeding: lochia
trembling or chills
bladder distention
fundal height
iii. observe episiotomy or repaired lacerations
b. psychological assessment
i. emotional response to birth
ii. early interaction with newborn
c. family interaction
2. Managing care, stage four: role of nurse on team with physician or
CNM
a. the RAFAP eleven
b. massage the fundus if soft
c. monitor initial bleeding/clots
d. inspect the perineum for bruises; help with hygiene,
perineal care
e. administer oxytocic drugs in IV
f. offer food and fluids; help with ambulation
g. monitor recovery from regional anesthesia
h. administer pain medication
i. facilitate first breast feeding
j. administer rubella vaccination or Rh immune globulin
(RhoGAM) if indicated
a. verbalize questions and concerns
b. report physical changes
c. ask for pain relief as necessary
d. hold the newborn
2. Normal Postpartum
Maternal Adaptations: Birth to Six Weeks (Puerperium)
Before Discharge from Hospital
F. Systems adaptations
1. Reproductive
a. uterine contraction
b. lochia (rubra)
c. perineal healing
2. Cardiovascular
3. Respiratory
4. Renal
5. Gastrointestinal
6. Integumentary
7. Musculo-skeletal
8. Endocrine
a. hormonal influences on lactation
b. hormonal influences on uterine contraction
G. Psychologic adaptations
1. Emotional responses: taking in
2. Interaction with newborn
3. Family dynamics and bonding, attachment
4. Role change: first 24 hours
H. Assessments based on adaptations
1. Initial postpartum history
a. labor and birth information
b. present symptoms
c. health history
d. reproductive summary
e. social factors
f. cultural and religious practices
g. lifestyle
h. diet history
i. risk factors
i. identified in pregnancy
ii. related to labor or birth
iii. adolescent parenting
iv. substance abuse
v. nutritional alterations
vi. family relationships
vii. poverty
viii. disability
High Risk Pregnancy Charactersitics

A. Age under 17 or over 35
B. Grand multiparity
C. Hereditary conditions
D. Chronic health problems
E. Complications in past pregnancies
F. Nutritional alterations
G. Substance abuse
H. Domestic violence
I. Poverty
J. Disability
K. Infection
L. Exposure to potential teratogens
M. Autoimmune diseases such as Lupus or Multiple Sclerosis
2. Physical examination
a. monitor vital signs compared to intrapartal data
b. perform head-to-toe assessment
c. examine breasts
d. examine fundus
i. within 12 hours fundal height is approximately one
cm above umbilicus, it descends one to two cm
every 24 hours
e. observe lochia
i. lochia rubra changes to lochia serosa after three to
four days
f. observe perineum and repaired episiotomy or lacerations
g. observe legs for edema, Homan's sign
h. assess for common problems
i. breast engorgement; sore nipples
ii. afterpains
iii. bladder distention; altered bowel function;
hemorrhoids
iv. swelling and discomfort from episiotomy
3. Lab data
a. hemoglobin and hematocrit compared to earlier data
b. rubella titer
c. blood Type and Rh Factor
d. urinalysis (clean catch)
e. cultures if indicated
4. Psychological assessment
a. initial emotional response to labor/birth
b. response to pain
c. early interactions with newborn
d. family support
e. cultural and religious practices
fundus
1. The larger part, base, or body of a hollow organ. 2. The portion of an organ most remote from its
opening. fundic, adj.
episiotomy
Incision of the perineum at the end of the second stage of labor to avoid spontaneous
laceration of the perineum and to facilitate delivery. In the U.S. episiotomy is done in about
40% of all vaginal deliveries, making the procedure one of the most common forms of surgery
performed on women.
Homan's sign
[John Homans, U.S. surgeon, 1877-1954] Pain in the calf when the foot is passively
dorsiflexed. This is a physical finding suggestive of venous thrombosis of the deep veins of
the calf; however, diagnostic reliability is limited, that is, elicited calf pain may be associated
with conditions other than thrombosis, and an absence of calf pain does not rule out
thrombosis.
rubella titer
A blood test to determine a person's immune status to rubella.
D. Managing care, postpartum before discharge: role of nurse on team with
physician or CNM
1. Maintain a caring relationship
2. Inform woman of physical changes and assessments
3. Respond to questions and concerns
4. Promote physical comfort and rest
5. Offer analgesics for pain relief
6. Teach fundal massage
7. Encourage frequent emptying of bladder
8. Teach perineal hygiene and care
9. Encourage ambulation
10. Help with first breast feeding
11. Offer food and fluids
12. Identify problems
13. Document assessments and care
E. Role of woman and family
1. Express questions and concerns
2. Hold and interact with the newborn and family
3. Rooming-in
4. Report physical or emotional changes
POSTPARTUM REPORTABLE SIGNS

1. Temperature above 100.4
2. Increased lochia, clots or odor
3. Perineal pain or swelling
4. Calf tenderness
5. Appetite loss
6. Sleep disturbances
7. Continued mood swings or depression
8. Elimination problems
INITIAL LACTATION
Lactation mechanics
1. Begin with placental delivery, stimulates prolactin from anterior pituitary,

which stimulates milk.
2. Sucking stimulates the "let-down" response and the release of oxytocin
from the posterior pituitary.
3. Oxytocin expels milk through the duct system, and contracts uterine
muscle.
4. Nurse's knowledge and support play a vital role in teaching and
encouraging breast feeding.
5. Put the newborn to breast right after birth or in recovery phase of
intrapartum.
6. Help the woman to a comfortable position so newborn can fully grasp the
areola.
7. Let the baby nurse vigorously, held so breast does not block its nose.
Show mother how to break suction when the baby has finished nursing.
8. If woman has not breast fed before, stay until she feels comfortable.
9. Be aware of cultural influences, which may affect initial breast feeding.
10. Briefly explain the lactation process.
11. Suggest warm compresses or a shower just before feeding.
12. Suggest that mother wear a supportive bra night and day.
13. Be available to answer questions, such as using alternate breasts or
stimulating a sleepy infant.
14. Encourage the woman. Follow up with printed materials, films, discussions
with other mothers and referral to a lactation specialist or LaLeche
League.
15. Colostrum - breast milk precursor. Present for first few days after birth
then changes to mature milk.
Methods of Contraception
A. Fertility awareness methods:
1. Calendar - estimate date of ovulation based on length of cycle
(rhythm method)
2. Basal body temperature - identifies ovulation by drop and rise in
temperature
3. Cervical musus method- identifies ovulation by increase in mucus

amount and stretchability.
B. Chemical agents, that destroy or immobilize sperm- creams, foams, jellies,
or suppositories
C. Mechanical barrier methods
1. Diaphragm- covers the external os
Disadvantage: must be fitted, provides no protection against
STD's and risk of TSS (toxic shock syndrome)
Most effective when used with a chemical agent
2. Condom:
Disadvanteage: decreases penile sensation and spontaneity
Advantage: inexpensive, accessible, and reduces spread of
STD's
D. Oral Contraceptives- hormones suppress ovulation
1. Single-hormone therapy - Estrogen given two weeks to suppress
LH and FSH. Progesterone given daily to make cervical mucus
impervious to sperm.
2. Combined-hormone therapy - combination of estrogen and
progesterone on a 25-day cycle.
Bleeding starts one to four days after the last pill.
Contraindications: family history of stroke, migraines,
hypertension, diabetes, chronic renal disease,
thrombophlebitis, tobacco use- smoking
Side effects: nausea and vomiting, edema and weight gain,
breakthrough bleeding, thrombophlebitis, pulmonary
embolism, stroke
E. Intrauterine devices - thought to prevent implantation
1. Side effects: heavy menstrual bleeding, severe cramping, bleeding
between periods
2. Complications: uterine perforation, infections
F. Long-acting methods
1. Implantable progestin (Norplant) - five years
2. Injectable progestin (Depo Provera) - one to three months
G. Permanent contraception
1. Male sterilization- vasectomy
2. Female steriization- tubal ligation, hypterectomy (removal of uterus)

A. Reasons
bloodstream
abortion (8 weeks)
Follow-up Home Visit (two to four days after discharge)

A. Data collection
1. Self assessment by monitor
2. Physical
a. vital signs:
i. temperature greater than 100.4 degrees Fahrenheit
in the first 24 hours after delivery may indicate
dehydration
ii. temperature greater than 100.4 degrees Fahrenheit
six hours apart after the first 24 hours after delivery
for two consecutive days may indicate a postpartum
infection
b. breasts filling - engorgement
c. nipples intact
d. uterine contraction and descent
e. lochia serosa
f. perineal healing
g. lower extremities
h. comfort and fatigue
i. elimination
3. Pshchological
a. emotional responses; self image
b. taking hold adaptations
c. parent-newborn interaction; family dynamics
d. coping; "blues"
e. family dynamics
f. financial concerns
g. healthcare follow-up concerns
Many types of exams are given at the testing center. Therefore, keyboarding or
other noises are considered a usual part of the testing environment. If this type of
noise bothers you, use the provided ear plugs.
B. Managing care, postpartum visit - role of nurse on team with physician or

CNM
1. Continue caring relationship
3. Show interest in newborn and siblings
4. Evaluate safety in newborn care
5. Reinforce nurturing behaviors
6. Identify problems (mother and baby)
7. Remind woman of follow-up visit date
C. Role of woman and family
1. Verbalize questions and concerns
2. Report physical changes/problems
3. Demonstrate safe newborn care
Follow-up clinic or office visit (three to six weeks postpartum)

A. Assessments
1. Involution complete
2. Letting-go behaviors
3. Lactation established
B. Managing care, newborn follow-up: role of nurse on team with physician
or CNM
1. Discuss health maintenance and promotion
2. Reinforce teaching of self care
4. Refer to resources
a. supplement teaching with handouts, films
b. discuss fertility awareness and birth control
C. Role of woman and family
1. Incorporate newborn into the family unit
2. Follow suggestions for a healthy lifestyle
3. Report reproductive health problems
4. Schedule regular health care visits
involution
1. A turning or rolling inward. 2. The reduction in size of the uterus after childbirth. 3. The
retrogressive change in vital processes after their functions have been fulfilled, such as the
change that follows the menopause. 4. A backward change. 5. The diminishing of an organ in
vital power or in size. 6. In bacteriology, digression from the usual morphological type such as
occurs in certain bacteria, esp. when grown under unfavorable conditions; degeneration.
V. Normal Newborn
Newborn: Adaptations in the First Month
Immediate Care after Delivery (from birth to two hours)
A. Systems adaptations
1. Fetal to newborn circulation (illustration )
2. Cardiovascular
3. Respiratory
4. Temperature regulation
5. Gastro-intestinal
6. Renal
7. Immune
8. Hepatic
9. Coagulation
10. Neurologic
B. Assessments
1. Respirations
2. Apgar score
3. Appearance
4. Risks
5. Umbilical cord
C. Management of care (physician or CNM and nurse)
1. Maintaining open airway
2. Drying the skin
3. Ensuring safety
4. Clamping the cord
5. Taking blood samples
6. Identifying mother and newborn
7. Instilling ophthalmic prophylactic ointment
8. Fostering parent contact
9. Documenting assessments and care
APGAR SCORE
1. Five tests, at 1 minute and 5 minutes after birth, show baby's overall
status
2. Apgar Scoring Totals and Interventions
a. 8-10 is normal
b. 5-7 means mild depression. The neonate may require some stimulation, such
as
gently but firmly slapping the soles of the feet or rubbing the spine or the
back.
Oxygen may be necessary.
c. 3-4 means moderate depression. The baby may need oxygen, and/or the
insertion
of a feeding tube to decompress the stomach
d. 0-2 means severe depression, requiring immediate life support
PROPHYLACTIC EYE TREATMENT OF NEWBORN

A. Choices of ointment or drops to prevent opthalmic neonatorum
1. Ophthalmic Erythromycin 0.5% ointment or drops in single-dose
tubes or ampules
2. Tetracycline 1% ointment or drops in single dose tubes or ampules
3. Silver Nitrate 1% in single-dose ampules
Currently, most practitioners prefer Erythromycin or Tetracycline since they are

less irritating to the eye. They kill many organisms, including Chlamydia.
B. Timing
1. Some clinicians administer eye drops in the first hour, others in the
first few hours after delievry
2. First, promote bonding with the mother, then instill ophthalmic
ointment, which may temporaily obscure newborn's visio
Newborn (birth until discharge)

A. Assessments based on adaptations
1. History
a. antepartal data
b. labor and birth information
c. risk factors
2. Physical examination of newborn
a. temperature (36.1-36.5 degrees Celsius [97-97.7 degrees
Fahrenheit]) axillary
b. apical heart rate (120-160 bpm)
c. blood pressure (50-75mm Hg)
d. respirations (30-60 per minute)
e. weight
f. measurements of length and head, chest and abdominal
circumference
g. head-to-toe assessment
h. reflexes
i. growth (gestational age): new ballard scale
3. Normal characteristics and common variations
a. caput succedaneum
b. cephalhematoma
c. molding
4. Sensory responses
5. Behavioral responses
6. Elimination
7. Lab data
a. complete blood count
1. hemoglobin should be between 14.5 and 22 g/dl
2. hematocrit should be between 44 and 72%
b. blood type and Rh factor
c. Coomb's test
d. glucose level 40-60 mg/dl
e. urinalysis urine culture
f. screening as indicated, (such as sickle cell screening)
g. bilirubin levels 0-1 mg/dl
caput succedaneum
Diffuse edema of the fetal scalp that crosses the suture lines. Head compression against the
cervix impedes venous return, forcing serum into the interstitial tissues. The swelling
reabsorbs within 1 to 3 days.
Coombs' test
[R. R. A. Coombs, Brit. immunologist, b. 1921] A laboratory test for the presence of antibodies,
usually blood type antibodies, in serum. The patient's serum is incubated with red blood cells
(RBCs) with known antigenic markers; if antibodies to the antigen are present in the serum,
they bind with the RBCs. When antihuman globulin is added, RBC clumping (agglutination)
occurs. The test is used for crossmatching blood before transfusions to ensure that no
antigen-antibody reactions will occur and to test for the presence of specific antibodies to
RBCs.
B. Managing care, normal newborn: role of nurse on team with physician
1. Analyze any vital signs outside normal range
2. Keep the baby warm
3. Clear the baby's airway
4. Position baby (on back or side)
5. Document findings of your assessments
6. Share assessments with parents
7. Report problems
8. Administer vitamin K
9. Observe behavioral and neurological changes
10. Note first void and stool within 24 hours
11. Assist with feedings
12. Administer hepatitis vaccine
13. Newborn screen for Phenylketonuria (PKU)
14. Routine cord care
15. Role of nurse: teaching parents
A. Nurturing behaviors
B. Newborn care
A. safety: use of car seat
B. feedings
C. hygiene
D. cord care
E. circumcision care
C. Elimination patterns
D. Initial weight loss
E. Newborn stimulation
F. Positioning and holding
16. Role of mother and family
A. Expressing questions and concerns
B. Bonding/attaching to newborn
C. Recognize newborn as a separate person
A. call baby by name
B. note unique things about baby
D. Describe cultural or religious beliefs
E. Demonstrate caregiving skills
F. Introduce siblings to newborn
Newborn: Discharge Teaching
A. Assessments
1. Share with parents
2. Follow-up lab tests
a. PKU-phenylketonuria
b. bilirubin test
B. Reportable signs
1. Fever
2. Vomiting
3. Stool changes; diarrhea
4. Behavioral changes; irritability
5. Feeding problems
6. Skin rash
7. Jaundice
C. Resources
1. Newborn nursery staff
2. Pediatrician
3. Family members
4. Support groups, such as LaLeche League
5. Telephone numbers, such as abuse hot lines
6. Infant CPR courses
phenylketonuria
ABBR: PKU. A congenital, autosomal recessive disease marked by failure to metabolize the
amino acid phenylalanine to tyrosine. It results in severe neurological deficits in infancy if it is
unrecognized or left untreated. PKU is present in about 1 in 12,000 newborns in the U.S. In
this disease, phenylalanine and its byproducts accumulate in the body, esp. in the nervous
system, where they cause severe mental retardation (IQ test results often below 40), seizure
disorders, tremors, gait disturbances, coordination deficits, and psychotic or autistic
behaviors. Eczema and an abnormal skin odor also are characteristic. The consequences of
PKU can be prevented if it is recognized in the first weeks of life and a phenylalanine-
restricted (very low protein) diet is maintained throughout infancy, childhood, and young
adulthood.
Newborn: Follow-up Home Visit
A. Assessment based on adaptations (compared to hospital records)
1. Parents' assessments
2. Nurse's physical assessment
a. vital signs
b. weight
c. head-to-toe examination
d. reflexes
e. behavior
f. sensory responses
g. elimination patterns
h. safe environment
i. contentment and sleep
3. Nurse's psychological and social assessment
a. interaction between family and newborn
b. emotional responses of family to newborn and each other
c. responses to newborn cues
B. Management of care - role of nurse on team with physician
1. Establish caring relationship
2. Display interest in the newborn
3. Encourage questions
4. Respond to concerns and questions
5. Share assessments with family
6. Demonstrate care giving skills as needed
7. Review newborn feeding
8. Reinforce parenting behaviors
9. Remind parents about well-baby schedule and immunizations
10. Review reportable signs for mother and infant

C. Role of family
1. Express questions and concerns
2. Incorporate newborn into family
3. Provide safe, nurturing care
4. Recognize reportable signs
5. Plan well baby follow-up care
POSTPARTUM REPORTABLE SIGNS

1. Temperature above 100.4
2. Increased lochia, clots or odor
3. Perineal pain or swelling
4. Calf tenderness
5. Appetite loss
6. Sleep disturbances
7. Continued mood swings or depression
8. Elimination problems
A. Growth and development in general
1. Patterns of growth and development
a. cephalocaudal: head to tail
b. proximodistal: near to far
c. differentiation: from simple operations to more complex
activities and functions
2. Growth measures
a. height
b. weight
c. frontal-occipital circumference
3. Theories of development
a. Piaget's theory of cognitive development
b. Erikson's theory of psychosocial development
c. Kohlberg's theory of moral development
d. language development
4. Assessment of growth and development: denver II
a. screens children from birth through six years of age
b. assesses four skills
i. personal-social
ii. fine motor adaptive
iii. language
iv. gross motor
PIAGET'S THEORY OF COGNITIVE DEVELOPMENT
Four Periods: Sensorimotor, Preoperational Thought, Concrete Operations,

Formal Operations
As children mature intellectually, they are more able to understand the

environment, create patterns of behavior, and reason through problems.
A. Piaget's sensorimotor period: birth to two years

1. Characteristics
a. reflexes are used to achieve equilibrium
b. repetitive acts help establish patterns of behavior
c. beginning object permanence is evident (learning that an
object still exists when it is out of sight.)
d. view of the world is egocentric
e. active experimentation as infant progresses
2. Nursing considerations: sensorimotor stage
a. children will explore their environment to learn more about it
expecially through use of thier mouth
b. cannot use logic to protect themselves
c. separation from parents is not as important to infants (under
six months) as it is to older children
B. Piaget's period of preoperational thought: two to seven years
1. Characteristics
a. object permanence becomes more established
b. still egocentric in thinking
c. use language as a symbol system more and more
d. increased magical thinking and imagination; called animism.
e. perceptions rule child's thinking and reasoning
f. attention span is short.
g. child has better concept of time as he/she approaches
school age
2. Nursing considerations
a. illness and hospitalization frighten toddlers and
preschoolers. They lack the cognitive powers to grasp these
experiences.
b. precognitive children use fantasy and magical thinking to
attempt to understand illness and hospitalization.
c. precognitive children have many fears, especially separation
which peaks from two through three years of age.
d. these children learn best if actively involved in the learning
process.
e. this age group relates well to discussions about what they
will see and feel. Visual and tactile learning is best.
C. Piaget's period of concrete operations: seven to ten years
1. Characteristics
a. thinking shifts from total egocentrism to more local
awareness
b. conscience develops
c. perception no longer dominates reasoning- recognized
cause-and-effect relationships.
d. understands basic ideas of conversation, number,
classification, and other concrete ideas.
e. attention span increases
f. can solve problems by trial and error
a. this age group benefits from health teaching with concrete
terms and explanations.
b. this age group reads and understands concepts related to
the human body.
D. Piaget's period of formal operations: 11 years to Adult
1. Characteristics
a. see new logical relationships
b. analyze situations and think more logically than before
c. think creatively since increased abilities to think abstractly
d. concern for moral and social issues are a priority over
Egocentric thinking
a. think much more like adults
b. are able to be taught health concepts at higher levels
c. more likely to understand adult vocabulary
ERIKSON'S THEORY OF PSYCHOSOCIAL DEVELOPMENT
A. Describes development as a series of tasks that must be accomplished in

order to progress psychosocially.
B. The tasks are described in positive and negative terms:
1. Infancy: trust vs. mistrust
2. Toddlerhood: autonomy vs. shame and doubt
3. Preschool: initiative vs. guilt
4. School age: industry vs. inferiority
5. Adolescence: identity vs. identity diffusion
6. Young adult: intimacy vs. isolation
7. Middle adult: generativity vs. stagnation
8. Elder adult: ego integrity vs. despair
Positive resolution of each task builds a strong personality while negative
resolution results in difficulty handling psychosocial problems
KOHLBERG'S THEORY OF MORAL DEVELOPMENT

A. Describes how children develop morally in 3 stages (levels):
1. Premorality: child behaves acceptably because child fears
punishment
2. Conventional morality: child behaves appropriately in order to
please others
3. Postconventional morality
a. An internal locus of control guides behavior
b. Based on concern for what is right and good for all
B. Children and adults may not progress through all levels.
B. Infancy (one month to 12 months)

1. Growth
a. period of very rapid growth.
b. doubles birth weight at six months, triples at one year
c. by one year birth length has increased by almost 50%
(occurs mainly in trunk)
d. by one year head circumference has increased by almost
33%
e. posterior fontanel closes six to eight weeks of age
f. anterior fontanel closes 12-18 months of age
g. tooth eruption begins at five to six months (illustration )
h. has six to eight teeth by one year
2. Motor development
a. sits without support at six to eight months of age
b. rolls completely over at six months of age
c. vocalization at eight months of age
d. pincer grasp at nine-11 months of age
e. crawling six to seven months of age
f. stands alone ten-12 months of age
g. cruises (walks holding on) ten-12 months of age
h. walks at 12-15 months of age.
i. begin feeding self at 11 months of age
3. Cognitive: Piaget's sensorimotor period
4. Psychological: Erikson's developmental task of trust vs.
mistrust
a. lays foundation for other developmental tasks
b. stranger anxiety/separation anxiety
5. Language development
a. cries, smiles, coos
b. produces chained syllables
c. says two or more words by one year
d. understands meaning of "no" by 11 months of age
e. can follow simple directions at one year
6. Play is solitary
a. game playing such as peekaboo and pat-a-cake by ten
months of age
7. Common fears
a. from birth to three months - fears sudden movements, loud
noises, and loss of physical support
b. from four-12 months - fears strangers, strange objects,
heights, and anticipation of previous uncomfortable
situations
8. Suggested toys
a. birth to six months - mobiles, unbreakable mirrors, music
boxes, rattles
b. six to 12 months - blocks, nesting boxes or cups, simple
take apart toys, large ball, large puzzles, jack in the box,
floating toys, teething toys, activity box, push-pull toys
PIAGET'S THEORY OF COGNITIVE DEVELOPMENT
Four Periods: Sensorimotor, Preoperational Thought, Concrete Operations,

Formal Operations
As children mature intellectually, they are more able to understand the
environment, create patterns of behavior, and reason through problems.
A. Piaget's sensorimotor period: birth to two years

1. Characteristics
a. reflexes are used to achieve equilibrium
b. repetitive acts help establish patterns of behavior
c. beginning object permanence is evident (learning that an
object still exists when it is out of sight.)
d. view of the world is egocentric
e. active experimentation as infant progresses
2. Nursing considerations: sensorimotor stage
a. children will explore their environment to learn more about it
expecially through use of thier mouth
b. cannot use logic to protect themselves
c. separation from parents is not as important to infants (under
six months) as it is to older children
B. Piaget's period of preoperational thought: two to seven years
1. Characteristics
a. object permanence becomes more established
b. still egocentric in thinking
c. use language as a symbol system more and more
d. increased magical thinking and imagination; called animism.
e. perceptions rule child's thinking and reasoning
f. attention span is short.
g. child has better concept of time as he/she approaches
school age
a. illness and hospitalization frighten toddlers and
preschoolers. They lack the cognitive powers to grasp these
experiences.
b. precognitive children use fantasy and magical thinking to
attempt to understand illness and hospitalization.
c. precognitive children have many fears, especially separation
which peaks from two through three years of age.
d. these children learn best if actively involved in the learning
process.
e. this age group relates well to discussions about what they
will see and feel. Visual and tactile learning is best.
C. Piaget's period of concrete operations: seven to ten years
1. Characteristics
a. thinking shifts from total egocentrism to more local
awareness
b. conscience develops
c. perception no longer dominates reasoning- recognized
cause-and-effect relationships.
d. understands basic ideas of conversation, number,
classification, and other concrete ideas.
e. attention span increases
f. can solve problems by trial and error
a. this age group benefits from health teaching with concrete
terms and explanations.
b. this age group reads and understands concepts related to
the human body.
D. Piaget's period of formal operations: 11 years to Adult
1. Characteristics
a. see new logical relationships
b. analyze situations and think more logically than before
c. think creatively since increased abilities to think abstractly
d. concern for moral and social issues are a priority over
Egocentric thinking
a. think much more like adults
b. are able to be taught health concepts at higher levels
c. more likely to understand adult vocabulary


resolution results in difficulty handling psychosocial problems.
C. Toddlerhood (one year to three years)

1. Growth
a. gains 1.8-2.7 kg (four to six lbs) per year
b. grows 7.5 cm (three inches) per year (occurs mainly in
legs)
c. lordosis and potbelly are characteristic
d. head circumference usually equal to chest circumference by
one to two years of age
e. primary dentition complete by 30 months of age
a. walking improves
b. runs
c. begins to climb and walk up and down stairs
d. builds tower of eight blocks by age three years
e. by end of toddlerhood can copy a circle on paper
f. dresses self in simple clothing
3. Cognitive: Piaget's period of preoperational thought
4. Psychological: Erikson's developmental task of autonomy vs.
shame and doubt
a. toilet training begins
i. bowel training usually accomplished before bladder
b. discipline becomes necessary
c. ritualistic: need to maintain sameness and reliability
d. negativism: persistent negative response to requests
e. frustration may result in temper tantrums or regression
5. Moral development: Kohlberg's preconventional or premoral
level
a. vocabulary grows from four to six words at 15 months to
over 300 words by age two
b. "no!" and "mine!" are key words
c. ability to understand speech is much greater than the
number of words the child can say
d. uses multiword sentences by age two
7. Play is parallel
8. Common fears include the dark, being alone, separation from
parents, some animals, and loud machines
9. Suggested toys: push-pull toys, finger paints, thick crayons, riding
toys, balls, blocks, puzzles, simple tape recorder, housekeeping
toys, puppets, cloth picture books, large beads to string, toy
telephone, water toys, sand box, play dough or clay, chalk and
chalkboard
DISCIPLINE
A. Parents need anticipatory guidance in discipline
B. Main purposes
1. Provide safe boundaries
2. Teach desirable behaviors

C. Limit setting
1. Helps child maintain control over internal urges
2. Helps child feel secure
3. Rules must be clear and simple
a. no hurting others
b. no hurting self
c. no destruction of equipment
D. Good discipline
1. Is consistent
2. Is timely
3. Fits the "crime"
E. Types of discipline
1. Corporal (spanking, slapping)
2. Reasoning - not appropriate for toddlers (one to three years of age)
3. Rewarding - a type of behavior modification
4. Ignoring as a penalty: Time-out - a "good guide" is "one minute of
time-out per year of age."
5. Restricting activities and freedom - works well with older children
and adolescents
KOHLBERG'S THEORY OF MORAL DEVELOPMENT

A. Describes how children develop morally in 3 stages (levels):
1. Premorality: child behaves acceptably because child fears
punishment
2. Conventional morality: child behaves appropriately in order to
please others
3. Postconventional morality
a. An internal locus of control guides behavior
b. Based on concern for what is right and good for all
B. Children and adults may not progress through all levels.
Practice relaxation exercises and S-L-O-W, DEEP breathing as a method to

reduce fatigue, stress, tension, and anxiety.
Become more flexible with yourself and others.

D. Preschool age (three years to six years)
1. Growth
a. average weight gain about two to three kg (five lb) per year
b. height: increase of 6.75 to 7.5 cm (2.5 to 3 inches) per year
(occurs in legs)
a. very active
b. can hop on one foot
c. pedals tricycle
d. refinement of previous learned motor skills
e. draws a person with one body part/year
3. Cognitive: Piaget's period of preoperational thought
4. Psychological: Erikson's developmental task of initiative vs
guilt
a. sexual curiosity, and
b. imitation of adult roles with dress-up games.
5. Moral development: Kohlberg
a. two to four years: punishment and obedience
b. four to seven years: naive instrumental orientation
a. by age five, has vocabulary of 2,100 words
b. knows name and address
c. asks questions constantly
d. uses fantasy in stories
e. "why?" is favorite word
7. Preschool play is associative and cooperative.
a. dress-up
b. fantasy play
c. imaginary playmates
8. Common fears of preschool child include body mutilation,
animals, supernatural beings, monsters, ghosts, unfamiliar routines,
separation from trusted adults, and abandonment, annihilation
9. Suggested toys: tricycle, gym and sports equipment, sandboxes,
blocks, books, puzzles, computer games, dress-up clothes, blunt
scissors, picture games, construction sets, musical instruments,
cash registers, simple carpentry tools
E. School age (six years to 12 years)

1. Growth
a. growth is slow and steady until growth spurt of
adolescence.
b. between ages six to 12, growth at average of two to three
kg (4.5-6.5 lbs) per year
c. brain growth is complete by nine-ten years of age.
d. height: average growth of five cm (two inches) per year
e. loss of deciduous teeth/acquisition of permanent teeth
f. child is usually lean, but some may become overweight
depending on eating habits and activity
a. full of energy
b. rides bicycle and plays active games
c. most enjoy sports
d. writes in cursive
e. more awkward as adolescence approaches
3. Cognitive: Piaget's period of concrete operations
4. Psychological: Erikson's developmental task of industry vs.
inferiority
a. develops a sense of accomplishment through completion of
tasks
b. joins clubs
c. has same-sex friends
d. peer approval is strong motivating power
5. Moral development - Kohlberg
a. develops a moral code and social rules
b. views rules not just as dictates from authority, but as
necessary principles of life
c. can judge flexibly and decide if rules apply to a given
situation
1. vocabulary of approximately 14,000 words

2. reading skills improve dramatically
2. Play is cooperative.
1. sports and games with rules
2. fantasy play in early years
3. clubs
4. hero worship
5. cheating
3. Suggested toys/activities: board or computer games, books,
collections, scrapbooks, sewing, cooking, carpentry, gardening,
painting
F. Adolescent (age 12-20)
1. Growth
1. boys increase in muscle mass; girls increase in fat deposits

2. may experience growth spurts
3. puberty (illustration 1 illustration 2 )
1. primary sex characteristics and secondary sex
characteristics
2. dentition is complete
1. increase in gross and fine motor abilities
2. increase in risk-taking behaviors
3. Cognitive: Piaget's period of formal operations
4. Psychological: Erikson's developmental task of identity vs role
diffusion
1. begins to develop a sense of "I"
2. peers become most significant group
3. separates from parents
5. Moral Development: Kohlberg
1. healthy adolescents consolidate moral development
2. understand that rules are not absolutes, but cooperative agreements that can be
changed to fit the situation
3. judge themselves by internalized ideals
4. group values become less significant in later adolescence
5. sense of right and wrong develops from applying values to daily decisions
6. Language development - increases as cognitive skills increase
7. Play / recreation
1. centers around social interactions: dating, phone calls, etc.
2. sporting and cultural activities
PUBERTY
A. Individuals vary widely in the timing of physical changes; following are

general guides
1. Girls tend to begin puberty earlier than boys
2. Right before puberty, height and weight increase
B. Hormonal bases of pubertal changes
1. Physical changes are the result of hormonal changes when the
hypothalamus begins to produce gonadotropin-releasing hormones
2. Gonadotropic hormones stimulate the ovaries to produce estrogen
and testicular cells to produce testosterone
3. Estrogen and testosterone govern development of secondary sex
characteristics and play a critical role in reproduction
C. Obvious physical changes of puberty include
1. Skeletal growth spurt
2. Appearance of pubic hair and axillary hair
3. In females
a. Breast development
b. Menarche
c. Ovulation
d. Widening and deepening of pelvis
4. In males
a. Enlargement of testes and scrotal sac
b. Voice changes - becomes deeper or lower-toned
c. Spermatogenesis
d. Facial hair
e. Shoulders widen
primary sex character
An inherited trait directly concerned with the reproductive tract.
G. Early adulthood
Post adolescence through Age 40
1. Physical pevelopment
a. period of optimal physical function
b. typically free of acute or chronic illness
c. effects of aging begin at about 20 years of age
d. musculo-skeletal System
i. growth completed about age 25
ii. height increased by three to five mm by age 30
e. cardiovascular system
i. peak strength about age 30
ii. men more likely to have high cholesterol level
iii. blood pressure changes noted by race, sex and
weight
f. gastrointestinal system
i. after age 30, digestive juices decrease
ii. wisdom teeth emerge
iii. average person tends to gain weight during the 30s
g. reproductive system
i. fully mature in 20s
ii. women: optimal reproductive time between 20-30
years of age

resolution results in difficulty handling psychosocial problems.
H. Middle adulthood
Ages 40 to 60
1. Physical development
a. signs of aging begin to show
b. subtle but gradual decline in most body systems
c. integumentary system
i. appropriate distribution of pigment
ii. graying of hair
iii. progressive decrease in skin turgor
d. respiratory
i. anteroposterior diameter of chest increases
ii. respiratory rate 16 to 21 breaths per minute
iii. normal breath sounds
e. cardiovascular
i. normal heart sounds
ii. pulse 60 to 100 beats per minute
iii. blood pressure: systolic 95 to 135mm Hg
iv. diastolic 60 to 85 mm Hg
f. reproductive
i. changes in menstrual cycle and flow
ii. menopause (climacteric) sets in about age 45 to 50
iii. decrease in ovarian function
iv. symptoms of diminished estrogen production: hot
flashes, headache, palpitations, mood swings, and
vaginal dryness resulting in itching, burning, and/or
painful intercourse
v. treatment includes diet, exercise, estrogen
replacement therapy and alternative therapies such
as herbs and Vitamin E
vi. complications include:
1. osteoporosis (illustration )
2. cystocele or rectocele
3. uterine prolapse
vii. sexual interest / desire
1. women: increases after age 35
2. men: stabilizes or decreases somewhat
viii. male erection takes longer to achieve
ix. male menopause: symptoms may include insomnia,
fatigue and circulatory problems
osteoporosis
A general term describing any disease process that results in reduction in the mass of bone
per unit of volume.
cystocele
A bladder hernia that protrudes into the vagina. Injury to the vesicovaginal fascia during
delivery may allow the bladder to pouch into the vagina, causing a cystocele. It may cause
urinary frequency, urgency, and dysuria. SYN: vesicocele.
rectocele
Protrusion or herniation of the posterior vaginal wall with the anterior wall of the rectum
through the vagina. SEE: cystocele.
prolapse of the uterus
Downward displacement of the uterus, the cervix sometimes protruding from the vaginal
orifice. The causes include age with weakening of pelvic musculature, traumatic vaginal
delivery, chronic straining in association with coughing or difficult bowel movements, and
pelvic tumors that push the uterus down.
g. sensory
i. visual acuity decreases
ii. presbyopia
h. cognitive
i. peak of intellectual development
ii. no longer views self as invincible
iii. chooses battles
i. psychosocial
i. Erickson: generativity versus stagnation
ii.midlife transition: time for assessing one's life
structure
iii. community emphasis peaks
iv. role reversal takes place with parents
v. more empathetic towards elderly
j. major health risks
i. leading cause of death is heart disease
ii. in women, osteoporosis and breast and uterine
cancer
iii. colorectal and lung cancer
visual acuity
A measure of the resolving power of the eye; usually determined by one's ability to read letters
of various sizes at a standard distance from the test chart. The result is expressed as a
fraction. For example, 20/20 is normal vision, meaning the subject's eye has the ability to see
from a distance of 20 ft (6.1 m) what the normal eye would see at that distance. Visual acuity
of 20/40 means that a person sees at 20 ft (6.1 m) what the normal eye could see at 40 ft
(12.2 m).
presbyopia
The permanent loss of accommodation of the crystalline lens of the eye that occurs when
people are in their mid-40s, marked by the inability to maintain focus on objects held near to
the eye (i.e., at reading distance). SEE: farsightedness.
I. Elderly adult
Over age 60
1. Biological theories of aging

a. crosslink theory
b. immunological theory
c. free radical theory
d. stress theory
e. error theory
f. biological programming
2. Psychosocial theories of aging
a. disengagement theory
b. activity theory
c. continuity theory
3. developmental tasks of elderly adult
a. Erickson: ego integrity versus despair
b. accepting self as aging person; coping with physiological
changes
c. adjusting to decreasing physical abilities
d. adjusting to retirement and decreased income
e. adjusting to death of spouse; redefining relationships with
children
f. maintaining satisfactory living arrangements, and quality of
life
disengagement
1. The emergence of the fetal head from within the maternal pelvis. 2. Any withdrawal from
participation in customary social activity. 3. In psychiatry, autonomous functioning with little or
no emotional attachment and a distorted sense of independence.
activity theory
A social theory of aging that asserts that the more active older persons are, the higher their
life satisfaction and morale. According to this theory, individuals who are aging successfully
cultivate substitutes for former societal roles that they may have had to relinquish
continuity theory
Holds that individuals will try to sustain current patterns of activity and interaction as they age.
4. Physical systems
a. integumentary system
i. dry, scaly skin (illustration )
ii. decreased perspiration
iii. decreased elasticity
iv. senile purpura (illustration 1 illustration 2 )
v. spotty pigmentation (illustration 1 illustration 2
)
b. respiratory
i. reduced vital capacity
ii. increased airway resistance
iii. kyphosis may cramp lung expansion
iv. decreased lung expansion
c. cardiovascular
i. decreased cardiac output
ii. baseline systolic and diastolic blood pressure may
rise
iii. peripheral pulses weaker
d. gastrointestinal
i. abdomen increases in size, protrudes more
ii. less saliva
iii. less gastric motility and absorption
iv. decreased interest in food
v. decreased peristalsis
vi. potential for malnutrition
vii. decreased hepatic clearance of drugs and other
substances
viii. constipation common
The Palm Press Pose

Instructions
Sit up straight. This exercise may be done in a half lotus sitting

position or in a chair.
Press your palms together against your chest, your elbows should be
parallel to the floor. INHALE twist to the right and look over your right
shoulder, keep the palms pressed in the same position. Hold your
breath for several seconds. EXHALE and twist to the left look over the
left shoulder. Then return to center and INHALE. Now reverse and
start with the left side.
Do 2 on each side.
senile purpura
Purpura occurring in debilitated and aged persons with ecchymoses and petechiae on the
legs.
airway resistance
The impedance to the flow of air into and out of the respiratory tract.
kyphosis
1. An exaggeration or angulation of the posterior curve of the thoracic spine, giving rise to the
condition commonly known as humpback, hunchback, or Pott's curvature. It may be due to
congenital anomaly, disease (tuberculosis, syphilis), malignancy, or compression fracture.
This term also refers to an excessive curvature of the spine with convexity backward, which
may result from osteoarthritis or rheumatoid arthritis, rickets, or other conditions. 2. The
normal posterior curvature of the thoracic and sacral spine. SYN: humpback; spinal curvature.
kyphotic, adj.
peristalsis
A progressive wavelike movement that occurs involuntarily in hollow tubes of the body, esp.
the alimentary canal. It is characteristic of tubes possessing longitudinal and circular layers of
smooth muscle fibers.
e. urinary
i. decreased renal filtration
ii. decreased bladder capacity
iii. benign prostatic hypertrophy
iv. female: urgency and stress incontinence
v. male: urinary frequency and retention
f. musculo-skeletal
i. reduced muscle mass and strength
ii. decreased joint mobility / decreased range of
motion
iii. decreased endurance
iv. postmenopausal women: bone demineralization
g. neurological
i. decreased rate of voluntary or automatic reflexes
ii. sleep cycle changes- require less sleep at night,
frequently nap in daytime
iii. impaired thermoregulation-prone to hypothermia
h. sensory
i. decreased visual acuity
ii. decreased accommodation (illustration )
iii. presbyopia
iv. decreased hearing acuity (presbycusis) (illustration
)
v. decreased pitch discrimination
vi. taste buds atrophy
vii. decreased sense of smell
visual acuity
A measure of the resolving power of the eye; usually determined by one's ability to read letters
of various sizes at a standard distance from the test chart. The result is expressed as a
fraction. For example, 20/20 is normal vision, meaning the subject's eye has the ability to see
from a distance of 20 ft (6.1 m) what the normal eye would see at that distance. Visual acuity
of 20/40 means that a person sees at 20 ft (6.1 m) what the normal eye could see at 40 ft
(12.2 m).
accommodation
ABBR: a; acc. 1. Adjustment or adaptation. 2. In ophthalmology, a phenomenon noted in
receptors in which continued stimulation fails to elicit a sensation or response. 3. The
adjustment of the eye for various distances whereby it is able to focus the image of an object
on the retina by changing the curvature of the lens. In accommodation for near vision, the
ciliary muscle contracts, causing increased rounding of the lens, the pupil contracts, and the
optic axes converge. These three actions constitute the accommodation reflex. The ability of
the eye to accommodate decreases with age. 4. In the learning theory of Jean Piaget, the
process through which a person's schema of understanding incorporates new experiences
that do not fit existing ways of understanding the world.
In your schedule identify times when you will have the highest concentration level and a
high energy level. Do the most difficult questions then.
5. Cognitive changes
a. expected: decreased short-term memory, narrowed interests
b. occur when cerebral dysfunction or trauma is present
6. Psychosocial
a. Erickson: ego integrity versus despair
b. expected: lessened adaptability, diminished emotional
responses
c. retirement; change in occupational and social roles;
economic changes
d. social isolation; attitudinal isolation
e. presentational isolation
f. behavioral isolation
g. geographic isolation
7. Sexual function will depend on general health, psychological
health, medications
8. Housing
a. home: single family, apartment, and retirement community
b. assisted living
c. day care
d. respite care
e. long-term care
9. Death
2. Health
1. Definitions of health vary
5. Traditional definition: freedom from disease
6. 1958 World Health Organization defined health as "state of
complete physical, mental and social well-being and not merely the
absence of disease and infirmity"
2. Health belief model
5. Psychological and behavioral theory
6. Attempts to explain individual health behaviors
7. Health behaviors are based on three factors
a. the individuals perception of susceptibility of illness
b. the individuals perception of seriousness of the illness
c. the likelihood that the person will take preventive action
8. Modifying factors
a. cultural beliefs
b. economics
c. political factors
d. social factors
e. personal beliefs
VIII. Health Promotion
A. Definitions
1. Health promotion behavior is behavior in which the client views
health as a goal and engages in behaviors designed to achieve or
maintain that goal.
2. Health care includes prevention, early detection, treatment and
rehabilitation for clients with potential for or existing illness or
disability.
3. Healthy lifestyle can increase or maintain client's level of wellness
and functional ability.
4. Health screening (for risk factors or illness) can prevent or
minimize illness and disability.
5. Disease prevention behaviors are behaviors designed to decrease
the likelihood/risk of illness.
a. primary prevention
i. health promotion and disease prevention
ii. applied to clients considered physically and
emotionally healthy
iii. example: exercise programs, healthy diet
b. secondary prevention
i. early detection of illness
ii. focuses on individuals who are experiencing health
problems and illnesses and who are at risk for
complications
iii. activities are directed at diagnosis and prompt
treatment
iv. example: breast self examination, cholesterol
screening
c. tertiary prevention
i. prevention of further deterioration in disease or
disability
ii. occurs when a defect or disability is permanent and
irreversible
iii. activities are directed at rehabilitation
iv. example: alcoholics anonymous
IX. Primary health care
A. Accessible, community-based or work-based health care services based on
principle of universal access, which ensures health care for all individuals
regardless of employment or insurance status.
B. Health Security Act of 1993 offered universal access to basic hospital,
preventive, physician and long-term services. It included these seven
services:
1. physical examinations
2. screening tests
3. diagnosis and treatment of common acute illnesses
4. management of chronic illnesses
5. liaison with community resources
6. provision of prenatal care
7. identification of need for specialty referrals
C. Providers include physicians, and advanced practice nurses, such as: nurse
midwives and nurse practitioners
D. Services provided through a managed care model
E. Specialty services provided and reimbursed only after referral from the
primary care provider
F. Primary care settings include
1. health maintenance organizations
2. public health departments
3. occupational health clinics
4. schools
5. nurse managed clinics
6. collaborative practice settings
Health Maintenance Organization

ABBR: HMO. A prepaid health care program of group practice that provides comprehensive
medical care, esp. preventive care, while aiming to control health care expenditures.
C. Healthy People 2010

1. The US Department of Health and Human Services released Healthy
People 2010: National Promotion and Disease Prevention Objectives
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 are:
a. increase quality and years of healthy life
b. eliminate health disparities
D. Health promotion model
1. Developed by Nola Pender
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. 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 occupation and diet
4. Non-modifiable risk factors include race and age
5. Examples: risk factors are important in
a. coronary artery disease
b. cancer
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 person with 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 IV 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 24-28 weeks gestation
vi. history of gestational diabetes
F. Screening recommendations for the average American
1. Cholesterol - once every five years if normal age 45 and older
2. In women: mammography
3. In women: papanicolau smear, onset of sexual activity or over age 18,
annually
4. In men: prostate-specific antigen - annually 50 years of age or at age 40
for those at risk
5. For colon cancer
Timing of Mammograms
The National Cancer Insitutute (NCI) and the American Cancer Society differ in their
recommendations for scheduling of mammorgrams.
The NCI recommends (2002):
Women in their 40s should be screened every one to two years with mammorgraphy.
Women aged 50 and older should be screened every one to two years.
Women who are at higher than average risk of breast cancer should seek expert medical
advice about whether they should begin screening before age 40 and the frequency of
screening.
The ACS guidelines for the detection of breast cancer in asymptomatic women (2002):
Women 40 years of age and older should have a mammogram every year.
Women 40 and older should have a physical examination of the breast every year,
performed by a health care professional, such as a physician, physician assistant, nurse
or nurse practitioner. This examiniation should take place near and prefereable before,
the annual mammogram.
Women 20-39 should have a physical examination of the breast every three years,
performed by health care professional such as a physician, physician assistant, nurse or
nurse practitioner.
BSE is an option for women starting in their 20s. Women should be told about the benefits and
limitiations of BSE. Women should report any breast changes to their health professional right
away.
Health Promotion Programs and Health Screening
A. Blood pressure screening
1. Screening should be done annually beginning at age 21 for both males
and females
2. Screening for children and adolescents is also recommended but optimal
interval has yet to be determined
3. Ausculatory method with a properly calibrated and fitting cuff should be
used
4. Person should be seated quietly in a chair for at least five minutes with
feet on the floor and arms supported at heart level
5. At least two measurements should be done, two minutes apart
6. Pre-hyerptensive individuals (SBP 120-139 and DBP 80-89) should be
counseled on lifestyle modifications such as wieght reduction, exercise,
diet, and smoking cessation
7. SBP > 140 and / or DBP > 90 should be referred to a health care
provider for antihypertensive drug therapy
B. Breast self-examinations
1. Should be started by age twenty
2. Done at the same time of the month - preferably seven days after onset
of the menstrual cycle; if no menstrual cycles, do at the same time each
month
3. Technique should be reviewed by a health care provider to ensure
effectiveness
4. Limited effectiveness, but when done regularly helps a woman
understand how her breasts normally feel
5. Most changes are benign, but unusual or spontaneous changes should
be checked by a health care provider without delay - these include:
a. lump or thickening (breast or underarm)
b. red or hot skin
c. orange peel skin
d. dimpling or puckering
e. itch or rash, especially in nipple area
f. retracted nipple
g. change in directon of nipple
h. bloody or spontaneous discharge
i. unusual pain
j. a sore on the breast that does not heal
C. Risky behaviors - assist in assessment of behaviors that impact the health of

individuals in the following developmental stages
1. Adolescents (age 13-19)
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 diseases
2. Young adult (age 20-35)
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 (age 35-65)
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. seatbelts
iii. suicide
iv. multiple medications
D. Scoliosis screening
1. Recommendations vary but generally accepted to perform screening at
onset of adolescence
2. Significantly more prevalent in girls than boys
3. Early intervention important because untreated scoliosis can lead to
disfigurement, impaired mobility, and cardiopulmonary complications
4. Technique: clothing should be removed from upper body
a. while standing, check adolescent for asymmetry of shoulders,
scapula, hips, or waist
b. assess for misalignment of spinous processes - lateral curvature
and convexity of thoracic spine indicate scoliosis
c. with feet together and legs straight, have adolescent bend
forward until back is parallel to floor; check for prominence of ribs
on one side only and hip and leg asymmetry - chest wall on side
of convexity is prominent and scapula on side of convexity is
elevated
5. Abnormalities are to be followed up by a health care provider and referral
to orthopedist may be necessary for severe curvatures
E. Testicular self-examinations
1. Monthly self-examination should begin in adolescence, since this is the
highest risk group
2. Best time to perform exam is during or after a bath or shower when the
scrotum is relaxed
3. Limited research to determine if regular examinations reduce death rate
but they are strongly encouraged for men with risk factors such as
a. family history of testicular cancer
b. cryptochidism
c. previous germ cell tumor in one testicle
4. Findings that should be reported to a health care provider include
a. hard lumps or nodules
b. change in size, shape, or consistency of the testes
prostate-specific antigen
ABBR: PSA. A marker for cancer of the prostate, found in the blood. It is secreted by both
benign and malignant prostate tumors, but cancerous prostate cells secrete it at much higher
levels. Prostate-specific antigen is used as a screening test for cancer of the prostate and as
a means of following the results of treatment in patients with known prostate cancer. SEE:
prostate cancer.
1. For colon cancer
a. digital rectal exam every year after the age of 40
b. guaiac test for occult blood every year after the age of 50
c. proctoscopy every three to five years after the age of 50 after two
negative annual exams
d. colonoscopy
2. Tuberculosis skin tests: intradermal injection of antigen
3. Diabetes: fasting plasma glucose, ideally eight to 12 hours fast
4. Vision: after age 39, medical eye exam every three to five years
5. Hearing: candidates for screening include:
a. family history of childhood hearing impairment
b. perinatal infection (rubella, herpes, cytomegalovirus)
c. low birth weight infants
d. chronic ear infection
e. down syndrome
guaiac test
A test for unseen blood in stool. SEE: fecal occult blood test.
proctoscopy
Inspection of the rectum with a proctoscope.
cytomegalovirus
A widely distributed species-specific herpesvirus; in humans, it inhabits many different tissues
and causes cytomegalic inclusion disease. A mother with a latent infection may transmit the
virus to her fetus either transplacentally or at the time of birth. The virus may also be
transmitted by blood transfusion. Although it is usually not harmful to those with functional
immune systems, it may cause a fatal pneumonia in immunocompromised patients.
Cytomegalovirus may infect the retina and cause blindness in AIDS patients.
Down syndrome
[J. Langdon Down, Brit. physician, 1828-1896] The clinical consequences of having three
copies of chromosome 21. The condition is marked by mild to moderate mental retardation
and physical characteristics that include a sloping forehead, low-set ears with small canals,
and short broad hands with a single palmar crease ("simian" crease). Cardiac valvular disease
and a tendency to develop Alzheimer-like changes in the brain are common consequences of
the syndrome. The syndrome is present in about 1 in 700 births in the U.S. and is more
common in women over age 40. In women who conceive after age 45, the syndrome affects 1
in 25 births. SYN: trisomy 21.
G. Compliance
1. Definition: adherence to primary or secondary prevention
recommendations
2. Factors influencing compliance
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
H. 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
I. Health Assessment
1. Health assessment in general
a. Purposes of health assessment
A. data collection
B. supplement, confirm or refute historical data
C. identify changes in client's status
D. evaluate the outcomes of care
b. Components of health assessment: history and physical
A. history
A. chief complaint
A. location
B. quality
C. quantity
D. precipitating or aggravating factors
E. duration
F. associated symptoms
B. general health status
C. medical history
D. family history
E. occupation
F. activity level
G. sleep
H. nutrition
I. medications; including substance use/abuse
J. psychosocial factors
b. physical exam: skills

i. inspection
process of observing the differences between normal
physical signs and deviations
requires knowledge of normal physical signs throughout
the lifespan
principles of Inspection
o in good lighting and with whole body part visible
o observe each area for size, shape, color, and
position
o compare body parts bilaterally for symmetry
ii. palpation
a. use touch to assess resistance, resilience, roughness, texture and mobility

b. palpation may be either light or deep in pressure
i. use light palpation to determine tenderness

ii. deep palpation usually depresses the area by one to two inches; use it to examine
specific organs
b. use palmar surface of fingers to determine position, texture, size, consistency, and
pulsation; also presence and shape of mass
c. use back of hand to test temperature
d. use palm of hand to sense vibration
c. percussion
i. tap the body with fingertips: to detect fluid, or to assess location,
size, density and borders of organs.
ii. tapping the body produces vibration and sound waves which you
hear as percussion tones
iii. methods
a. direct: striking the body surface with two fingers
b. indirect: striking the middle finger of the nondominant 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
iv. 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. assess presence of sounds and their character
a. frequency (high or low pitch)
b. loudness (loud or soft)
c. quality (blowing, gurgling, booming, thudlike, hollow, flat)
d. duration (short, moderate, long)
CHARACTER OF PERCUSSION SOUNDS

Tympany:
Drumlike, loud, high pitch, moderate duration; usually found
over spaces containing air such as the stomach
Resonance: Hollow sound of moderate to loud intensity; low pitch, long

duration; Usually heard over lungs
Hyperresonance: Booming sound of very loud intensity; very low pitch, long
duration; Usually heard in the presence of trapped air (such as
emphysematous lung)
Flatness: Flat sound of soft intensity; high pitch; short duration; Usually
heard over muscle
Thud-like sound of soft intensity; high pitch; moderate duration;

Dullness: Usually heard over solid organs (such as heart, liver)
v. olfaction
use of sense of smell to differentiate common body odors
from abnormal ones
common odors include
o urine: ammonia
o skin: body odor
o body wastes: feces, vomitus
o mouth: halitosis
vi. physical exam

equipment
client positions
EQUIPMENT NEEDED FOR PHYSICAL EXAM
Client Gown
Drapes
Stethoscope
Gloves
Percussion Hammer
Sphygmomanometer (Blood Pressure gauge and cuff)
Thermometer
Tape measure
Cotton swabs
Flashlight
Tongue depressor
Scale
Lubricant
Eye chart
Miscellaneous: safety pin, ruler, paper towels
reporting general appearance and behaviors
gender and race
age
obvious signs of distress
body type
posture
gait
body movements
hygiene
dress
affect and mood
speech
vital signs
height and weight
body temperature
range: 36 to 38 degrees Celsius (98.6 to 100.4
degrees Fahrenheit)
measure core tem: rectum, tympanic membrane,
esophagus, or urinary bladder
measure surface temperature: skin, axilla, or mouth
body temperature normally varies with
age
exercise
hormone level
circadian rhythm (time of day)
stress
environment
Health Assessment by Body Part

B. Eye
1. History
a. current symptoms
b. past problems
c. family history - glaucoma, cataracts
d. harmful exposure - chemical sunlight
2. Physical exam
a. vision test
b. extraocular muscle functions (EOM's)
c. external eye structures
d. internal eye structures and red reflex
e. optic disc
f. retinal vessels
3. Geriatric alterations of eye
a. arcus senilis
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
f. presbyopia
g. color perception may be dimmed
C. Ear (illustration )
1. History
a. presenting problem or injury
b. presence of hearing loss
c. use of hearing assist
d. associated symptoms
e. onset
f. precipitating factors
g. aggravating and alleviating factors
h. lifestyle factors: swimming, musician
i. medical history
j. family history of allergy or hearing disease
k. medications
arcus senilis
Opaque white ring about the periphery of the cornea, seen in aged persons; caused by the
deposit of fat granules in the cornea or by hyaline degeneration
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
a. palpate auricle, tragus and mastoid area for tenderness and
elevated local temperature
b. normal findings: auricle is normally smooth without lesions
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, usually orange cerumen
(ear wax). Cerumen is usually dry in Asians, Native
Americans, and the elderly
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
tophus
pl. tophi A deposit of sodium biurate in tissues near a joint, in the ear, or elsewhere in
individuals with gout. SYN: gouty pearl.
mastoid
1. Shaped like a breast. 2. The mastoid process of temporal bone. 3. Pert. to mastoid process.
mastoidal, adj.
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: tuning fork of 512 cps is set to vibrate and
placed perpendicularly on the midline vertex of the skull.
Client asked to report in which ear sound is heard. If heard
in one ear, suspect sensorineural loss in the other
d. Rinne test - compares sound conduction: air versus bone
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 cm 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
B. Mouth and pharynx
5. 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
b. sense of taste may be diminished
c. decreased saliva
d. lips thinner, shiny
e. teeth may appear yellowish
f. tongue may appear smoother
buccal mucosa
The lining of the cheeks of the oral cavity. It is characterized by stratified squamous
nonkeratinized epithelium that may become keratinized in local areas due to cheek-biting. It
may also contain ectopic sebaceous glands. SEE: Fordyce's disease.
papilla
pl. papillae A small, nipple-like protuberance or elevation.
ruga
pl. rugae A fold or crease, esp. one of the folds of mucous membrane on the internal surface
of the stomach.
uvula
1. The free edge of the soft palate that hangs at the back of the throat above the root of the
tongue; it is made of muscle, connective tissue, and mucous membrane. 2. Any small
projection.
E. Skin (illustration )
1. General appearance - inspection
a. color
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
a. alterations in skin color
i. hyperpigmentation
ii. hypopigmentation
iii. cyanosis
iv. jaundice
v. erythema
b. moisture
c. temperature
d. texture: varies from part to part
i. smooth or rough
ii. supple or tight
iii. indurated
e. turgor
i. normally decreases with age
ii. decreased in dehydration
f. vascularity
i. in older people, capillaries are more fragile
ii. petechiae
g. edema
hyperpigmentation
Increased pigmentation, esp. of the skin.
hypopigmentation
Diminished pigment in a tissue.
erythema
Reddening of the skin. Erythema is a common but nonspecific sign of skin irritation, injury, or
inflammation. erythematic, erythematous, adj.
petechiae
sing. petechia 1. Small, purplish, hemorrhagic spots on the skin that appear in patients with
platelet deficiencies (thrombocytopenias) and in many febrile illnesses. 2. Red spots from the
bite of a flea.
h. lesions
i. normal finding: free of lesions
ii. age-related changes include keratosis senilis, cherry
angiomas, and atrophic warts. (See also 2. Geriatric
changes, on page 20)
iii. primary lesions
macule
papule (illustration )
patch
plaque
vesicle
bulla
pustule
nodule
iv. secondary lesions (arise from primary)
scale
crust
lichenification (illustration 1 illustration
2 )
scar
excoriation
ulcer
fissure
keloid
erosion
v. for every lesion, note eight aspects:
color
location
texture
size
shape
type
grouping
distribution
keratosis senilis
An inaccurate synonym for actinic keratosis, which is caused by accumulated ultraviolet light
exposure, not by aging.
lichenification
1. Cutaneous thickening and hardening from continued irritation. 2. The changing of an
eruption into one resembling a lichen.
ix. hair
hirsutism
alopecia
x. nails
xi. factors affecting skin condition
hygiene
nutritional status
underlying disorders
xii. geriatric changes in skin (besides wrinkling, and
loss/graying of both head and body hair)
thinner skin
more freckles
hypopigmented patches
skin is drier, especially on lower extremities
less perspiration
all skin becomes less elastic; hanging parts sag
toenails may be thick, distorted, and yellowish
lesions: cherry angiomas, senile keratosis, atrophic
warts
hirsutism
Condition characterized by the excessive growth of hair or the presence of hair in unusual
places, esp. in women. Hirsutism in women is usually caused by abnormalities of androgen
production or metabolism, or it may be a side effect of medication or hormonal therapies. In
patients who do not have an adrenal tumor, this condition may be treated symptomatically by
shaving, depilatories, or electrolysis. The goal of medical therapy is to decrease androgen
production. This may involve the use of various agents including hormones or an
antiandrogen (cyproterone acetate).
alopecia
Absence or loss of hair, esp. of the head.
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
3. Auscultation
a. client takes three positions: sitting, supine, left lateral
recumbent
b. use stethoscope to auscultate heart sounds
c. s1
i. closing of the mitral valve
ii. after long diastolic pause and
iii. before short systolic pause
iv. heard best at apex
d. S2
i. closing of aortic valve
ii. after short systolic pause and
iii. before long diastolic pause
iv. heard best over aorta - second right interspace
v. high pitched, dull in quality
e. pulse deficit
f. murmurs
i. grading system
ii. asymptomatic or symptomatic
iii. thrill
iv. systolic murmur occurs between S1 and S2
v. diastolic occurs between S2 and S1
G. Vasculature
1. Blood pressure
a. reflects relationship between cardiac output, peripheral
vascular resistance, blood volume and viscosity, and
arterial elasticity
(illustration )
b. factors influencing blood pressure
i. age
ii. stress
iii. race
iv. drugs
v. diurnal (day-night) variations
vi. gender
c. alterations in blood pressure
i. hypertension
ii. hypotension
d. range of normal blood pressure
i. child under age two weighing at least 2700g: use
flush technique,30-60mg Hg
ii. child over age two: 85-95/50-65 mm Hg
iii. school age: 100-110/50-65 mm Hg
iv. adolescent: 110-120/65-85 mm Hg
v. adult: <130 mm Hg Systolic / <85 mm Hg diastolic
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 three 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/minutes
toddlers: 90 to 140 beats/minutes
preschool/school-age: 75 to 110 beats/
minute
adolescent/adult: 60 to 100 beats/minute
iii. factors affecting rate
exercise
temperature
stress
drugs
hemorrhage
postural changes
pulmonary conditions causing poor
oxygenation
bruit
An adventitious sound of venous or arterial origin heard on auscultation.
LOCATIONS OF PULSES
Head - Neck
1. Temporal: over temporal bone lateral to eye

2. Carotid: over the carotid artery in neck
Chest
3. Apical: between 4th and 5th intercostal space usually mid-clavicular line
Arm
4. Brachial: in the antecubital area of arm
5. Radial: on thumb side of wrist
6. Ulnar: medial wrist
Leg
7. Femoral: below the inguinal ligament
8. Popliteal: behind the knee
9. Posterior tibial: on inner side of each ankle
10. Dorsalis pedis: along top of foot
1. rhythm - regular (normal) or irregular
2. strength
1. reflects volume of blood ejected with each beat
2. grading system
3. equality
4. alterations
5. dysrhythmias
6. tissue perfusion
1. temperature
2. color: Cyanosis
3. clubbing
4. edema
5. skin and nail texture
6. hair distribution on lower extremities
7. presence of ulcers
PULSE GRADING SCALE

=0
No pulse
Weak pulse
= 1+
Difficult to palpate = 2+
Normal = 3+
= 4+
Bounding
PITTING EDEMA GRADING SCALE
H. Lungs (illustration )
1. History: smoking, infections, pain, discomfort, dyspnea, activity
intolerance, fever
2. Inspection
a. general appearance: respirations
i. breathing should be quiet and easy
ii. respiration involves ventilation, diffusion, and
perfusion of gases
iii. factors influencing respirations
exercise
pain
anxiety
stress
anemia
posture
drugs: narcotics, amphetamines
iv. normal rates of respiration
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, irregular; Normal finding: regular
vii. skin color
viii. chest wall configuration
normal findings: symmetrical with bilateral

muscle development
a-p to transverse ratio range: one to five: two
to seven
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
i. vibration felt when patient speaks
ii. increased over areas of consolidation
4. Percussion - normal findings: resonance heard throughout lung
fields
5. Auscultation
a. normal findings: quiet breathing throughout all lung fields
b. whispered pectoriloquy
i. client whispers "one, two, three"
ii. over normal areas of the lung, only 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"
6. Alterations in lung function
a. cough
b. expectoration
c. dyspnea
d. bradypnea
e. tachypnea
f. hyperpnea
g. apnea
h. Cheyne-Stokes respiration
i. Kussmaul's breathing
j. Biot's breathing
k. grunting
l. retractions
m. hemoptysis
n. pain
o. accessory muscle use
p. cyanosis
q. adventitious sounds
r. pursed-lip breathing
i. prolonged exhalation
ii. breathing out through puckered lips
s. pleural friction rub
i. grating sound produced by inflamed pleura rubbing
together
ii. usually heard loudest over lower lateral anterior
chest at end of inspirat
Adventitious Lung Sounds

Crackles or Rales
1. Discontinuous crackling sounds created by air moving through
fluid / mucous filled alveoli or bronchioles
2. Exaggerated with deep breath
3. Do not clear with coughing
4. Sign of inflammation with fluid / mucous
Rhonchi
1. Low-pitched, coarse, rumbling sounds caused by air moving past
secretions in larger airways, larger bronchioles
2. Sign of secretions
Wheezes
1. Musical, continuous sounds; usually expected to be expiratory with
COPD
2. Caused by air passing through narrowed airways, usually
bronchioles
3. The higher the pitch, the narrower the airway
4. Inspiratory wheezes are more critical than expiratory
Stridor
1. Primarily an inspiratory sound
2. Indicates partial obstruction of larynx or trachea, often from a
spasm
3. Is a medical emergency
Pediatric differences
smaller, shorter, more pliable airways,
underdeveloped supporting cartilage
above two factors increase the risk of obstruction due to
mucus, edema, or foreign body
flexible larynx more susceptible to spasm
immature immune system
incomplete myelinization
increased basal metabolic rate
decreased ability to mobilize secretions
less forceful cough
4. Breasts
Inspection (performed with client in lying, sitting, or standing
position)
size: vary from convex to pendulous
symmetry (the left breast is commonly larger than the
other)
skin: color, venous pattern, possibly a few hairs around
areola
alterations
retraction
dimpling
lesions
edema
inflammation
alterations with pregnancy and lactation
enlargement of breasts
soreness of nipples during lactation
possible striae
nipple and areola
size
color: ranges from pink to brown
shape
areola: round or oval
nipples: everted
symmetry: normally symmetrical
direction: normally nipples point in same direction
alterations
discharge
inverted nipples
bleeding
Palpation - breast
lymph nodes - normal findings: not palpable
breast tissue
client in supine position with hand placed behind
neck
methods of examining breast tissue
clockwise or counterclockwise circling
breast from nipple outward
back and forth with fingers moving up and
down each breast
consistency:
varies widely from person to person
normal findings: dense, firm and elastic
alteration - fibrocystic disease of the breast
geriatric alterations
relaxed breasts
may appear elongated or pendulous
decrease in glandular tissue
fibrocystic disease of the breast

A nonspecific diagnosis for a condition marked by palpable lumps in the breasts, usually
associated with pain and tenderness, that fluctuate with the menstrual cycle. At least 50% of
women of reproductive age have palpably irregular breasts caused by this condition. SYN:
cystic mastitis. SEE: breast self-examination.
J. 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 (illustration )
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. Percussion
a. normal findings: tympany over stomach and intestines;
dullness over liver, spleen, pancreas, kidneys and distended
(>150cc) 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 six to 12 cm at right midclavicular
line
c. spleen
i. left posterior midaxillary line: dullness at sixth to
tenth rib
ii. left intercostal space in anterior axillary line:
tympany
4. Palpation
a. normal findings: soft with no palpable masses, no
tenderness or rigidity
b. bladder noted as a bulge in abdomen when filled with more
than 500cc of urine
c. deep palpation may produce tenderness - liver, kidneys,
spleen inguinal nodes generally not palpable
5. Auscultation
a. bowel motility - normal findings: audible in all quadrants
b. vascular sounds - normal findings
i. no vascular sounds over aorta or femoral arteries
ii. renal artery bruits can be heard
6. Alterations
a. distention
b. ascites
c. paralytic ileus
d. borborygmus
e. guarding (muscles contract)
f. tenderness
g. pain
a. increased fat deposits over abdominal area
b. muscle tone more lax
K. Female reproductive system

1. History: sexually transmitted disease, menstrual history, obstetrical
history, contraception (illustration )
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 two cm in length and 0.5 cm 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 ten to 15 cm in length
Papanicolaou test
[George Nicholas Papanicolaou, Gr.-born U.S. scientist, 1883-1962] ABBR: Pap test. A
cytological study used to detect cancer in cells that an organ has shed. The Pap test has been
used most often in the diagnosis and prevention of cervical cancers, but it also is valuable in
the detection of pleural or peritoneal malignancies, and in the evaluation of cellular changes
caused by radiation, infection, or atrophy. SYN: Pap smear.
Skene's glands
Glands lying just inside of and on the posterior area of the urethra in the female. If the margins
of the urethra are drawn apart and the mucous membrane gently everted, the two small
openings of Skene's tubules or glands, one on each side of the floor of the urethra, become
visible. Trauma frequently causes a gaping of the urethra and ectropion of the mucous
membrane. In acute gonorrhea, these glands are almost always infected. SYN: paraurethral
glands
Bartholin's gland
One of two small compound mucous glands located one in each lateral wall of the vestibule of
the vagina, near the vaginal opening at the base of the labia majora.
3. Palpation
a. ovaries may or may not be palpable; firm, slightly tender,
oval, mobile; about four cm in diameter
b. uterus: mobile; rounded; palpable at level of pelvis
c. Skene's gland and Bartholin's gland - normal findings:
nontender, 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
B. Male reproductive system
3. History: sexual history, sexually transmitted disease, contraception,
surgery, associated urinary problems
(illustration )
4. 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, millimeters from tip of glans; 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 - normal finding: no bulging
5. 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 two - four cm in
diameter, smooth and rubbery; nontender
b. inguinal canal
I. normal finding: inguinal lymph nodes not palpable
a. increased bogginess of prostate
b. testes softer
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 cm in diameter
normal findings: firm, protrudes < one cm
into rectum
c. alterations
i. femorrhoids (illustration )
ii. fissures
iii. fistulas
iv. polyps
v. pain
M. Musculoskeletal
1. History: participation in sports, risk factors for osteoporosis,
impact of current problem on activities of daily living
2. Inspection
a. gait - normal findings: client walks with arms swinging
freely at sides; coordinated and smooth; rhythmic with push
off and swing through
b. posture and balance - normal findings
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
i. normal findings: 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
b. Adduction
c. Dorsiflexion
d. Eversion
e. Extension
f. Flexion
g. Hyperextension
h. Inversion
i. Plantar flexion
j. Pronation
k. Supination
5. Muscle strength and symmetry - normal findings: arm on dominant
side generally stronger
6. Alterations
a. kyphosis
b. lordosis
c. scoliosis
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. less knee and ankle lifts
f. steps may be shorter and more rapid
g. may need to hold onto furniture as age increases
h. muscles atrophy with disuse
i. weaker grip
j. active range of motion may be slower and limited in one or
more joints
k. joints appear larger than surrounding tissue; may be stiff
N. Neurological system
1. History
2. Mental status
a. Mini-Mental State Exam (MMSE)
3. Emotional status - normal findings: affect matches speech
4. Cranial nerve function (illustration )
Mini-Mental State Examination

A commonly used assessment tool to quantify a person's cognitive ability.
CRANIAL NERVE FUNCTION
1. Olfactory (CN I)
Can identify variety of smells

Deviation: Inability to identify aroma
2. Optic (CN II)

Has visual acuity and full visual fields
Fundoscopic exam reveals no pathology
Deviation: Inability to identify full visual fields - total or partial blindness of
one or both eyes
3, 4, 6. Oculomotor (CN III), trochlear (CN IV), and abducens (CN VI)
Follows up to six cardinal positions of gaze

Pupils are unremarkable
Exhibits no nystagmus and no ptosis
Deviation: one or both eyes will deviate from its normal position
5. Trigeminal (CN V)
Clenches teeth with firm bilateral pressure

Has no lateral jaw deviation with mouth open
Feels a cotton wisp touched to forehead, cheek and chin
Differentiates sharp and dull sensations on face
Corneal reflex; blinks when cotton is touched to each cornea
Deviation: Absent or one-sided blinking of eyelids
7. Facial (CN VII)
Has facial symmetry with and without a smile

Can raise the eyebrows symmetrically and grimace
Can shut eyes tightly
Can identify sweet, sour, salt or bitter on the anterior tongue
Deviation: Irregular and unequal facial movements
Deviation: Inability to taste or identify taste
Deviation: Inability to taste or identify salt, sweet, sour, or bitter
substances on the anterior two-thirds of the tongue
Deviation: Inability to smile symmetrically
8. Acoustic (CN VIII)
Can hear a whisper at 1-2 feet

Can hear a watch tick at 1-2 feet
Does not lateralize the Weber test
Can hear AC (air conduction) better than BC (bone conduction) in the
Rinne test
Deviation: Inability to hear spoken word
9, 10. Glossopharyngeal (CN IX) and Vagus (CN X)
Swallows and speaks without hoarseness

Palate and uvula rise symmetrically when patient says "ah"
Bilateral gag reflex
Can identify taste on the posterior tongue
Deviation: Unequal or absent rise of uvula and soft palate as the client
says, "ah"
Deviation: Absent gag reflex
Deviation: inability to taste or identify taste on the posterior tongue
11. Spinal accessory (CN XI)
Resists head turning

Can shrug against resistance
Deviation: Weak or absent shoulder and neck movement
12. Hypoglossal (CN XII)
Can stick tongue out and move it from side to side

Can push tongue strongly against resistance
Deviation: Tongue deviates to side
1. Level of consciousness (LOC) - normal findings
a. alert
b. responds appropriately to visual, auditory, tactile and
painful stimuli
c. able to carry out simple commands
d. Glasgow Coma Scale
e. alterations in LOC
Glasgow Coma Scale
ABBR: GCS. A scale used to determine a patient's level of consciousness. It is a rating from 3
to 15 of the patient's ability to open his or her eyes, respond verbally, and move normally. The
GCS is used primarily during the examination of patients with trauma or stroke. Repeated
examinations can help determine if the patient's brain function is improving or deteriorating.
Many EMS systems use the GCS for triage purposes and for determining which patients
should be intubated in the field. SEE: coma; Trauma Score.
ALTERATIONS IN LEVEL OF CONSCIOUSNESS
Alert
1. Awake and aware of person, place, time, and situation
2. Responds appropriately and to verbal stimuli
Lethargic
1. Sleeps but easily aroused
2. Speaks and responds slowly and appropriately
Obtunded
1. Difficult to arouse
2. Returns to sleep quickly; may respond inappropriately
Stuporous
1. Aroused only through pain
2. No verbal response
Semicomatose
1. Responds only to pain
2. Gag and blink reflexes intact
Comatose
1. No response to pain
2. No reflexes or muscle tone
Note: dying clients will proceed through these levels in this above-listed
sequence.
6. Sensory function - normal findings

a. visual: recognizes objects
b. auditory: identifies sounds
c. tactile: identifies objects through blind touch; perceives
pain, hot and cold and vibration; two-point discrimination
d. olfactory: identifies familiar smells
ASSESSMENT OF SENSORY NERVE FUNCTION

(done with client's eyes closed)
Superficial pain
Prick with sterile needle
Have client identify whether sharp or dull
Temperature
Two test tubes: one filled with hot water, the other with cold water
Client identifies hot versus cold sensation and where it is felt
Light touch
Cotton ball; apply light wisp of cotton to different surface points;
Client identifies when touched
Vibration
Low pitched tuning fork
Apply to distal interphalangeal joint of finger then toe,
Client identifies when vibration stops
Position
Grasp client's finger or great toe, holding by its sides
Client identifies if moving up or down
Two-point discrimination
Two safety pins
Apply lightly and simultaneously to two different places on skin's

surface.
Usually start with finger pads,
Find minimal distance at which client can discriminate one from two
points, normally <5mm 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 identification)
Number is traced on the client's palm by a blunt object
Client identifies number
Extinction
Corresponding areas on both sides of body are simultaneously

stimulated
Client identifies where touched

olfactory: identifies familiar smells
Cerebellar function - position and balance
Speech and language - normal findings
smooth flowing speech
able to formulate words without difficulty
varied inflection
able to write letters and numbers to dictation
vocabulary appropriate to educational level
Intellectual - normal findings
memory: immediate recall and remote recall
oriented to person, place and time
able to abstract
demonstrates consistent insight and perception of self
Reflexes - assessment and grading
pediatric considerations
Geriatric alterations in neuro status
longer response time to sensory stimulation
may resist new ideas or change
thought patterns may become more concrete
kinesthesia diminishes
superficial and deep reflexes may be diminished or absent
CEREBELLAR FUNCTION
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 walking: walks heel to toe in straight line
Rapid skills:
1. Pronates and supinates hands rapidly with equal timing and
purposeful movement
2. Touches alternate finger to nose rhythmically with eyes open and
closed
3. Moves finger alternately from nose to examiner's finger in
coordinated fashion
4. Runs contralateral heel down shin with bilateral coordination
One-foot balance
1. Maintains balance on one foot for at least five seconds
2. Bilateral response with eyes open and closed
TESTS FOR REFLEXES

Deep tendon reflexes with selected site stimulus
1. Biceps reflex (C5, C6): flexion of arm at elbow
2. Triceps reflex (C6, C7): extension of arm at elbow and contraction
of triceps muscles
3. Brachioradialis (supinator) reflex (C5, C6): flexion at elbow and
pronation of forearm
4. Quadriceps (knee-jerk or patellar) reflex (L2, L3, L4): extension of
leg at knee and contraction of quadriceps
5. Achilles (ankle-jerk) reflex (S1, S2)
Superficial reflexes
1. Pharyngeal reflex (CN IX, CN X)
2. Upper Abdominal reflex (T8, T9, T10): upward movement of
umbilicus toward stimulus above umbilicus
3. Lower Abdominal reflex (T10,T11,T12): downward movement of
umbilicus toward stimulus below umbilicus
4. Cremasteric reflex (T12, L1) Elevation of ipsilateral testicle (the side
stimulated)
5. Gluteal reflex (L4-S3): contraction of anal sphincter with gloved
finger insertion
Pathologic reflexes in adults - documented as "positive for ___"
1. Babinski reflex (Plantar) (L4-S2): stroking lateral sole of foot causes
dorsiflexion of great toe with fanning of other toes (normal
expectation in children up to age 18 months on the average)
2. Chaddock reflex (L4-S2): stroking below lateral malleolus causes
dorsiflexion of great toe with fanning of other toes
3. Ankle Clonus: Brisk dorsiflexion of foot with knee flexed causes up
and down movement of foot; found in severe preeclampsia
4. Oppenheim: stroking tibial surface causes great toe fans out
5. Gordon: squeezing calf muscle; great toe fans out
6. Hoffmann: flicking middle finger down; flexion of the thumb
Common expected reflexes - normal for all ages
1. Gag
2. Corneal
Client/Family Education
1. Adult learning theory
Self-directed
Reservoir of experience
Adults prefer mutual planning/goal setting
Internally motivated
Established orientation to learning
Educator is facilitator of learning
Experiential rather than didactic
Must be immediately applicable to life
2. Teaching/learning process
Assessment
Identification of learning needs
Outcome (goal) setting
Educational offerings
Evaluation of outcomes
3. Learning styles
Vary with individuals
Learners can be visual, auditory, or tactile (kinesthetic)
4. Teaching strategies
Demonstration / return demonstration
Programmed instruction
Role playing
Simulation
Case study analysis
May be individualized or in groups
May be computerized
May be media-based or print
5. Legal implications
American Hospital Association issued the Patient Bill of Rights in
1972 that guaranteed clients the right to information necessary to
give informed consent before treatment begins.
Individualized teaching must be documented in client's chart
Alterations for geriatric clients
make sure client has glasses or hearing aid
face the client and use a lower pitched voice
supplement oral presentation with print materials
use large print
provide good lighting
some clients have a hard time seeing color; use black on
white or yellow paper
keep sessions short and work with survival-level
information initially
repeat often for clients prone to memory loss
break down learning into small steps
use specific, step-by-step directions and have the client
redemonstrate them
get frequent feedback regarding client's level of
understanding
Health Insurance Portability and Accountability Act (HIPAA)-
signed into law in 1996. This law includes important new
protections for millions of working Americans and their families
who have preexisting medical conditions or might suffer
discrimination in health coverage based on a factor that relates to
an individual's health. HIPAA places requirements on employer-
sponsored group health plans, insurance companies and health
maintenance organizations (HMOs). HIPAA includes changes that:
limit exclusions for preexisting conditions
prohibit discrimination against employees and dependents
based on their health status
guarantee renewability of health coverage to certain
employers and individuals
protect many workers who lose health coverage by
providing better access to individual health insurance
coverage.
The first-ever federal privacy standards to protect patients' medical
records and other health information provided to health plans,
doctors, hospitals and other health care providers took effect on
April 14, 2003. Developed by the Department of Health and
Human Services (HHS), these new standards provide patients with
access to their medical records and more control over how their
personal health information is used and disclosed.
The new privacy regulations ensure protection for patients by
limiting the ways that health plans, pharmacies, hospitals and other
covered entities can use protected medical records and to other
individually identifiable health information, whether it is on paper,
in computers or communicated orally. Key provisions of these new
standards include:
access to medical records
notice of privacy practices
limits on use of personal medical information
prohibition on marketing
stronger state laws
confidential communications
complaints
Before Birth
Early and regular antepartal (before-birth) care is critical. First trimester health
directly influences the development of organs in embryo and fetus.
To identify risks, nurses need both subjective (client's) and objective (the nurse's
own) 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.
Labor
Maintain safety and asepsis (sterilize instruments; wear gown, gloves, mask)
through the labor and birth process to reduce risks to mother and fetus/newborn.
Ideally, same caregivers stay through all stages of labor.
Recognize urgent signs and act promptly.
Constantly assess and analyze problems to prioritize actions.
Reinforce the childbirth preparation techniques practiced by the couple during
pregnancy.
Effective teaching during labor must be flexible. Mother will have shorter
attention span, increasing discomfort, and emotional responses to labor.
Promote privacy of the woman and support person as much as possible.
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.
Provide for the woman's needs and comfort.
Communicate caring and concern to the woman and her family through
therapeutic techniques.
Document assessments, changes in condition and care as promptly as possible.
Postpartum
Teach (by demonstration and praise) self assessment and care. Start soon after
birth.
The newborn is first of all a family member.
Share your assessments and plans with parents; welcome their input.
Respect culture and religious beliefs of the family.
Praise the parent's skills.
Media and pamphlets are useful teaching aids if the parent has a chance to discuss
them.
Visits and Teachings
Mothers are discharged quickly, 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.
Growth and Development
Normally proceed in a regular fashion from simple to complex and in

cephalocaudal and proximodistal patterns.
Are orderly, directional, predictable, interdependent and complex processes.
Are unique to individuals and their genetic potential.
Occur through conflict and adaptation.
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.
In the care of children, key concepts are anticipatory guidance and prevention of
disease.
Major developmental tasks of infancy are: 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 grow rapidly, so nurses must stress optimum nutrition
and give anticipatory guidance related to nutrition.
In children over one year of age, the leading cause of death is injuries.
Elder Adults
Elder adults must adjust to lessening physical and cognitive abilities. Over 85%
have some type of chronic disease.
When elder adults experience cognitive changes, check for possible substance
abuse or polypharmacy.
Cognitive impairment can be acute and reversible, or it can be chronic and
irreversible.
Up to 60% of 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.
Elder adults need more time to complete tasks.
Age is a weak predictor of survival in traumatic injury and critical illness.
Health Risks in Elder Adults
Major health problems typically include cardiovascular, cerebrovascular, and

respiratory diseases; diabetes; and cancer.
The elder adult will change social roles, and these changes may affect
psychological health, leading to depression.
Elder adults need the same nutrition as other adults, but more bulk and fiber,
calcium, and vitamins C and A.
Contraindications for estrogen replacement therapy include
o hypertension
o thrombophlebitis
o cardiac dysfunction
o family history of breast or uterine cancer
Elder 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.
Health Promotion: 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 clients 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 clients 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 arms left versus right

Compare blood pressure with client lying, sitting and standing
Lungs - Airway
Anemic patients may never become cyanotic

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 harsh sound produced near larynx by vibration of structures in upper
airway. Classic "barky cough"
Crackles or rales adventitious sounds, usually on inspiration and indicating
inflammation
Breast
Breast tissue shrinks with menopause
Teach client breast self examination (illustration )
Abdomen - Reproductive System

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 clients abdomen.
Men breathe abdominally; women breathe costally.
Auscultate all four quadrants for bowel sounds
Auscultate abdomen between meals
Musculoskeletal
Older adults walk with smaller steps and need a wider base of support
Neurological
Glasgow Coma Score

o not valid in patients who have used alcohol or other mind-altering drugs
o possibly not valid in patients who are hypoglycemic, in shock, or
hypothermic (below 34C)
o 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
Hyperactive reflexes suggest an upper motor neuron disorder
Teaching client and family
Teaching-learning process mirrors the nursing process

Select teaching strategies that are compatible with the clients learning style, age,
culture, level of education
Client teaching should be multi-sensory
Always confirm the clients understanding of the information presented
Teaching must be geared to the level of the learner
Repeat key information and summarize main points at intervals
Explain medical terminology in lay terms
Determine the clients 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
Question Number 1 of 20
The parents of a child who has suddenly been hospitalized for an acute illness state
that they should have taken the child to the pediatrician earlier. Which approach by
the nurse is best when dealing with the parents' comments?
The correct response is "D".

A) Focus on the child's needs and recovery
B) Explain the cause of the child's illness
C) Acknowledge that early care would have been better
D) Accept their feelings without judgment
Your response was "B".
The correct answer is D: Accept their feelings without judgment

Parents often blame themselves for their child''s illness. Feeling helpless and angry
is normal and these feelings must be accepted.
Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their
families. USA: Thompson, Delmar, Learning.
Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd
edition). Mosby: St. Louis, Missouri.
A client states, "People think Im no good, you know what I mean?" Which of these
responses would be most therapeutic?
The correct response is "C".

A) "Well people often take their own feelings of inadequacy out on others."
B) "I think youre good. So you see, theres one person who likes you."
C) "Im not sure what you mean. Tell me a bit more about that."
"Let's discuss this to see the reasons you create this impression on
D)
people."
Your response was "A".
The correct answer is C: "Im not sure what you mean. Tell me a bit more about that."
This therapeutic communication technique elicits more information, especially when
delivered in an open, non-judgmental fashion.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.
Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice.

(2nd ed). Clinton Park, New York: Delmar.
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical
area. Which of the following assessments is appropriate for the nurse to perform?
The correct response is "B".

A) Measure the length of the mass
B) Auscultate the mass
C) Percuss the mass
D) Palpate the mass
The correct answer is B: Auscultate the mass

Auscultation of the abdomen and finding a bruit will confirm the presence of an
abdominal aneurysm and will form the basis of information given to the provider. The
mass should not be palpated because of the risk of rupture.
Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.
Weber, J., and Kelley, J. (2003). Health Assessment in Nursing. (2nd edition).
Philadelphia, PA: Lippincott Williams & Wilkins.
When observing 4 year-old children playing in the hospital playroom, what activity
would the nurse expect to see the children participating in?

A) Competitive board games with older children
B) Playing with their own toys along side with other children
C) Playing alone with hand held computer games
D) Playing cooperatively with other preschoolers
The correct answer is D: Playing cooperatively with other preschoolers

Cooperative play is typical of the late preschool period.
edition). Mosby: St. Louis, Missouri
When screening children for scoliosis, at what time of development would the nurse
expect early signs to appear?

A) Prenatally on ultrasound
B) In early infancy
C) When the child begins to bear weight
D) During the preadolescent growth spurt
The correct answer is D: During the preadolescent growth spurt

Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable
at the beginning of the preadolescent growth spurt. It is more common in females
than in males.
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the
main source of fluids for an infant until about 12 months of age?
The correct response is "A".

A) Formula or breast milk
B) Dilute nonfat dry milk
C) Warmed fruit juice
D) Fluoridated tap water
The correct answer is A: Formula or breast milk

Formula or breast milk are the perfect food and source of nutrients and liquids up to
1 year of age.
When teaching effective stress management techniques to a client 1 hour before
surgery, which of the following should the nurse recommend?

A) Biofeedback
B) Deep breathing
C) Distraction
D) Imagery
Your response was "D".
The correct answer is B: Deep breathing

Deep breathing is a reliable and valid method for reducing stress, and can be taught
and reinforced in a short period pre-operatively.

The nurse has been teaching adult clients about cardiac risks when they visit the
hypertension clinic. Which evaluation data would best measure learning?

A) Performance on written tests
B) Responses to verbal questions
C) Completion of a mailed survey
D) Reported behavioral changes
The correct answer is D: Reported behavioral changes

If the client alters behaviors such as smoking, drinking alcohol, and stress
management, these suggest that learning has occurred. Additionally, physical
assessments and lab data may confirm risk reduction.
Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan.
(5th edition). St. Louis, Missouri: Mosby.
Missouri: Mosby.
A client being treated for hypertension returns to the community clinic for follow up.
The client says, "I know these pills are important, but I just can't take these water
pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to
go to the bathroom." Which of these is the best nursing diagnosis?

A) Noncompliance related to medication side effects
B) Knowledge deficit related to misunderstanding of disease state
C) Defensive coping related to chronic illness
D) Altered health maintenance related to occupation
The correct answer is A: Noncompliance related to medication side effects

The client kept his appointment, and stated he knew the pills were important. He is
unable to comply with the regimen due to side effects, not because of a lack of
knowledge about the disease process.
Key, J.L. and Hayes, E.R. (2003). Pharmacology, a nursing process approach. (4th
edition). Philadelphia: Saunders.
The nurse is assessing a client who states her last menstrual period was March 16,
and she has missed one period. She reports episodes of nausea and vomiting.
Pregnancy is confirmed by a urine test. What will the nurse calculate as the
estimated date of delivery (EDD)?

A) April 8
B) January 15
C) February 11
D) December 23
The correct answer is D: December 23

Naegele''s rule states: Add 7 days and subtract 3 months from the first day of the last
regular menstrual period to calculate the estimated date of delivery.
Condon, M.C. (2004). Women''s health, an integrated approach to wellness and

illness. Upper Saddle River, New Jersey: Prentice Hall.
edition). Mosby: St. Louis, Missouri
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1611 C) Discuss diet with the client to learn the reasons for not following the diet
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D) Make a referral to Meals-on-Wheels
The correct answer is C: Discuss diet with the client to learn the reasons for not
following the diet
When new problems are identified, it is important for the nurse to collect accurate
assessment data. Before reporting findings to the provider, it is best to have a
complete understanding of the client''s behavior and feelings as a basis for future
teaching and intervention.
The family of a 6 year-old with a fractured femur asks the nurse if the child's height
will be affected by the injury. Which statement is true concerning long bone fractures
in children?

A) Growth problems will occur if the fracture involves the periosteum
B) Epiphyseal fractures often interrupt a child's normal growth pattern
C) Children usually heal very quickly, so growth problems are rare
D) Adequate blood supply to the bone prevents growth delay after fractures
The correct answer is B: Epiphyseal fractures often interrupt a child''s normal growth
pattern
The epiphyseal plate in children is where active bone growth occurs. Damage to this
area may cause growth arrest in either longitudinal growth of the limb or in
progressive deformity if the plate is involved. An epiphyseal fracture is serious
because it can interrupt and alter growth.
Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease
processes. (6th edition). Mosby: St. Louis, Missouri.
A 64 year-old client scheduled for surgery with a general anesthetic refuses to
remove a set of dentures prior to leaving the unit for the operating room. What would
be the most appropriate intervention by the nurse?

Explain to the client that the dentures must come out as they may get lost
A)
or broken in the operating room
B) Ask the client if there are second thoughts about having the procedure
C) Notify the anesthesia department and the surgeon of the client's refusal
Ask the client if the preference would be to remove the dentures in the
D)
operating room receiving area
The correct answer is D: Ask the client if the preference would be to remove the
dentures in the operating room receiving area
Clients anticipating surgery may experience a variety of fears. This choice allows the
client control over the situation and fosters the client''s sense of self-esteem and self-
concept.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.
A partner is concerned because the client frequently daydreams about moving to
Arizona to get away from the pollution and crowding in southern California. The
nurse explains that

such fantasies can gratify unconscious wishes or prepare for anticipated
A)
future events
B) detaching or dissociating in this way postpones painful feelings
converting or transferring a mental conflict to a physical symptom can lead
C)
to conflict within the partnership
isolating the feelings in this way reduces conflict within the client and with
D)
others
The correct answer is A: such fantasies can gratify unconscious wishes or prepare
for anticipated future events
Fantasy is imagined events (daydreaming) to express unconscious conflicts or
gratify unconscious wishes.
Fontaine, K.L. (2003). Mental Health Nursing, (5th ed.). Upper Saddle River, NJ:
Prentice-Hall.
Varcarolis, E. (2002). Foundations of Psychiatry Mental Health Nursing A Clinical

Approach (4th ed.). Philadelphia: Saunders.
While the nurse is administering medications to a client, the client states "I do not
want to take that medicine today." Which of the following responses by the nurse
would be best?

A) "That's OK, its all right to skip your medication now and then."
B) "I will have to call your doctor and report this."
C) "Is there a reason why you don't want to take your medicine?"
"Do you understand the consequences of refusing your prescribed
D)
treatment?"
The correct answer is C: "Is there a reason why you don''t want to take your
medicine?"
When a new problem is identified, it is important for the nurse to collect accurate
assessment data. This is crucial to ensure that client needs are adequately identified
in order to select the best nursing care approaches. The nurse should try to discover
the reason for the refusal which may be that the client has developed untoward side
effects.

An appropriate treatment goal for a client with anxiety would be to

A) ventilate anxious feelings to the nurse
B) establish contact with reality
C) learn self-help techniques
D) become desensitized to past trauma
The correct answer is C: learn self-help techniques

Exploring alternative coping mechanisms will decrease present anxiety to a
manageable level. Assisting the client to learn self-help techniques will assist in
learning to cope with anxiety.
Missouri: Mosby.

When teaching a 10 year-old child about their impending heart surgery, which form
of explanation meets the developmental needs of this age child?

A) Provide a verbal explanation just prior to the surgery
B) Provide the child with a booklet to read about the surgery
C) Introduce the child to another child who had heart surgery 3 days ago
D) Explain the surgery using a model of the heart
Your response was "C".
The correct answer is D: Explain the surgery using a model of the heart
According to Piaget, the school age child is in the concrete operations stage of
cognitive development. Using something concrete, like a model will help the child
understand the explanation of the heart surgery.
The nurse is planning care for an 18 month-old child. Which action should be
included in the child's care?

A) Hold and cuddle the child frequently
B) Encourage the child to feed himself finger food
C) Allow the child to walk independently on the nursing unit
D) Engage the child in parallel games with other children
The correct answer is B: Encourage the child to feed himself finger food
According to Erikson, the toddler is in the stage of autonomy versus shame and
doubt. The nurse should encourage increasingly independent activities of daily living
that allow the toddler to assert his budding sense of control.
The nurse is assessing a 4 month-old infant. Which motor skill would the nurse
anticipate finding?

A) Hold a rattle
B) Bang two blocks
C) Drink from a cup
D) Wave "bye-bye"
The correct answer is A: Hold a rattle

The age at which a baby will develop the skill of grasping a toy with help is 4 to 6
months.

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I.

3. Cervical musus method- identifies ovulation by increase in mucus

Nurses Role in Family Planning

B. Interruption of pregnancy (abortion)

II. Uncomplicated Pregnancy

Fetal Development Stages and Circulation

By 16 weeks: Joint cavities are present. Bile is secreted. Intestines assume

By 20 weeks: Brain grossly formed. Spinal cord myelinization begins. Lanugo

By 28 weeks: Face matures. Eyelashes and eyebrows form. Viable as a

By 32 weeks: Increase in subcutaneous fat. Hair evident. Still covered with

Fetal circulation (illustration )

Normally ceases to exist after birth

Screenings for Fetal Problems in Uncomplicated

Maternal Health in Pregnancy

Maternal Physical Changes

Assessment Based on Adaptations

High Risk Pregnancy Charactersitics

Rh(D) Immune Globulin or RHoGAM

Example: June 10, 2001 first day of last menstrual period

Estimate date of birth (EDB): March 17, 2002

4. Keep appointment schedule (monthly visits)

Maternal Physical Changes

Warning Signs in Pregnancy

Regular Monthly Assessments, Based on Adaptations

A. Current signs and symptoms

Assessments Based on Adaptations

A. Current health status

The fetus is described in documentation according to its:

-and during the process, the Stations it passes.

Rh(D) Immune Globulin or RHoGAM

A. Factors affecting labor include the five P's: passageway, passenger,

Stations of Fetal Descent

Reframe your thoughts from I should or have to do 3000 to 5000 practice

Early Signs of Labor Versus True Labor Signs

first stage: onset until complete dilation

A. First stage of labor: latent phase

Early Signs of Labor Versus True Labor Signs

Try to answer the question before looking at the options.

Electronic Fetal Monitoring

6. RN notices abnormal patterns such as decelerations

Maternal Adaptations: Birth to Six Weeks (Puerperium)

Before Discharge from Hospital

High Risk Pregnancy Charactersitics

POSTPARTUM REPORTABLE SIGNS

1. Begin with placental delivery, stimulates prolactin from anterior pituitary,

3. Cervical musus method- identifies ovulation by increase in mucus

Rh(D) Immune Globulin or RHoGAM

Follow-up Home Visit (two to four days after discharge)

B. Managing care, postpartum visit - role of nurse on team with physician or

Follow-up clinic or office visit (three to six weeks postpartum)

Newborn: Adaptations in the First Month

Immediate Care after Delivery (from birth to two hours)

d. 0-2 means severe depression, requiring immediate life support

PROPHYLACTIC EYE TREATMENT OF NEWBORN

Currently, most practitioners prefer Erythromycin or Tetracycline since they are

Newborn (birth until discharge)

10. Review reportable signs for mother and infant

POSTPARTUM REPORTABLE SIGNS

Four Periods: Sensorimotor, Preoperational Thought, Concrete Operations,

As children mature intellectually, they are more able to understand the

A. Piaget's sensorimotor period: birth to two years

ERIKSON'S THEORY OF PSYCHOSOCIAL DEVELOPMENT

A. Describes development as a series of tasks that must be accomplished in