Category 2: Health Promotion and

Maintenance
In this section, the registered nurse provides and directs nursing care of the client that incorporates
knowledge of expected growth and development principles; prevention and/or early detection of
health problems; and strategies to achieve optimal health.
They must be able to:

 Provide care and education for the newborn less than 1-month-old through the infant or toddler client
through 2 years
 Provide care and education for the preschool, school-age and adolescent client ages 3 through 17 years
 Provide care and education for the adult client ages 18 through 64 years
 Provide care and education for the adult client ages 65 through 85 years and over
 Provide prenatal care and education
 Provide care to the client in labor
 Provide post-partum care and education
 Assess and teach clients about health risks based on family, population, and/or community
characteristics
 Assess client's readiness to learn, learning preferences and barriers to learning
 Plan and/or participate in community health education
 Provide information about health promotion and maintenance recommendations (e.g., physician visits,
immunizations)
 Perform targeted screening assessments (e.g., vision, hearing, nutrition)
 Provide information for the prevention and treatment of high-risk health behaviors (e.g., smoking
cessation, safe sexual practices, drug education)
 Assess client ability to manage care in the home environment and plan care accordingly (e.g. equipment,
community resources)
 Perform a comprehensive health assessment

Related content includes, but is not limited to:

 Aging Process
 Anti/Intra/Postpartum and Newborn Care
 Developmental Stages and Transitions
 Health Promotion/Disease Prevention
 Health Screening
 High-Risk Behaviors
 Lifestyle Choices
 Self Care
 Techniques of Physical Assessment

Aging Process: NCLEX-RN

In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills the aging process in order to:

 Assess client's reactions to expected age-related changes

 Provide care and education for the newborn less than 1 month old through the infant or toddler client
through 2 years
 Provide care and education for the preschool, school age and adolescent client ages 3 through 17 years
 Provide care and education for the adult client ages 18 through 64 years
 Provide care and education for the adult client ages 65 through 85 years and over

Assessing the Client's Reactions to

Expected Age Related Changes
From the day of conception throughout the entire life span, humans grow and develop in a rather
predictable manner with specific needs from birth to the elderly years. There are also expected age
related changes that also occur throughout the life span. These changes can include rather
predictable physical changes, predictable developmental changes, psychological, cognitive, and
emotional changes, and social changes.
Like all changes, people react to their expected age related changes in different ways. Some of these
reactions lead to adaptive and healthy responses by the client and other reactions can be
dysfunctional, maladaptive, abnormal and unhealthy. Nurses, therefore, must assess all clients'
responses to expected age related changes and plan their care as based on these assessed responses
and reactions to their expected age related changes.
For example, a toddler may emotionally react with anger and defiance to their developmentally
expected toilet training regimens; a school aged child may react to the normal physiological changes
associated with puberty in the expected and normal manner; a young adult may adapt to pregnancy
in an adaptive and healthy and other young adults may have dysfunctional, maladaptive, and
abnormal responses and reactions to the changed bodily image associated with pregnancy; and the
elderly may adapt or not adapt to the physiological, economic and social changes associated with the
normal aging process such as decreased physical stamina and social isolation.

Providing Care That Meets the Needs

of the Newborn Less than 1 Month
Old Through the Infant or Toddler
Client Through 2 Years of Age
Neonates
Neonates are assessed according to the five criteria of the APGAR score which are A for
appearance, P for pulse, G for grimace and reflexes, A for appearance in terms of skin color, and R
for respiratory rate and effort. Each of these criteria is scored from zero to two with a zero as no
activity or the poorest possible color, for example.
APGAR scores are done one minute after birth, five minutes after birth and more often when the
neonate is not scoring well in terms of their adaptation to extrauterine life after birth. An APGAR
score of less than less indicates that the neonate is in severe distress and in need of intensive care
and treatment. An APGAR score of four to six indicates that the neonate is in moderate distress.
Scores between seven and ten are considered good.
Gestational age, which indicates the neonate's level of morbidity and mortality, is also determined
and assessed among neonates. The New Ballard Scale is used for this assessment. This scale
measures physical and neuromuscular maturity from negative one to five according to the neonate's
arm recoil, posture, heal to ear movement, the scarf sign which is the neonate's crossing of the arms
over the chest and square window formation which is the neonate's wrist movement.
The normal physical size of a neonate is 18 to 22 inches in length, 12 to 13 inches for chest
circumference and 12.6 to 14.5 inches for the circumference of the head. The normal weight is from
The normal vital signs for the neonate are:

 Respirations from 30 to 60 per minute

 The pulse from 100 to 160 beats per minute
 A systolic blood pressure from 60 to 80 mm Hg
 A diastolic blood pressure from 40 to 50 mm Hg
 A bodily temperature from 97.7 to 98.9 degrees

The normal neonatal abdomen is round; bowel sounds should present within a couple of hours after
birth, the umbilical cord and site should be free of any signs of infection like redness and pus, and
the neonatal abdomen moves up and down with respirations. Neonates and infants are abdominal
breathers.
The eyes are bilaterally equal in terms of their size and shape, the red and papillary reflexes are
present, and normal smooth eye movement should be apparent. The neonate's ears should be
normally placed bilaterally and they should have with firm and well-formed cartilage; the neonate's
ability to hear sounds and noise is normally present. Low set ears and unusual eyes can, at times,
possibly indicate the presence of Down's syndrome.
The skin of the neonate should be without any signs of blueness, jaundice or cyanosis; the texture
should be soft and smooth and with some normal wrinkles; Vernix caseosa, a thick cheesy substance
over the skin, fine hair called lanugo, small red spots called milia, telangiectatic nevi, also referred to
as stork bites, purple blue Mongolian spots, and port wine stains called nevus flammeus are often
seen on the skin. These unusual skin findings are most often temporary and normally occurring,
with the exception the port wine stains which can be permanent and distressing to the parents.
The neonate's fontanels are soft and flat and they should also be without any signs of bulging or
fontanel depression. Bulging fontanels can be a sign of increased intracranial pressure and fontanel
depression can indicate decreased intracranial pressure and dehydration, respectively. These neonatal
fontanels close by the time the infant is 12 to 18 months of age. The sutures and the yet to be
developed skull are normally separated and some normal molding of the skull can occur with a
vaginal delivery.
The oral palate is a normally closed palate, the mouth has pink oral mucosa, symmetrical lip and
tongue movements are present, possible small white oral cysts called Epstein pearls may be on the
tongue, and little saliva is seen when the neonate's mouth is assessed. Down's syndrome may be
present when the tongue protrudes and a possible tracheoesophageal fistula is present when there is
excessive salivation.
Neonates normally pass meconium and produce urine at about twenty four hours after birth. Male
testes are in the testicles, the urinary meatus is on the tip of the penis and the scrotum has rugae.
The female may have some edema of the labia and a small amount of vaginal blood, both of which
are normal for some neonates.

Infants
Some passive immunity from the mother remains, but the infant does not have a fully developed
immune system so the infant is at risk for infections.
As the neonate grows, they gain five to seven ounces during the first six months and then they
double their birth weight during the first year; the head circumference increases a half inch each
month for six months and then two tenths of an inch until the infant is one year of age. Similarly,
the height or length of the newborn increases an inch a month for the first 6 months and then 1/2
inch a month until the infant is 1 year of age. Teeth appear, the infant begins to speak with babble,
and they start to walk in about one year.
The infant is in the sensorimotor stage according to Jean Piaget's stages of cognitive development
and in Erik Erikson's the trust versus mistrust stage of psychosocial development. The infant begins
to see self as separate from others; and separation anxiety and the fear of strangers, including nurses,
begins. They communicate with noises and sounds and they receive communication with touch and
sounds. Age appropriate toys include rattles, large balls and teething toys.
Commonly occurring injuries and accidents among infants include falls, poisoning, drowning and
burns. Aspiration and poisonings are great risks for infants because they are in the oral stage of
development and they tend to put foreign bodies in the mouth.
Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100
mLs per kilogram of body weight.

The Toddler
The normal vital signs for the toddler are a pulse rate from 90 to 140 beats per minute; the normal
respiratory rate for the toddler ranges from 20 to 40 breaths per minute, the diastolic blood pressure
is typically between 50 and 80 mm Hg and the systolic blood pressure is from 80 to 110 mm Hg.
The normal bodily temperature is 98.6 degrees and it remains at the level throughout the remainder
of life.
The toddler grows approximately 3 inches per year and the weight becomes four times the child's
birth weight. Toilet training is completed during the toddler years and the child walks without
holding onto things by about fifteen months of age. They can jump by the time they are 2 ½ years
of age.
Toddlers move from Piaget's sensorimotor to the preoperational stage of cognitive development;
the child's vocabulary improves and the toddler can now speak and communicate with brief but
meaningful phrases. They understand parental boundaries and discipline.
The toddler is in Erik Erikson's autonomy versus shame and doubt stage of psychosocial
development and the toddler begins to form their own gender identity. They are very curious and
energetic; they lack impulse control, they have a short attention span, they are concrete rather than
abstract thinkers and they also are mystical thinkers. Toddlers also have a low tolerance for pain,
frustration and strangers.
Nutritionally, toddlers eat 3 meals per day totaling about 900 to 1,800 calories each day. Some may
be finicky eaters and most enjoy finger foods that they can pick up, manipulate and eat.
Supplemental iron is needed for the adequate production of red blood cells.
Large and colorful toys that cannot be placed in the mouth, picture books and blocks are some
examples of age appropriate toys. Although toddlers play with other children and siblings, this play
is parallel play rather than actual interactive play with other children. They parallel play in close
proximity to other children but they do not interact with them in the same manner that an older
children does.
Toddlers are at risk for downing, falls, aspiration, burns, automobile accidents and suffocation.
Providing Care That Meets the Needs
of the Preschool, School Age and
Adolescent Client Ages 3 Through 17
Years of Age
The Preschool Child
The normal vital signs are for the preschool child are a pulse rate from 80 to 110 beats per minute;
the normal respiratory rate for the preschool child ranges from 20 to 30 breaths per minute, the
diastolic blood pressure is typically between 50 and 75 mm Hg and the systolic blood pressure is
from 80 to 110 mm Hg. The normal bodily temperature remains at 98.6 degrees and it remains at
the level throughout the remainder of life.
Physically, the preschool child gains about 4 to 7 pounds a year and they grow 2 to 3 inches in
height each year. Their gross and fine motor skills continue to be developed and enhanced.
Preschool children have fears about the dark and mutilation; separation anxiety decreases; and they
are able to express their feelings and wishes to others verbally. They can follow brief, simple and
concrete directions from others including the parents and health care providers.
Preschool children should consume about 2,000 calories per day and they are less prone to fluid and
electrolyte than toddlers and infants. They often need between meal snacks to satiate their hunger
and meet their caloric needs.
Commonly occurring injuries among the members of the age group are poisonings, drowning, burns
and automobile accidents
Preschool children begin to interactively play with others and they ask a lot of "why" questions.
Dress up, role playing, painting, puzzles and reading simple books with lots of pictures are
appropriate age specific activities for the preschool child.
Preschool children are in Piaget's stage of preoperations and they can speak in full sentences. In
terms of Erik Erikson's psychosocial developmental stages, the preschool child is in the initiative
versus guilt stage. Gender identity is complete and gender related activities increase. Some preschool
children can understand simple explanations about the human body and illnesses. At times the use
of a simple picture, a puppet and a simple picture book can assist with the child's understanding.

The School Age Child

The normal vital signs for the school age child are a pulse rate from 70 to 100 beats per minute; the
normal respiratory rate for the toddler ranges from 20 to 25 breaths per minute, the diastolic blood
pressure is typically between 55 and 80 mm Hg and the systolic blood pressure is from 80 to 120
mm Hg.
The school age child's height, weight and muscle mass increase with their growth spurts. These
changes require additional calories of about 2,500 calories a day, additional calcium, additional iron
and additional vitamins, particularly vitamins B and A.
The school age child now prefers same gender friends and they may begin to question and challenge
their parents and other authority figures including their teachers and health care providers.
Commonly occurring fears include fears of the unknown, bodily mutilation, fears associated with
death, and the fear of failure.
Physically, the school age child gains about 4 to 9 pounds a year and they go through growth spurts.
Permanent teeth begin to appear, secondary sex characteristics, puberty and menarche can occur.
Their stage of cognitive development, according to Jean Piaget, is concrete operations and a full
command of their native language and vocabulary is almost complete by the age of twelve. Erikson's
stage of industry versus inferiority marks the school age years. Peers become increasingly important,
morals develop and curiosity about sexuality occurs. Age appropriate activities include sports, board
and computer games, and pet care.
Burns, automobile accidents, substance abuse, and drowning are the major accidents and concerns
among members of this age group.

Adolescents
The normal vital signs for the adolescent are now the same as for the adult.
Adolescents have high nutritional and caloric needs because of the growth spurt when the skeletal
and muscular systems double to its completion. Vitamins, protein, and calcium needs have to be
met. Females need iron supplementation because of menstruation. Some teens may develop bulimia
and anorexia nervosa, both of which are eating disorders.
Sexual maturity is complete; most teens are attracted to the opposite gender; they are self-conscious,
they want their own identity, they want to be accepted by their peer group and they are sometimes
unpredictable and rebellious towards authority figures.
Adolescents complete the last of Piaget's stages of formal operations which is formal operations.
They are in Erikson's identity versus role confusion stage and they begin to think about and plan
their future including their career and advanced education beyond high school.
Common threats, accidents and injuries for this age group are substance abuse, injuries from
weapons, burns, auto accidents, sexually transmitted diseases and unwanted pregnancy.
Providing Care That Meets the Needs
of the Adult Client Ages 18 through
64 Years
The Young Adult
Normally, young adults form and maintain relationships, some of which are long lasting and
permanent. They assume adult roles as a spouse, parent and salary earner with gainful employment.
They also accept responsibility for their own beliefs, attitudes, opinions, values and actions.
Significant others include the spouse or partner, the children, friends, in laws, and co-workers.
Characteristic stressors for this age group include raising children, finding and maintaining a career,
finances and managing their multiple roles.
Physical growth is complete; the young adult remains in the formal operations stage of Piaget, the
last stage, and Erikson's intimacy versus isolation phase.
Commonly occurring injuries and events include auto accidents, weapon injuries, substance abuse
and sexually transmitted diseases.

Middle Age Adults

The normal stages of the aging begin during middle adult years; muscular strength weakens, sex
drive decreases, menopause and the male climacteric occur and male erectile dysfunction may occur.
Calcium and vitamin D supplementation are needed to prevent osteoporosis and bone loss that can
occur as the result of menopause.
Middle age adults are in Erikson's generativity versus stagnation stage; major stressors include the
loss of youth, parenting, and the empty nest syndrome. This group is referred to as the sandwich
generation because members of this age group are often squeezed and conflicted with their care of
children in addition to the care of their elderly parents.
Heath screenings for this age group includes eye examinations for glaucoma and Dexa screening for
osteoporosis.
Providing Care That Meets the Needs
of the Adult Client Ages 65 through
85 years and Over
In terms of growth and development, this age group undergoes the normal changes of the aging
process including changes in terms of their sensory and neurological changes, cardiovascular
changes, musculoskeletal changes, joints and bone changes, renal system changes, hepatic
functioning changes, skin and hair changes, respiratory system changes, and fluid and electrolyte
changes. All of these normal changes of the aging process were fully discussed below with the
section entitled "Changes Associated With the Aging Process".
Adults 65 years of age and older are in the ego integrity versus despair phase according to Erikson.
Caloric needs are less than other age groups. Some of the safety hazards affecting the aging
population are falls and accidental poisonings.
Some of the theories of aging are the:

Programmed Theories of Aging

Programmed Longevity Theory: This theory states that genetic instability and changes occur such
as some genes turning on and off lead to the aging process.
Endocrine Theory: Aging results from hormonal changes and the biological clock's ticking.
Immunological Theory: Aging results from the decline of the person's immune system and the
decreased ability of the antibodies to protect us.

Damage and Error Theories of Aging

Wear and Tear Theory: This theory describes aging as a function of the simple wearing out of the
tissues and cells as one ages.
Rate of Living Theory: One's longevity is the result of one's rate of oxygen basal metabolism.
Cross Linking Theory: This theory of aging explains that aging results for cell damage and disease
from cross linked proteins in the body.
Free Radicals Theory: This theory is based on the belief that free radicals in the body lead to
cellular damage and the eventual cessation of organ functioning.
Somatic DNA Damage Theory: Somatic DNA Damage theory is based on the belief that aging
and death eventually occur because DNA damage, as continuously occurs in the human cells,
continues to the point where they can no longer be repaired and replaced and, as a result, they
accumulate in the body.
Changes Associated With the Aging
Process
Now, we will review the physiological changes related to the aging process system by system.
Generally, all of these changes are decreases, rather than increases, of functioning.

 Sensory and neurological changes: Sensory and neurological changes include decreased vision,
hearing, smell and touch, lowered reaction times and night blindness.

 Cardiovascular system changes: Cardiac changes include decreases in cardiac output, stroke volume,
venous return, and the cardiac output.

 Musculoskeletal system changes: Musculoskeletal changes include decreased muscular tone and
strength, the degeneration of joints and bones as the result of decalcification, and decreased
intervertebral disc spaces which lead to some loss of height among the elderly.

 Renal changes: Renal function among the elderly is also affected with aging. Some of these changes
include decreased renal size, decreased renal blood supply, decreased creatinine clearance, decreased
glomerular functioning, and decreased tubular functioning.

 Hepatic function changes: Liver function is also altered as the result of the normal aging process.
There is decreased hepatic blood flow and functioning. This change reduces hepatic metabolism and it
can increase the concentrations of medications in the patient's body.

 Integumentary system changes: Integumentary, skin, changes include the loss of skin turgor and
elasticity, thinning and increased fragility of the skin, dry skin and hair, the presence of wrinkles, "age
spots" and skin tags on the skin, faded and grey hair, thicker ear and nasal hair, thicker nails, and
diminished sweat gland activity.

 Respiratory system: Age related respiratory changes include decreases in lung expansion and air
exchanges, dry and more fragile mucous membranes, a diminished cough reflex, and a decrease in the
efficiency of the body's natural protective immune system which may place elders at greater risk for
respiratory infections than their younger counterparts.

 Changes in fluid and electrolyte balances: Some fluid and electrolyte alterations associated with the
aging process are imbalances secondary to the decreased function of those hormones that regulate fluids
 and electrolytes, impaired thirst sensation, more diluted urine, and changes in the amount of total body
water and intracellular fluids.

Medication dosages are often reduced for the elderly because the changes of the aging process make
them at risk for more side effects, adverse drug reactions, and toxicity and over dosages. The
distribution of drugs is impaired by decreases in the amount of body water, body fat and serum
albumin; drug absorption is decreased with the aged patient's increases in gastric acid pH and
decreases in the surface area of the small intestine which absorbs medications and food nutrients.

Anti/Intra/Postpartum and
Newborn Care: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of antepartal, intrapartal, postpartum, and newborn care in order to:

 Assess client's psychosocial response to pregnancy (e.g., support systems, perception of pregnancy,
coping mechanisms)
 Assess client for symptoms of postpartum complications (e.g., hemorrhage, infection)
 Recognize cultural differences in childbearing practices
 Calculate expected delivery date
 Check fetal heart rate during routine prenatal exams
 Assist client with performing/learning newborn care (e.g., feeding)
 Provide prenatal care and education
 Provide care to client in labor
 Provide post-partum care and education
 Provide discharge instructions (e.g., post-partum and newborn care)
 Evaluate client's ability to care for the newborn

Introduction to the Female

Reproductive System
The internal organs and structures of the female reproductive system are the:
Uterus
Anatomically, the uterus is comprised of the endometrium which is the most inner layer of the
uterus, the second layer of the uterus which is the myometrium and the perimetrium which encases
the entire organ; and two major sections which are the body or corpus of the uterus and the cervix
which is the lower part of it.
The uterus is an internal organ of female reproduction, however, it enlarges to the point that it
becomes an abdominal organ at about the 12th week of gestation so that the growth of the fetus is
accommodated.
In pregnancy and non pregnancy states, the cervix protects the internal environment of female
reproduction from the exterior environment; during pregnancy, the cervix additionally protects the
fetus. For example, during early pregnancy, a mucous plug is formed in the cervix to protect the
developing fetus from the external environment.

Vagina
This internal organ of reproduction connects the exterior female reproductive system structures to
the internal female reproductive organs and structures. It serves as a protection against infection
during pregnancy because it produces high acidity; and the vaginal also becomes more vascular
during pregnancy.

Fallopian Tubes
The fallopian tubes are the site of fertilization; after about 4 days after fertilization, the fertilized
ovum moves from the trumpet like ampulla of the fallopian tube to the uterus, with the exception of
ectopic pregnancies which abnormally maintain the fertilized ovum in the fallopian tube.

Ovaries
Unlike other organs of reproduction, the ovaries serve as both an endocrine organ and a
reproductive organ.
Anatomically, the ovaries are comprised of the three distinct layers which from the outer most to the
innermost layer, are:

 The tunica albuginea

 The medulla that contains ovarian circulation
 The cortex which contains the corpora lutea, the ova and the follicles

The ovaries, as an endocrine organ, produce hormones such as progesterone and estrogen. These
hormones play an integral part in the female's menstrual cycle, breast development, and the
retention of a developing fetus during pregnancy.
Bony Pelvis
The bony pelvis which consists of two innominate bones which are the sacrum and the coccyx, and
that, unlike other parts of the human's skeletal system, become more pliable and able to change in
order to facilitate the movement of the fetus to the external world during labor and a vaginal
delivery.
The external organs and structures of the female reproductive system are the:

 Mons pubis
 Urethral meatus
 Vaginal vestibule
 Labia minora
 Labia majora
 Clitoris and the
 Perineal body

Conception
Conception and fertilization are complex processes that entail cellular division, gametogenesis, and
chromosomal arrangement. A singular cell is formed at the time of fertilization with mitosis and
meiosis; gametogenesis is the production of a single male sperm or a single female ova each of
which has 23 pairs of chromosomes and, that, after fertilization form the zygote of 46 pairs of
chromosomes. Females and males have a total of 23 pairs of chromosomes, two of which are
sexually assigned autosomes and the remaining are not. Females have XX female chromosomal
arrangements and males have XY chromosomal arrangements.

Maternal Physical Changes During

Pregnancy
Some of the physical changes that occur during pregnancy include the presumptive, probable and
positive signs of pregnancy, urinary system changes, circulatory system changes, endocrine system
changes, gastrointestinal system changes, skin changes, respiratory system changes, skeletal changes,
central nervous system changes, metabolic changes, and vital sign changes.
The presumptive signs of pregnancy are:

 Urinary frequency
 Fatigue
 Amenorrhea
 Nausea and vomiting which is referred to as morning sickness
 Breast soreness
 Darkened areolae
 Large Montgomery glands
 Uterine enlargement
 Vaginal discoloration
 Skin pigmentation changes and
 Fetal movement which is referred to as quickening

The probable signs of pregnancy include:

 Hegar's sign which is changes to the lower portion of the uterus

 Abdominal enlargement
 A positive human chorionic gonadotropin or HCG test
 Braxton Hicks contractions
 Chadwick's sign which is a blue tinge to the vagina and cervix
 Gooddell's sign which is the softening of the cervix
 The ability to palpate the fetus which is referred to as fetal ballottement and
 Cervical and uterine changes in terms of consistency, size and shape

And, lastly, the positive signs and symptoms of pregnancy are:

 Fetal heart tones

 Ultrasound evidence of a fetus and
 The objective assessment of fetal movement

Assessing the Client's Psychosocial

Responses to Pregnancy
In addition to assessing the client's physiological changes and responses to pregnancy, the registered
nurse also assesses the client's psychosocial responses to pregnancy including those relating to the
mother's response to and perceptions of the pregnancy, the father's response to and perceptions of
the pregnancy, the coping mechanisms used by the mother and father as they cope with this
developmental and maturation change, the emotional preparedness of the parents for the pregnancy,
and the support systems, including the mother's and father's familial support systems and their
utilization of appropriate and available support systems in the community.
Many emotions and different perceptions can occur as a response to pregnancy. Some of these
emotions include joy, fear, mood swings, anxiety, financial concerns, depression, and adverse
emotional reactions to the bodily changes of pregnancy. The father may also have similar reactions.
The emotions and perceptions can vary among clients and they can also vary according to the
particular clients' specific situation.
It is believed that about 50% of all pregnancies are unplanned and it is known that single mothers,
including teenage mothers, often become pregnant. Some mothers and fathers can successfully
adapt to and welcome an unwanted pregnancy and others cannot. Stressful decisions such as those
relating to abortion and adoption have to be supported by the nurse.
Social support systems are highly beneficial in terms of normal and abnormal coping with a
pregnancy. Some women may have a lot of social supports during this maturational milestone in
terms of family members and their spouse or partner and others may have little or no support. This
is particularly true when the partner is absent and/or not welcoming of an unwanted pregnancy.

Assessing the Maternal Client For

Antepartal Complications
Although most pregnancies are without complications, there are many pregnancies that are adversely
affected with antepartal, intrapartal and postpartum complications. These antepartal complications
will now be discussed.
As you will learn in this section maternal antepartal complications during the antepartal periods
include:

Infections
All infections pose antepartal dangers and risks for the pregnant woman and the developing fetus.
Some examples of these infections are briefly discussed below:

HIV/AIDS
The mother's immunosuppression can lead to the development of other infections and this virus can
infect the neonate perinatally as well as during breast feedings. The mother's treatment of
HIV/AIDS continues as it did prior to the pregnancy and all procedures during pregnancy that can
increase the risk of infection to the fetus are avoided whenever possible. Some of the invasive
procedures and interventions that are avoided include episiotomy, amniocentesis, internal fetal heart
monitoring, forceps deliveries, and vacuum extractions

Salpingitis and Endometritis

Salpingitis is an inflammation or infection of the fallopian tubes; this infection most often occurs as
the result of untreated endometritis and it can lead to life threatening pelvic inflammatory disease,
massive sepsis, tubo-ovarian abscesses and infertility.
Endometritis, an inflammation or infection of the uterine endometrium, most often occurs after a
miscarriage, spontaneous abortion, after a planned abortion and as the result of another infection in
the postpartum period of time.
Diminished bowel sounds, tachycardia, elevated white cells, a fever, abdominal tenderness and pain
and foul smelling lochia are some of the signs and symptoms associated with endometritis and
salpingitis.
Interventions, in addition to the administration of antimicrobial drugs such as clindamycin or
gentamycin, can include fluid rehydration, and the symptomatic relief of the fever and abdominal
pain.

Tubo-Ovarian Abscesses
Tubo-ovarian abscesses, often the result of acute salpingitis, can also occur as the result of other
infections such as pelvic inflammatory disease after a delivery, abortions and spontaneous abortions.
It, too, can lead to massive sepsis and death when left untreated.
Tubo-ovarian abscesses can be signaled with foul smelling lochia, a high fever, and the signs of
peritonitis including abdominal and pelvic pain.
Intravenous broad scope antibiotics, fluid replacement, and electrolyte replacements, and
hospitalization are typically indicated.

Gonorrhea
Gonorrhea can also be transmitted to the fetus in utero and also with delivery. The signs and
symptoms of this sexually transmitted disease can include a yellowish - greenish vaginal discharge,
dysmenorrhea, abdominal discomfort and dysuria. This infection can also be asymptomatic.
Medications used for the treatment of gonorrhea include broad scope antibiotics such as ceftriaxone
and azithromycin.

Chlamydia
Chlamydia, the most frequently occurring sexually transmitted disease, when symptomatic, can
present with vaginal spotting, perineal itching and dysuria. During pregnancy, the woman is treated
with amoxicillin or azithromycin for chlamydia.

Candida Albicans
This fungal infection most frequently occurs as the result of diabetes, the use of oral contraceptives
and a recent course of antibiotic therapy. Candida albicans can also be transmitted to the neonate
upon delivery.
Oral candida albicans is characterized with white-gray patches on the tongue and other oral surfaces;
and vaginal candida albicans is characterized with a white vaginal discharge and genital redness. This
infection is treated with over the counter clotrimazole or fluconazole.

Chorioamnionitis
Choriomnionitis results from a bacterial infection of the chorionic membranes and the fetal amnion.
Choriomnionitis can occur as the result of a premature rupture of the membranes.
Choriomnionitis is associated with complications such as bacteremia, potentially life threatening
sepsis, pelvic abscesses, fetal complications and postpartum hemorrhage.
Choriomnionitis can be signaled with signs and symptoms such as a maternal fever, maternal
leukocytosis of > 15000 to 18000 cells/μL, maternal tachycardia, uterine tenderness and a purulent
vaginal discharge. The fetal heart rate typically exceeds 160 beats per minute.
When immediate and intense intravenous antibiotic therapy is not successful, an emergency cesarean
section may be necessary.

TORCH Infections
TORCH is an acronym for:

 Toxoplasmosis
 Other infections
 Rubella
 Cytomegalovirus
 Herpes

The infections included in TORCH are clustered in this manner because all of these infections cross
the normally protective placental barrier and as such, not only threaten the health and wellbeing of
the pregnant woman, but they also serious threaten and jeopardize the growth and development of
the developing fetus with the adverse teratogenic effects that all of these infections have. Because
these infections pose such great dangers, immunological TORCH screening is often done to detect
the presence of all of these offending infections among pregnant women.
The risk factors and the treatments of these TORCH infection vary according to the specific
infection and the severity of each infection.
Toxoplasmosis can be contracted by handling of contaminated feline feces and from consuming
meat that is not cooked enough; rubella is transmitted with contacts with someone with the disease
when the host is not immunized against it; cytomegalovirus is spread via contact with bodily fluids,
such as vaginal secretions, semen, blood, placental tissue, breast milk, and other bodily fluids; and,
lastly, maternal herpes simplex infections occur as the result of direct contact with infectious genital
or oral lesions, and the neonate is exposed to this infection during a vaginal delivery when the
pregnant woman has infectious and active herpes simplex lesions on the genitalia at the time of
delivery.

Group B Streptococcus B-Hemolytic Infection

Group B streptococcus B-hemolytic infections can also be transmitted to the fetus during the
processes of labor and delivery.
Some of the risk factors associated with group B streptococcus B-hemolytic infections are a
premature delivery, a low birth weight infant, a maternal history of group B streptococcus B-
hemolytic infections, a premature rupture of the membranes, a maternal age of less than 20 years of
age, and also secondary to invasive intrauterine fetal monitoring.
Intravenous amoxicillin and penicillin G are used for the treatment of group B streptococcus B-
hemolytic infections and, at times, for the prophylaxis of these infections during pregnancy.

Toxic Shock Syndrome

Toxic shock syndrome, a staphylococcus aureus or streptococcal infection, can occur as the result
burns, childbirth, surgical procedures, and other forms of trauma. Streptococcal toxic shock
syndrome is typically more serious and life threatening than staphylococcus toxic shock syndrome
and the former is often associated with systemic collapse.
The signs and symptoms of toxic shock syndrome include hypotension, skin desquamation of the
palms of the hands, an erythematous skin rash, a high fever, altered levels of consciousness, nausea,
vomiting and elevated nitrogen and creatinine levels.
The antimicrobial drugs of choice are a first generation cephalosporin or penicillin; however, those
with a sensitivity to or allergy to these antimicrobials, can receive vancomycin or clindamycin.
Additionally, hospitalization for treatments and closer monitoring of the pregnant woman may be
indicated to prevent the high morbidity and mortality rates associated with toxic shock syndrome
during pregnancy.

Urinary Tract Infections (UTI)

The greatest risk period for a urinary tract infection during pregnancy is from the 6th to the 24th week
of pregnancy. The risk of urinary tract infections among pregnant women is greater than other
populations because of the normal anatomical changes associated with pregnancy such as the
increased size and weight of the uterus which can block the free flow of urine through the urinary
tract.
The classical signs and symptoms of urinary tract infections, such as a fever, dark or grossly bloody
colored urine, and pain occur.
The complications of urinary tract infections during pregnancy can affect the mother and the
developing fetus. Some of these complications can include maternal hypertension, a low birth
weight, preterm labor and possible renal damage. Levofloxacin, ampicillin and ciprofloxacin are
typically the drugs of choice to treat these urinary tract infections when their effectiveness is
confirmed with a urine culture and sensitivity.

Pyelonephritis
Pyelonephritis, most likely caused by E. coli, is a risk for the pregnant woman particularly when the
woman is a diabetic and when they have a urinary tract infection, a urinary tract obstruction,
bacteriuria, and/or chronic kidney disease.
Although some clients with acute or chronic pyelonephritis may be asymptomatic, most present
with an elevated blood urea nitrogen level, malaise, dysuria, foul smelling urine, hematuria, increased
white blood cells, a fever and decreased creatinine clearance.

Cardiac Disease
Cardiac diseases and disorders during pregnancy, similar to those in a non-pregnancy state, are
associated with significant elevations in terms of morbidity and mortality rates. Even though cardiac
diseases can preexist prior to pregnancy, some mothers develop cardiac disease during the course of
their pregnancy since pregnancy increases the mother's cardiovascular demands because of the
pregnancy.
Some examples of cardiac disorders that complicate pregnancy, in addition to preexisting and
gestational hypertension, are:

 All maternal, preexisting congenital heart disorders

 Cardiomyopathy associated with left ventricular dysfunction
 Pulmonary hypertension secondary to Eisenmengger syndrome which is left to right cardiac shunting
 Rheumatic heart disease
 Marfan syndrome, a genetic disorder that places the mother at risk for aortic dissection or rupture
 Mitral valve prolapse

Although the symptoms may vary among pregnant clients, among the different cardiac disorders,
and according to the severity of the cardiac disorder, some of the most common signs and
symptoms experienced by the pregnant woman include fatigue, shortness of breath and dyspnea,
chest pain, palpitations, and abnormal and adventitious breath sounds like rales.
Cardiac disease in classified according to its level of severity from Class I cardiac disease to Class IV
cardiac disease with Class I cardiac disease as the least severe and Class IV cardiac disease as the
most severe of all. Class I and Class II are associated with no limitations of symptoms with physical
activity and symptoms with exertion. These classifications do not typically lead to maternal
complications, however, Class III and Class IV cardiac disease may, particularly if left untreated, lead
to maternal and fetal complications and even death. Class III cardiac disease is characterized with
maternal cardiac symptoms with normal exertion and Class IV cardiac disease is characterized with
maternal cardiac symptoms with rest and during periods of time without any physical activity.

Diabetes
Some pregnant women have diabetes prior to their pregnancy and other pregnant women develop
gestational diabetes during the course of their pregnancy, but regardless of etiology diabetes during
pregnancy is a complication for pregnant woman because all diabetes adversely affects glucose. The
ideal blood glucose level is between 70 and 110 mg/dL during pregnancy.
As you should know, the commonly occurring risk factors associated with diabetes mellitus include
obesity, a family history of diabetes and a high body mass index. Additional risk factors that place
pregnant women at risk for gestational diabetes are an age at pregnancy of more than 25 years of age
and a history of a stillborn or an infant who was large for gestational age. Research indicates that
almost half of the women who develop gestational diabetes during pregnancy will have type 2
diabetes in the future.
Although many women with gestational diabetes may have the classical signs and symptoms of
diabetes mellitus, such as urinary frequency and thirst, many others are asymptomatic. For this
reason, all pregnant women are screened for the presence of diabetes.
The maternal complications of diabetes during pregnancy include:
 Hypertension
 Ketoacidosis
 Infections resulting from elevated urinary glucose such as urinary tract and vaginal infections
 Preeclampsia
 Eclampsia

The fetal complications of diabetes, when not effectively treated, include:

 Hydramnios
 Hypoglycemia
 Jaundice
 Respiratory distress syndrome
 Macrosomia which is excessive birth weight
 Spontaneous abortion
 Pre-term birth
 Hypertension
 Preeclampsia and eclampsia
 Preterm Labor/Post term Pregnancy

Hypertension
Like diabetes, pregnant women can be adversely affected by hypertension that they have had prior
to the pregnancy and they can also develop gestational hypertension during the course of their
pregnancy, typically with its onset at or about the 20th week of pregnancy. Pregnant women less than
20 years of age and older than 40 years of age are more at risk for gestational hypertension than
other women of other ages. Additional risk factors associated with gestational hypertension are
diabetes, renal disease, a family history and/or a personal history of gestational hypertension,
pregnancy with multiples, the mother's first pregnancy, and a molar pregnancy.
In terms of its severity, hypertension during pregnancy is classified as mild hypertension, mild
preeclampsia, severe preeclampsia, and HELLP.
HELLP stands for:

 H: Hemolysis which can lead to anemia

 EL: Elevated liver enzymes
 LP: Low platelet count which can lead to disseminated intravascular coagulopathy (DIC),
thrombocytopenia and abnormal clotting

The treatment includes close medical monitoring and control including maternal life style choices
such as diet and exercise. When indicated, antihypertensive medications, such as methyldopa,
hydralazine, labetalol, and nifedipine, are used. Angiotensin II receptor blockers and ACE inhibitors
are contraindicated in most cases.
Fetal complications associated with maternal hypertension include, among other things, premature
delivery, a low birth weight and the complications that can result from maternal preeclampsia and
eclampsia, as discussed immediately below.

Preeclampsia
Most often preeclampsia precedes eclampsia but this is not always the case. Preeclampsia typically
has an onset after the 20th week of gestation and it is typically initially identified and assessed with
the presence proteinuria and hypertension. The severity of preeclampsia and eclampsia and
associated fetal and material complications are greatest when the preeclampsia, or eclampsia, emerge
before the 35th week of gestation. Untreated and unmanaged, it may progress to life threatening
eclampsia.
The risk factors associated with preeclampsia and the progression of preeclampsia to eclampsia are:

 Diabetes
 Obesity
 Hypertension
 Multiple gestations
 Pregnancy after the age of 35 years of age
 African American descent

In addition to proteinuria and hypertension, the signs and symptoms of preeclampsia can impact on
virtually all bodily systems. These signs and symptoms are:

 Gastrointestinal alterations such as vomiting and nausea

 Hyperreflexia, headache, clonus and dizziness which indicate neurological alterations
 Elevated serum transaminase and elevated liver enzymes which indicate altered hepatic functioning
 Oligura, a creatinine level more than 90 µmol/L and proteinuria, as afore mentioned, indicate altered
renal functioning
 The emergence of hemolysis, a low platelet count, disseminated intravascular coagulation,
thrombocytopenia and HELLP which indicate alterations in the mother's circulatory system
 Other circulatory system changes such as edema
 Right upper quadrant and epigastric pain
 Respiratory changes as the result of pulmonary edema

Eclampsia
Of all the many possible complications of pregnancy, eclampsia is the leading cause of maternal
death and poor fetal outcomes.
In addition to the signs and symptoms of preeclampsia, as listed immediately above, eclampsia is
characterized with seizure activity that is not attributable or correlated with another cause such as
hypoglycemia, central venous sinus thrombosis and/or an amniotic fluid embolus.
Some of the maternal complications associated with eclampsia are:

 Seizures
 Cerebral, hepatic and renal damage
 Cerebral hemorrhage
 Coma
 Death

The possible fetal complications of eclampsia include:

 Placenta abruption
 Fetal demise
 Abnormal fetal growth and development
 Low birth weight
 A premature delivery
 Damage to organs such as the brain, liver and kidneys

Because of these serious fetal complications, the mother and the fetus are monitored on a frequent
basis and, when the need arises, the preservation of fetal life may depend on an immediate delivery.
Some of the interventions that can be indicated, as based on the current status and condition of the
mother and the fetus, include monitoring the urinary output and expecting it to be at least 30 mL
per hour, monitoring the maternal vital signs, assessing the mother's level of consciousness,
checking maternal reflexes such as the deep tendon reflex.
The treatments for eclampsia, and some cases of preeclampsia, can include:

 The administration of magnesium sulfate which is an anticonvulsant medication

 The administration of corticosteroids which facilitates lung development for the fetus and better hepatic
and platelet functioning
 The administration of antihypertensive medications to control maternal hypertension and to prevent the
complications associated with this hypertension
 The restriction of fluid intake
 Maintaining urinary output at 30 mL per hour
 Bed rest as indicated
 Labor induction or a planned delivery as indicated

Clients who are taking magnesium sulfate must be carefully monitored for the signs and symptoms
of life threatening magnesium sulfate toxicity including a diminished level of consciousness, cardiac
arrhythmias, respiratory depression, a urinary output of less than 30 mL per hour and neurological
deficits such as an absent patellar deep tendon reflex response.
Magnesium sulfate toxicity is treated with the immediate cessation of the magnesium sulfate IV, and
the administration of calcium gluconate which is the antidote for magnesium sulfate.

Preterm Labor
Preterm labor, technically defined, is the occurrence of true uterine contractions and the emergence
of cervical changes characteristic of the full term changes with a full term delivery, between the
20th and 37th weeks of gestation.
Some of the risk factors associated with preterm labor including, but not limited to:

 A lack of adequate prenatal care

 Diabetes
 Hypertension
 Multiple gestations
 Substance use and abuse
 Maternal age < 17 years of age or > 35 years of age
 Uterine abnormalities
 Hydramnios
 Infections, such as chorioamnionitis and others, that adversely affect amniotic fluid
 Multiple pregnancies in rapid succession
 A previous history of spontaneous abortions, preterm births or miscarriages

The signs and symptoms of preterm labor are the same as those of true, full term labor, as will be
discussed in a subsequent section of the NCLEX-RN review.
The goals of the treatments for preterm uterine contractions and cervical changes are to cease
preterm labor and maintain the pregnancy for as long as possible. Some of the treatments and
interventions for preterm labor include:

 Activity restriction
 Positioning on the left lateral position to decrease uterine activity
 Insuring hydration to prevent oxytocin release which stimulates contractions
 The administration of medications such as nifedipine or indomethacin to suppress contractions, and
magnesium sulfate to relax smooth muscle and to suppress contractions
 The administration of betamethasone to stimulate fetal lung surfactant production and to enhance fetal
lung maturation

Post Term Pregnancy

A post term pregnancy is defined as a pregnancy that lasts more than 294 days and WITHOUT any
miscalculations of the due date of delivery. Post term pregnancies can result from a number of
different factors and forces including, but not limited to, fetal anencephaly, a placental sulfatase
deficiency, and maternal primiparity.
The fetal complications associated with a post term pregnancy are oligohydramnios, the aspiration
of meconium, umbilical cord compression, a higher than normal mortality rate, birth trauma, and
shoulder dystocia.
Post term pregnancy does not typically lead to any maternal complications other than a more
difficult labor and delivery because of the typically large size and weight of a post term baby.

Subchorionic Hematoma
A subchorionic hematoma occurs when there is a blood clot between the membranes of pregnancy
and the wall of the uterus that separates and leads to maternal bleeding.
Although a rare complication of pregnancy, the signs and symptoms of a subchorionic hematoma
include vaginal bleeding and abdominal cramps. At times, the pregnant woman may be
asymptomatic.

Hydatidform Moles
A hydatidform mole occurs as the result of a paternal chromosomal aberration. A hydatidform mole
can be a complete or a partial molar pregnancy. There is no fetus with a complete hydatidform mole.
The classic sign of a hydatidform mole is the formation of grape like clusters that can even be seen
in the vagina. Other signs and symptoms include pelvic pressure, maternal hypertension, vaginal
bleeding during the first trimester, an abnormally rapid growth of the uterus, anemia, and maternal
nausea and vomiting.

Hyperemesis Gravidarum
Hyperemesis gravidarum, affectionately known as morning sickness, is a persistent and excessive
amount of maternal nausea and vomiting.
Hyperemesis gravidarum often occurs during the first trimester of pregnancy but some pregnant
women may be affected with hyperemesis gravidarum throughout the course of the entire
pregnancy. It is medically defined as nausea for the majority of the day and vomiting three or more
times per day.
Other signs and symptoms include hypotension, tachycardia, dizziness, dehydration, and maternal
weight loss.

Incompetent Cervix
Simply defined, an incompetent cervix, or cervical insufficiency, is a cervix that effaces and dilates
too early during the pregnancy. An incompetent cervix is diagnosed typically as early as the fourth
month of gestation. This premature effacement and dilation can lead to the rupture of the
membranes and a miscarriage unless it is successfully treated.
The signs and symptoms of an incompetent uterus include back, pelvic, and abdominal cramping,
vaginal spotting or bleeding, and other changes in the vaginal discharge.
Anemias
Iron deficiency anemia and folic acid deficiency anemia are also complications of pregnancy during
the antepartal period of time. Both of these anemias can have adverse effects on both the pregnant
mother and the developing fetus.
The risk factors associated with a folic acid deficiency include some medications that deplete folic
acid, a history of a neural tube defect pregnancy in the past, an abnormal excessive excretion of folic
acid, gastrointestinal malabsorption syndrome, and a less than adequate dietary intake of foods high
in folic acid, coupled with the need for increased folic acid during pregnancy. Some of the signs and
symptoms of folic acid deficiency anemia include diarrhea, depression, confusion, and glossitis.
Folic acid deficiency anemia, which can be simply prevented with the administration of folic acid
supplementation during the prenatal period, can lead to fetal brain abnormalities and other neural
tube abnormalities.
Iron deficiency anemia during pregnancy, like folic acid deficiency anemia, can result from a number
of factors and forces such as the increased need for iron during pregnancy, a lack of maternal iron
stores to meet the demands of pregnancy, an inadequate dietary intake of iron, and the fact that the
maternal volume of plasma expands without a proportionate increase in the mother's hemoglobin,
thus creating an iron deficit. The greatest need for iron occurs during the second trimester of
pregnancy.
Some of the signs and symptoms suggestive of iron deficiency anemia include pallor, headache,
irritability, pica, shortness of breath with moderate exertion, fatigue, brittle finger and toe nails,
irritability, and palpitations.
A confirmative diagnosis is made when the laboratory diagnostic tests show a Hgb < 11 mg/dL
during the 1st and 3rd trimester, a Hgb < 10.5 mg/dL during the 2nd trimester and a Hct < 33%.
The treatment of iron deficiency anemia includes ferrous sulfate 325 mg bid or, when oral iron
supplementation cannot be tolerated, iron dextran can be used.
The effects of iron deficiency anemia in terms of the fetus can prematurity, a low birth weight, and
fetal demise; the mother, on the other hand, can be adversely affected with infections, postpartum
hemorrhage and preeclampsia, for example.

Cardiopulmonary Maternal Collapse

Cardiopulmonary maternal collapse is a severe antepartal complication that can be a life threatening
medical emergency for both the pregnant woman and the developing fetus.
The risk factors associated cardiopulmonary maternal collapse are:

 Hemorrhage including an intracranial bleed

 Heart disease
 Genitourinary tract infections
 Major trauma
 Eclampsia
 Thromboembolism
 A ruptured ectopic pregnancy
 An amniotic fluid emboli

The signs and symptoms of cardiopulmonary maternal collapse are INCREASED:

 Pulmonary capillary wedge pressure

 Systemic vascular resistance
 Clotting factors
 Tidal volume
 Volume of erythrocytes
 Sequestration of blood to the uterus
 Plasma volume by 40% to 50%
 Cardiac rate by 15 to 20 beats per minute
 Cardiac output by 40%
 Oxygen consumption by 20%
 Arterial blood pressure by 10 to 15 mm Hg
 Functional residual capacity by 25%

According to the physical status of the pregnant woman and the fetus, some of the life saving
interventions for the correction and treatment of cardiopulmonary maternal collapse include
cardiopulmonary resuscitation and advanced cardiac life support, an immediate caesarean section to
preserve the lives of both the pregnant woman and the baby, and a post mortem caesarean section
to save the baby after the mother has died.

Disseminated Intravascular Coagulation

Disseminated intravascular coagulation, also referred to as DIC, is an acquired clotting factor
abnormality that can occur during pregnancy, particularly when the pregnant woman is affected with
another disorder such as an amniotic fluid embolism, eclampsia, an incomplete abortion, a retained
dead fetus, or the retention of the placenta.
The signs and symptoms of disseminated intravascular coagulation include the signs and symptoms
of blood clotting and the signs and symptoms of bleeding. Other signs and symptoms include
possible decreases in the level of consciousness, cyanosis, hypotension, hypothermia, tachycardia,
behavioral and mood changes. Without treatment, disseminated intravascular coagulation can lead to
death.

Ectopic Pregnancy
Ectopic pregnancy is another complication of pregnancy. Ectopic pregnancy occurs when the
fertilized egg is implanted anywhere other than the uterus. Most ectopic pregnancies occur when the
fertilized egg is implanted in the fallopian tube. Unilateral pain, nausea, vomiting, a brown vaginal
discharge, and faintness are some of the signs and symptoms that can occur with an ectopic
pregnancy.
Substance Use and Abuse
Substances both illicit and legal can adversely affect a pregnancy. For example, legal alcohol,
prescription drugs, over the counter drugs, cigarettes, other legal tobacco products pose risks in
terms of the pregnancy. For example, placental abruption, spontaneous abortions, a small for
gestational age infant, as well as sudden infant death syndrome after birth and attention deficit
hyperactivity disorder as the infant matures can result from tobacco use; fetal alcohol syndrome,
impaired intrauterine fetal growth, mental retardation, microcephaly and cardiac anomalies can result
from alcohol use and abuse; and tobacco use can lead to placental abruption, spontaneous abortions,
Prescription medications such as tranquilizers can cause fetal drug withdrawal, hypotonia,
hypothermia, a low APGAR score upon birth, cleft palate and/or lip, and respiratory compromise.
Medications are categorized according to five categories in terms of their degree of risk in terms of
fetal development and growth. Categories A and B are generally considered safe for pregnant
women; and medications classified as category C, D, and X are not considered safe, therefore,
category C, D, and X medications are not given to pregnant women unless they are absolutely
necessary and the benefits associated with the particular medication greatly outweigh the fetal
complications associated with their maternal use.
Additionally, the use of these illicit and illegal products and substances can lead to antepartal
complications for both the fetus and the pregnant woman. The substances and the potential
complications associated with each are listed below.

 Marijuana: Intrauterine growth restriction, neonatal withdrawal, and developmental and behavioral
abnormalities as the infant matures.
 Heroin: Impaired respiratory functioning, tremors, convulsions, and neonatal irritability and withdrawal.
 Methadone: Preterm labor, placenta abruptio, meconium aspiration, and fetal withdrawal
 Barbiturates: Intrauterine fetal growth restrictions and fetal withdrawal
 Methylenedioxymethamphetaime (MDMA or Ecstasy): Memory and learning deficits
 Lysergic acid diethylamide (LSD): Chromosomal aberrations
 Crack/cocaine: Microcephaly, genitourinary abnormalities, cardiac abnormalities, central nervous
system depression and sudden infant death syndrome after birth.

Spontaneous Abortions
Spontaneous abortions, also referred to, as unintended abortions or miscarriages, most often occur
during the first trimester of the pregnancy. Spontaneous abortion is defined as all losses of the fetus
with the exception of an elective abortion to end an unwanted pregnancy.
Spontaneous abortions occur as the result of one or more factors including chemical and/or
radiation exposures, abnormalities of the mother's anatomical structures such as the uterus, and
maternal diseases and disorders such as infections, diabetes, and thyroid conditions.
Spontaneous abortions are classified into a number of different types of spontaneous abortions. An
inevitable abortion is accompanied with bleeding, abdominal cramping, cervical dilation, and
perhaps the rupture of the membranes. Threatened spontaneous abortions can be signaled with
bleeding, abdominal, and back pain that is not accompanied with any cervical dilation or the rupture
of the membranes.
An incomplete abortion also has the signs and symptoms of abdominal and back cramping as well as
bleeding, but only part of the membranes is lost. A complete spontaneous abortion presents with
severe bleeding, severe cramping, and the complete loss of the membranes well before the expected
date of delivery.
Ultrasound and a speculum examination confirm the diagnosis of a spontaneous abortion.
Some of the complications associated with spontaneous abortions include disseminated intravascular
coagulation (DIC), increases in terms of the maternal thromboplastin levels and fetal autolysis.
Dilation and curettage (D and C) is typically done to remove the products of the pregnancy;
additionally, misoprostol may be required in order to remove any remaining contents.
Other interventions after a spontaneous abortion, as based on the client's condition, intravenous
fluid replacement, blood or blood products, and a suction evacuation or dilatation and curettage (D
& C) when the products of conception are not expelled spontaneously.

Premature Rupture of the Membranes

Premature rupture of the membranes occurs when the amniotic membranes break and rupture 1
hour or more prior to the onset of labor. Premature rupture of the membranes, a serious
complication of pregnancy, can lead to infection as a result of the premature loss of the protective
amniotic sac and its fluids. For example, an infection of the remaining amniotic membranes, referred
to as chorioamnionitis, can occur as the result of a premature rupture of the membranes.
In addition to infection, another serious complication of premature rupture of the membranes is a
prolapsed umbilical cord, accompanied with prolonged or variable deceleration, which can endanger
the fetus prior to delivery. This complication is confirmed with a direct inspection of the introitus
and with fetal heart monitoring that reveals prolonged or variable deceleration.
The signs and symptoms of a premature rupture of the membranes, referred to by many clients as
"breaking the water", may include:

 Pyrexia
 Leakage or gushing of the fluid from the vagina
 Foul smelling vaginal discharge
 Maternal tachycardia
 Increased fetal heart rate
 Positive findings with the ferning test
 Positive findings with a nitrazine paper test

The treatment of premature rupture of the membranes includes antibiotics to prevent infections,
betamethasone to facilitate fetal lung maturity and surfactant production, and to prepare for
childbirth.
Multiple Gestations
Multiple gestations is defined as a pregnancy with two or more fetuses. Even though multiple
gestations is considered a risk, the risks associated with it are significantly decreased with good
prenatal care.
In addition to the signs of pregnancy, multiple gestations are suspected during the first trimester
when the mother's has a greater than normally expected weight gain, fatigue, abdominal expansion,
and/or nausea and vomiting and when the fetal movements are felt sooner than normally. Multiples
are confirmed with an ultrasound examination.
Maternal complications can include a number of different disorders and complications such as
anemia, hydramnios, hyperammonemia, hypoglycemia, hypertension, preeclampsia and eclampsia,
gestational diabetes, pulmonary embolism, coagulopathy, and a premature rupture of the
membranes.
The fetal complications related to multiple gestations during the first trimester include infections and
the complications of infection, spontaneous abortion, chromosomal anomalies, fetal growth
restriction, an incompetent cervix, spontaneous abortion and the "vanishing twin" phenomena
which threaten the second trimester of pregnancy with multiples. The "vanishing twin" phenomena
occurs when one or more of the multiple fetuses is reabsorbed.

Fetal Growth Restriction

Fetal growth restriction and a small for gestational age fetus can occur as the result of both genetic
and non genetic causes. Some of the maternal risk factors associated with restricted uterine growth
are placental insufficiency, kidney disease, some infections like cytomegalovirus, diabetes,
hypertension, and substance abuse.
The fetal complications of fetal growth restriction include perinatal asphyxia, polycythemia which
gives the neonate a ruddy complexion, tachypnea, lethargy, meconium aspiration, and hypoglycemia,
of which the most serious and life threatening is perinatal asphyxia which can occur during labor
with each uterine contraction at which time the maternal placental perfusion decreases. An
immediate delivery is indicated when fetal distress is present.

Oligohydramnios
Oligohydramnios is defined as an insufficient amount of amniotic fluid; the normal volume of
amniotic fluid is from 5 to 25 and values less than 5 are considered oligohydramnios.
Oligohydramnios can result from a number of causes including medications like NSAIDs and ACE
inhibitors, abruptio placentae, premature rupture of the membranes, restricted fetal growth, a post
term pregnancy, hypertension, preeclampsia, eclampsia, chromosomal abnormalities of the fetus,
and a maternal thrombolytic disorder.
The complications of oligohydramnios can include restricted fetal growth, impaired fetal lung
development, and fetal demise. Ongoing monitoring with biophysical profiles, ultrasonography, and
nonstress testing is done, and when necessary, induced labor or the immediate delivery of the fetus
are done.
Polyhydramnios
Polyhydramnios is an excessive amount of amniotic fluid with a value of > 25.
Some of the factors that impact development of polyhydramnios are Rh incompatibility, hemolytic
anemia, multiple gestations, infection and genetic fetal abnormalities. Some of the signs and
symptoms of polyhydramnios are maternal respiratory distress and pre term labor contractions. The
complications associated with polyhydramnios are premature rupture of the membranes, life
threatening umbilical cord compression, preterm labor, abruption placentae, fetal distress and fetal
death.
Continuous monitoring and the manual withdrawal of excessive amniotic fluid, may be indicated.
This withdrawal of amniotic fluid is referred to as an amnioreduction.

Assessing the Client For the

Symptoms of Postpartum
Complications
Maternal assessment and management continues after the delivery of the neonate. These
assessments are done with the knowledge that infections and hemorrhage are the most frequently
occurring postpartum complications.
During the immediate postpartum period the acronym BUBBLE is a good way to remember the
essential components of the postpartum assessment in addition to the assessment of the client's vital
signs, the level of pain and discomfort, and other assessments.
The acronym BUBBLE stands for the assessment of the mother's:

 The B of BUBBLE is the breasts

 The U of BUBBLE is the uterine fundus height, consistency and placement
 The B of BUBBLE is the bowel and other gastrointestinal functioning
 The second B of BUBBLE is bladder functioning
 The L of BUBBLE is lochia amount, consistency, color and odor
 The E of BUBBLE is episiotomy edema and redness

Vaginal discharge progresses from bloody vaginal drainage with some small clots for about 10 days
after which the vaginal drainage is brown and may continue for up to about 6 weeks. The breasts
will be normally engorged, particularly when the mother is breast feeding; urinary output may
increase during the first day or two of the postpartum period of time; about 12 or 13 pounds is lost
by the new mother; and hormonal shifts may lead to depression for about two weeks, after which
this depression may be serious and a sign of postpartum psychosis, rather than the "baby blues".
All the vital signs should return to their normal levels in about 24 hours after delivery. Infection and
postpartum hemorrhage must be ruled out when the signs of infection or hemorrhage present. The
local signs of infection are site pain, redness, heat, swelling and some bodily part dysfunction; and
the systemic signs and symptoms of infection include fatigue, chills, hyperthermia, prodromal
malaise, tachypnea, tachycardia, nausea, vomiting, anorexia, confusion, incontinence, abdominal
cramping and diarrhea, among other signs and symptoms as based on the type of infection.

Recognizing Cultural Differences in

Childbearing Practices
Culture, cultural practices and cultural beliefs can impact on the childbearing practices of many
clients. For example, some cultures, more than others, promote the importance of large families,
while others such as the Chinese limit the size of the family. Some cultures also differ in terms of
their beliefs relating to single parenthood, pregnancies among unmarried couples, prenatal care,
gender preference, breast feeding and places where the delivery of the infant should take place.
These practices and beliefs can impact on the importance of having children, health practices during
pregnancy, beliefs about pregnancy and infant feeding.

Calculating the Expected Date of

Delivery
The expected date of delivery is calculated using Nagle's rule which is:

 The first day of last menstrual period – 3 months + 7 days = the estimated date of delivery

For example, when the first day of the last menstrual period is 9/20/2015 you would:

1. Subtract three months from 9/20/2015 and then get 6/20/2015 and then
2. Add seven days to 6/20/2015 and then get 6/27/2015, after which you would
3. Add one year to 6/27/2015 to get the estimated date of delivery for 6/27 of the following year which is
2016.
Checking and Monitoring the Fetal
Heart during Routine Prenatal Exams
and During Labor
Now we will discuss monitoring the fetal heart rate during the antepartum period of time. Some of
the terms used in respect to fetal heart rate monitoring will be defined now.

 The baseline fetal heart rate is the average fetal heart rate per minute during a 10 minute period of time
WITHOUT any periods of significant variability or any period when the rate varies by more than 25
beats per minute.

 A wandering baseline fetal heart rate is a fluctuating fetal heart rate from the baseline. This abnormal fetal
heart rate pattern can indicate disorders like a congenital abnormality or metabolic acidosis.

 An acceleration is defined as an increased fetal heart rate over the fetal heart rate baseline with a less than
30 second duration from the onset to the peak. Accelerations can be prolonged, episodic, or periodic.

 A prolonged acceleration is an acceleration of the fetal heart rate that lasts more than 2 minutes.

 An episodic acceleration is defined as an assuring fetal heart rate pattern that normally occurs with fetal
movements.

 Periodic acceleration is an acceleration that occurs with contractions. They are normal.

 A deceleration is a fetal heart rate that is less than the baseline. Decelerations can be early, late, variable
or prolonged.

 The onset of deceleration is the point where the fetal heart rate falls below the baseline.

 The nadir of deceleration is the lowest point of the deceleration.

 The descent of deceleration is the time between the onset and the nadir of deceleration.

 The depth of deceleration is the number of beats per minute that occur during a deceleration until it
reaches its nadir.
 The duration of a deceleration is the time elapsed from the onset of the deceleration to the fetus' baseline
fetal heart rate.

 The recovery of the deceleration is the time elapsed from nadir to the fetus' baseline fetal heart rate.

 A late deceleration is a gradual decrease of the fetal heart rate heart rate below baseline during
contraction.

 An early deceleration is a gradual increase of the fetal heart rate below the baseline during contraction
which occurs during the peak of the contraction.

 Variable decelerations occur when the fetal heart rate suddenly decreases by at least 15 beats per minute
that lasts at least 15 seconds before it returns to the baseline.

 A prolonged deceleration is defined as a decrease in the fetal heart rate of 15 or more beats per minute
that persists more than 2 minutes from its onset to its return to the baseline.

 Variability is classified as with minimal variation when it varies by less than 5 beats per minute; moderate
variability occurs fetal heart rate varies by 6 to 25 beats per minute; and with marked and severe
variability the fetal heart rate varies by more than 25 beats per minute.

Nonreassuring fetal heart rates and heart rate patterns include the absence of any variability, late
decelerations, variable decelerations, fetal tachycardia, and fetal bradycardia. Noninvasive fetal heart
rates are monitored on a continuous or an intermittent basis. The necessity of fetal heart monitoring
is underscored when the mother has complications such as abnormal uterine contractions,
hypertension, diabetes, a post term pregnancy, and renal disease and/or the fetus is at risk as the
result of one or more factors such as fetal distress, meconium stained amniotic fluid, multiple
gestations, placenta previa, abruptio placentae, an abnormal contraction stress test, an abnormal
nonstress test, bradycardia and intrauterine growth restriction.
Noninvasive external fetal monitoring is advantageous over invasive internal fetal heart monitoring
because there is less risk of infection, and there is no need for the rupture of the membranes or the
dilation of the cervix at 2 or more centimeters, and there is no need for the fetus to have a
descended presenting part.
Invasive internal fetal monitoring, when compared and contrasted to external fetal monitoring, is
advantageous because it provides a higher quality and more accurate reading that is also not
impaired with factors such as maternal obesity, fetal positioning and maternal positioning.
Normally, fetal heart rate baselines are from 110 and 160 beats per minute excluding any
decelerations, accelerations, or episodes of variability over a 10 minute period of time. Fetal heart
rates less than 100 indicate fetal bradycardia; and rates greater than 160 beats per minute indicate
fetal tachycardia.
Assisting the Client with
Performing/Learning Newborn Care
Mothers, particularly new mothers and significant others, need some assistance and support in terms
of newborn care and infant feeding. They must know the nutritional needs of the baby, how to
breast feed or bottle feed, how to provide cord care and circumcision care, diapering, bonding,
attachment, preventing accidents, such as placing the infant on their back to prevent suffocation,
and how to respond to the baby's crying.

Nutritional Needs and Feeding the Infant

The nutritional needs of the neonate include about 110 kcals per kilogram a day for the first 3
months of life and then 100 kcals per kilogram a day until the infant is about 6 months of age.
Neonates and infants also need 2 ¼ to 4 grams of protein each day, and 140 to 160 mLs of fluid per
day.
Human milk is considered the best form of nutrition for infants up to at least 6 months of age.
Breast milk is produced in the breast as the result of the hormone prolactin. Prolactin, in addition to
oxytocin, both of which are endocrine hormones that are secreted by the pituitary, regulate milk
production. Breast milk is more readily and easily absorbed and digested than formula milk.
The decision to breastfeed or formula feed is a personal decision that should be made by the mother
after a full discussion about the advantages and disadvantages of each type of infant feeding. Some
of the factors and forces that impact on this decision include cultural practices and beliefs, the
mother's employment, life style choices and socioeconomic status. For example, some cultures have
the belief that breastfeeding is the natural and preferable choice and other cultures may not share
this same belief; life style choices like a desire to drink alcoholic beverages after the delivery of the
baby prevent the mother from breast feeding; and some places of employment may not
accommodate the needs of the breast feeding woman with breaks for pumping and/or feeding the
infant.
A healthy diet for the lactating breast feeding mother should include small amounts of fats, protein,
whole grains, dairy products, fresh fruits and vegetables. Special foods are not needed to produce
milk or to maintain an ample milk supply.
The normal breastfeeding process includes the proper positioning of the infant and mother, latch on
and the sucking and swallowing sequence.
Positioning and holding the neonate for breast feeding will become a personal preference, however,
there a number of positions that the mother should be instructed about including the football clutch
hold position, the cradle position, the modified cradle position, and the side lying position.
Latch on is placing the areola and a large portion of the breast into the baby's mouth. The infant's
rooting reflex promotes their latching on and it can be stimulated by stroking the baby's cheek when
the nipple is in the baby's mouth. The suck and swallow sequence starts when the infant starts to
suck, the milk is then moved with the infant's tongue to the back of the mouth and then the infant
swallows.
Mothers who choose to bottle feed should be instructed about the safe and proper way to feed their
infant. They should be instructed to hold the baby and NOT prop the bottle up for automatic
feeding.

Cord Care
The umbilical cord stump should be gently handled and kept clean in order to prevent an infection.
The umbilical cord stump typically dries up and falls off at about two to three weeks after birth.
Cleansing entails the use of plain water and NOT alcohol as was done in the past. After cleansing
with water, the stump should be permitted to air dry or dried with an absorbent pad. Sponge
bathing, rather than tub baths, is encouraged and the stump should be exposed to circulating air and
not covered with a diaper in order to promote its drying out and falling off.
The mother should also be instructed how to identify any signs or symptoms of umbilical cord
stump infection such as swelling, pus and redness.

Circumcision Care
The circumcision site is kept clean and inspected for any complications such as infection, bleeding
and an alteration in urinary output.
The penis is cleansed, coated with a bit of petroleum jelly, and then covered with a sterile dressing
until it is healed which typically occurs in about one week.

Diapering
New mothers also make choices in terms of what kind of diapers they will use for their infant until
they are toilet trained. Some choose cloth diapers and other new mothers choose disposable diapers.
Some of the factors that may come into play in terms of this decision include socioeconomic factors,
the accessibility of a washer and dryer and personal preferences in terms of convenience. For
example, based on the fact that many neonates and infants need 10 or more daily diaper changes,
some parents choose cloth diapers because the cost associated with disposable diapers is prohibitive;
and some choose disposable diapers rather than cloth diapers because they do not have access to a
washer and dryer, and they prefer the convenience of disposable diapers.
Diapering techniques are relatively simple for the new parents to learn, however, diapering safety has
to be emphasized. NO infant should ever be left unattended on a changing table or bed. These types
of falls occur far more frequently than you can imagine.

Bonding and Attachment

Bonding and attachment to the parents is critically important to the healthy growth and
development of the new baby. Bonding and attachments give the neonate and infant positive
feelings of trust and intimacy.
Poor and absent bonding and attachments can lead to lifelong consequences such as mistrust, a lack
of intimacy, and impairments in terms of cognitive and psychological development.
Nurses can promote bonding and attachments by encouraging both parents, and siblings, to hold
the infant, to feed the infant and to communicate with the infant with touch, rocking and soothing
cooing sounds.

Accident Prevention
The greatest safety risks among neonates and infants include suffocation, falls and strangulation.
Suffocation can be prevented by keeping all objects out of the crib and always positioning the infant
on their back and not on their stomach.

Providing Prenatal Care and

Education
Prenatal care consists of a complete and thorough assessment of the mother, including a complete
past medical history and physical assessment, client education, and ongoing care.
The initial client assessment during the first contact with a woman that may be pregnant should
minimally consist of a complete health history and a complete physical assessment.
The components of this maternal health history, in addition to the data that is typically collected
with other health histories, include the mother's gynecological history, the number of living children,
the number of full term births, the number of preterm births, the number of spontaneous and
elective abortions, any complications experienced in prior pregnancies, any current medical concerns
related to the pregnancy or otherwise, the first day of the last menstrual period, the parents' genetic
history, and the woman's psychological and emotional responses to the current pregnancy.
Some of the maternal routine diagnostic tests that are done during the prenatal period of time
include:

 Urinary or blood human chorionic gonadotropin to diagnose a pregnancy

 One hour glucose tolerance test and a possible three hour glucose tolerance test
 Tests for HIV, hepatitis B, gonorrhea, tuberculosis, Group B streptococcus, chlamydia, streptococcus,
and syphilis
 TORCH infections screening
 Blood type including the Rh factor
 Papanicolaou (PAP)
 Hgb electrophoresis to detect conditions like sickle cell anemia
 CBC with differential
 Hgb and Hct
 Rubella titer
 Serum alpha-fetoprotein

Some of the fetal diagnostic tests that are done during the prenatal period of time include:

 Biophysical Profile: This test measures and assesses fetal breathing, fetal movement, fetal tone, the fetal
heart rate acceleration and the volume of the amniotic fluid.

 Diagnostic Ultrasound: Transabdominal and transvaginal ultrasound, according to the American

College of Obstetricians and Gynecologists, is used for a wide variety of normal and abnormal conditions
such as fetal presentation, gestational age, fetal growth, an ectopic pregnancy, abruptio placentae and
placenta previa.

 Lung Maturity Studies: Lung maturation studies include the lecithin/sphingomyelin or L/S ratio, the
lung profile and the phosphatidylglycerol (PG) level.

The lecithin/sphingomyelin or L/S ratio is the ratio of lecithin to the amount of sphingomyelin in
the amniotic fluid that comprises the fetus' lung surfactant. A ratio < 2:1 is abnormal and suggestive
of the fact that the newborn may be affected with respiratory distress syndrome and a ratio of < 1:5
indicate that the fetus is a high risk for infant respiratory distress syndrome.
The presence of phosphatidylglycerol prior to the 36th week of gestation indicates the possibility of
neonatal respiratory distress syndrome; and the lack of phosphatidylglycerol indicates a significant
risk of respiratory distress syndrome.
A lung profile consists of the lecithin/sphingomyelin ratio and the phosphatidylglycerol (PG).

 Nonstress Test: This noninvasive, nonstress test monitors and measures the fetal heart rate and fetal
movements. The results of this test is considered normal and reactive when the fetus' heart rate increases
by at least 15 beats per minute over 15 seconds when the fetus moves; and the results of nonstress test
are considered abnormal and nonreactive when the fetus' heart rate does NOT increase by at least 15
beats per minute over 15 seconds when the fetus moves.

 Contraction Stress Test: This noninvasive test measures fetal responses to contractions that are
stimulated with intravenous oxytocin or the mother's manual stimulation of her nipples. A normal
contraction stress test occurs when there are no late or variable decelerations during at least three uterine
contractions. This normal test is referred to as a negative contraction stress test. An abnormal, positive
contraction stress test occurs when there are late or variable decelerations during contractions.
 Amniocentesis: According to the American College of Obstetricians and Gynecologists, amniocentesis
is indicated when the pregnant woman is at risk for complications, is older than 35 years of age and when
there is a personal or family history of chromosomal aberrations and/or neural tube abnormalities.

Withdrawn amniotic fluid is laboratory tested to identify fetal abnormalities including fetal distress,
for example, when it is brown, red or green in terms of color.

 Chorionic Villus Sampling: Chorionic villus sampling, like amniocentesis, is beneficial for the
assessment of the fetus for fetal abnormalities.

 Percutaneous Umbilical Blood Sampling: Percutaneous umbilical blood sampling is effective for the
assessment of the fetus in terms of the presence of any infections and chromosomal abnormalities in
addition to the determination of the fetus' blood type and Rh factor.

 Alpha-Fetoprotein: Maternal alpha-fetoprotein, also referred to as α-fetoprotein, can identify genetic

disorders. Elevations of α-fetoprotein is suggestive of disorders such as anencephaly and spina bifida; and
lower than normal maternal alpha-fetoprotein levels can indicate the possibility that the fetus is affected
with Down's syndrome, hydatidiform mole and other abnormalities.

 Triple Screens: The maternal blood test includes the laboratory testing of maternal alpha-fetoprotein,

human chorionic gonadotropin and estriol to determine the presence of fetal abnormalities. For
example, elevated levels of human chorionic gonadotropin can indicate trisomy 21; and low levels of
unconjugated estriol can also indicate the presence of trisomy 21.

 Amniotic Fluid Index: The amniotic fluid index is used to assess fetal wellbeing. An amniotic fluid
index of < 5 indicates the need for further assessments and determinations.

Prenatal Education
Ideally, prenatal education should be provided to the client even before they plan a pregnancy. For
example, the client should be instructed about methods of birth control, the signs of pregnancy, and
ways to prepare for pregnancy.
Upon initial contact, the pregnant woman and their partner should be taught about a wide variety of
things that they will have to consider and make choices about. For example, they should be taught
about their choices in terms of the care provider that will care for the mother during pregnancy and
delivery, the possible birth settings, childbirth preparation classes, the birthing plan, who will be with
the mother during labor and delivery, newborn care classes, sibling preparation classes, breast
feeding and bottle feeding and:

 Normal gestational growth and development

 Normal physiological changes that occur during pregnancy
 The presumptive, probable, and positive signs of pregnancy.
 The signs and symptoms of complications during pregnancy
 Nutrition during pregnancy
 Exercise during pregnancy
 The stages of labor and delivery
 The postpartum period

Some of the settings for childbirth include a hospital, a community based birthing center and the
home of the pregnant woman. All of these settings have their advantages and disadvantages. For
example, a home delivery may be a disadvantage when the mother and/or the neonate are in need
for emergency care and treatments and a hospital delivery may be perceived by the parents as
impersonal and unnatural.
Choices in terms of the care provider that will care for the mother during pregnancy and delivery
include an obstetrician, a nurse midwife and a non nursing midwife. Possible support people during
the labor and delivery processes can include family members, spouses, a professional doula, friends,
siblings and nursing students.
Pregnant women also should make knowledgeable decisions about childbirth methods and
childbirth preparation classes should they elect to take advantage of them. The most common
childbirth preparation classes are the Lamaze method, the Kitzinger method, the Bradley method,
the Alexander method and the Hypno Birthing method.
The Lamaze method supports the fact that childbirth is a normal and natural process about which
the mother has instinctive knowledge about. The Lamaze method childbirth preparation classes
include information and education relating to pain management choices, methods of feeding the
infant, the labor process, the postpartum period, and relaxation and breathing techniques for each
stage of labor.
The Bradley method childbirth preparation classes include deep abdominopelvic controlled
breathing to use during labor, good nutrition during pregnancy, breastfeeding, exercise during
pregnancy, relaxation techniques, and the stages of labor. The Bradley method is a partner coached
birth that supports the fact that participation in the labor and delivery processes is a satisfying and
rewarding experience.
The Alexander method childbirth preparation classes include comfort measures to use during
pregnancy and labor, pushing during delivery, and ways to promote the pregnant woman's flexibility,
movement, balance, and coordination.
The Kitzinger method, a home delivery childbirth preparation method, consists of educational
classes that include the home delivery method that clients without the risk for complications can
decide upon. These classes include antepartum care, breast feeding, therapeutic touch during labor,
chest breathing, abdominal relaxation and the use of sensory memory to facilitate the mother's
understanding of her body and its functioning during pregnancy and the birth process.
Hypno Birthing childbirth preparation includes instruction on self hypnosis and how self hypnosis
promotes the release of endorphins which is considered a natural anesthetic. In addition to self
hypnosis, the pregnant woman is also taught about relaxation techniques and pushing techniques.
Providing Care to the Client in Labor
Labor is the natural process or induced process that consists of involuntary, rhythmic uterine
contractions that increase in terms of frequency and intensity. Labor leads to the necessary
effacement and dilation of the cervix that is needed for the vaginal delivery of the baby after
pregnancy.
Effacement is the thinning and shortening of the cervix and dilation is the opening of the cervix.
Labor usually begins about two weeks prior to the expected delivery date; labor usually lasts from
twelve to eighteen hours.
The stages of labor and delivery include the first, second, third and fourth stages of labor.
The first stage of labor consists of the latent, active and transition phases. The latent phase of the
first stage of labor typically lasts for several hours and the contractions are mild. During the active
phase of the first stage of labor, the contractions become more frequent and severe, the cervix
dilates up to seven centimeters and the fetus begins to descend in the birth canal. The transition
phase of the first stage of labor is characterized with the increased frequency, intensity and duration
of the contractions. The cervix dilates up to 10 cm.
The second stage of labor begins when the cervix is dilated 10 cm and it ends with the birth of the
infant. The third stage of labor begins with the vaginal delivery of the baby and it ends when the
products of conception, that is the placenta, are expelled. The fourth stage occurs during the first
several hours after delivery.
During the latent phase of the first stage of labor, the mother should be encouraged to rest, walk,
perform relaxation techniques and take deep breaths. Food and fluids are limited and restricted
during this phase of the first stage of labor. They should also be encouraged to urinate every hour.
During the active phase of the first stage of labor, the client should be encouraged to continue
voiding every hour and also to continue with ambulation, rest and relaxation exercises. At times,
such as with prolonged labor, intravenous fluids may be used to prevent and treat dehydration.
Nurses promote comfort and provide basic nursing are with things like massages, oral care and
frequent positioning for comfort. The spouse or significant other should also be encouraged to care
for their partner during this and all the other stages of labor.
Contractions and maternal vital signs are checked and monitored every 15 minutes; and the fetal
heart rate is also monitored at least every 15 minutes. Fetal assessments include assessing and
monitoring the fetal heart rate at least every 15 minutes as well and much more often and even
continuously when the fetus is at risk. The mother must be reminded to pant rather than push in
spite of the fact that the woman in labor has a strong urge to push.
The fetal lie, presentation, attitude, station and position are also monitored and assessed during
labor.
Fetal lie is defined as the relationship of the fetus's spine to the mother's spine. Fetal lie can a
longitudinal, transverse or oblique life. Longitudinal lie, the most common and normal lie, occurs
when the fetus' spine is aligned with the mother's spine in an up and down manner; a transverse lie
occurs when the fetus' spine is at a right ninety degree angle with the maternal spine; and, lastly, an
oblique lie occurs when the fetus' spine is diagonal to the mother's spine.
Fetal presentation is defined by where the fetus' presenting part is within the birth canal during
labor. The possible fetal presentations are the cephalic presentation, the cephalic vertex presentation,
the cephalic sinciput presentation, the cephalic face presentation, the cephalic brow presentation, the
breech presentation, the complete breech presentation, the frank breech presentation, the shoulder
breech presentation, and the footling presentation.
The cephalic head presentation, the most common and normal presentation, is the fetus' head as the
presenting part. The cephalic presentation can be further classified and categorized as the cephalic
vertex presentation where the fetus' head is on its chest, the cephalic sinciput presentation where the
head is partly flexed, the cephalic face presentation where the face is the presenting part of the head
because the fetus' head is hyperextended, and the cephalic brow presentation which occurs when the
fetus' head is extended.
A breech presentation occurs when a fetal body part, other than the head, is the presenting part. The
breech presentation can be further classified and categorized as the complete breech presentation
when the fetus' buttocks are the presenting part, the frank breech presentation that occurs when the
buttocks present and the legs are straight up, the shoulder breech presentation when the shoulder
presents, and the footling presentation were one or both of the feet presents.
Fetal attitude is the positioning of the fetus's body parts in relationship to each other. The normal
attitude is general flexion in the "fetal position". All attitudes, other than the normal attitude, can
lead to a more intense and prolonged labor.
Fetal station is level of the fetus' presenting part in relationship to the mother's ischial spines. Fetal
station is measured in terms of the number of centimeters above or below the mother's ischial
spines. Fetal station is -1 to -5 when the fetus is from 1 to 5 centimeters above the ischial spines and
it is from +1 to +5 when the fetus is from 1 to 5 centimeters below the level of the maternal ischial
spines.
Fetal position, simply stated, is the relationship of the fetus' presenting part to the anterior,
posterior, right or left side of the mother's pelvis. The relationship of the fetus's presenting body
part, such as left anterior, left posterior, right posterior and right anterior, in relationship to the
maternal pelvis which is called the anterior, posterior, right and left pelvis which are noted and
documented as A, P, R or L. The presenting part of the fetus is referred to as mentum, occiput,
sacrum, and acromion. These presenting parts are noted and documented as M, O, S, and A
respectively. The only normal positions are the left and right occiput anterior fetal position which is
the ROA and the ROL, respectively.
Face presentation positions are noted and documented as:

 RMA for the right mentum anterior position

RMT for the right mentum transverse position
RMP for the right mentum posterior position
LMA for the left mentum anterior position
 LMT for the left mentum transverse position
LMP for the left mentum posterior positionVertex presentation positions are noted and documented as:
 ROA for the right occiput anterior position
 ROT for the right occiput transverse position
 ROP for the right occiput posterior position
 LOA for the left occiput anterior position
 LOT for the left occiput transverse position
 LOP for the left occiput posterior position

Breech presentation positions are noted and documented as:

 RSA for the right sacrum anterior position

RST for the right sacrum transverse position
RSP for the right sacrum posterior position
LSA for the left sacrum anterior position
LST for the left sacrum transverse position
LSP for the left sacrum posterior position

Acromian presentation positions are noted and documented as:

 RAA for the right acromian anterior position

RAT for the right acromian transverse position
RAP for the right acromian posterior position
LAA for the left acromian anterior position
LAT for the left acromian transverse position
LAP for the left acromian posterior position

There are several types of delivery including:

 Vaginal deliveries
 Operative deliveries such as a forceps delivery, a vacuum delivery and a Caesarean and a
 Vaginal Birth After a Caesarean Section

Vaginal deliveries are the most common form of delivery. Vaginal deliveries can be done with or
without an episiotomy. An episiotomy may be indicated when the baby is excessively large, when
there is shoulder dystocia, and/or maternal and/or fetal stress are present.
Forceps facilitate the delivery of the baby by providing traction and they can also facilitate the
rotation of the fetus' head to the vertex position. All forceps except Piper forceps are applied to the
sides of the head and only when the fetus' presentation is presenting downward. Piper forceps are
used for breech presentations after the fetus' head is reachable after the delivery of the rest of the
body.
The complications of forceps deliveries include maternal trauma, lacerations, pelvic floor damage,
bleeding and an inadvertent extension of the episiotomy to the anus. Neonate complications include
a low Apgar score, neurological trauma and damage, a fractured clavicle and Erb's palsy.
Vacuum deliveries are done with the application of suction to the occipital part of fetal head to assist
in the delivery when the second stage of labor is extensively long and/or there is a nonreassuring
fetal heart rate pattern. Attempted vacuum deliveries are ceased when there is no success after about
one half hour.
Cesarean births are indicated with placenta abruptio, placental previa, cephalopelvic disproportion, a
nonreassuring fetal heart pattern, and a cord prolapse. The incision can be a skin incision with can
be vertical or transverse and a uterine incision which is done into the uterus.
Some of the maternal complications associated with Cesarean births are infection, hemorrhage,
shock, emboli and adverse reactions to anesthetic agents.
Trial labor and a vaginal delivery can be attempted after the mother has had a Cesarean section in
the past except under some circumstances such as an inadequate pelvis.

Providing Post-Partum Care and

Education Including Discharge
Instructions
As previously detailed with the section entitled "Assessing the Client For the Symptoms of
Postpartum Complications", postpartum care and monitoring focuses on BUBBLE, and for the
signs of infection and/or hemorrhage, which are the two most frequently occurring postpartum
complications.
Mothers, particularly new mothers and significant others, need some assistance and support in terms
of newborn care and infant feeding. Details about this necessary education were previously
discussed with the section entitled "Assisting the Client with Performing/Learning Newborn Care".

Evaluating the Client's Ability to Care

for the Newborn
Again, new mothers are monitored in terms of their abilities to provide care to the infant. Teaching
and the reinforcement of teaching are necessary when a learning need is assessed.
The essentials of newborn care include bathing, feeding, quieting strategies, swaddling, diapering,
cord care, and circumcision care.

Developmental Stages and

Transitions: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of developmental stages and transitions in order to:

 Identify expected physical, cognitive and psychosocial stages of development

 Identify expected body image changes associated with client developmental age (e.g., aging, pregnancy)
 Identify family structures and roles of family members (e.g., nuclear, blended, adoptive)
 Compare client development to expected age/developmental stage and report any deviations
 Assess impact of change on family system (e.g., one-parent family, divorce, ill family member)
 Recognize cultural and religious influences that may impact family functioning
 Assist client to cope with life transitions (e.g., attachment to newborn, parenting, puberty, retirement)
 Modify approaches to care in accordance with client developmental stage (use age appropriate
explanations of procedures and treatments)
 Provide education to client/staff members about expected age-related changes and age-specific growth
and development (e.g., developmental stages)
 Evaluate client's achievement of expected developmental level (e.g., developmental milestones)
 Evaluate impact of expected body image changes on client and family

This section will provide you with the expected stages of growth and development for all age groups
and how to modify and adjust approaches to care as based on these stages.
The age groups along the lifespan and their age parameters are:

 The neonate which is the first four weeks of life

 The infant who is from four weeks old to one year old
 The toddler who is from one to three years of age
 The preschool child who is from three to five years of age
 The school age child who is from six to twelve years of age
 The adolescent which ranges from thirteen to seventeen years of age
 The young adult who is from eighteen to twenty five years of age
 The adult which is defined as from twenty six to sixty five years of age and, lastly,
 The older adult who is over sixty five years of age
Identifying Expected Physical,
Cognitive and Psychosocial Stages of
Development
Age and developmental stages are assessed to determine if the client is at the expected level of
growth and development, to plan care that is age and developmentally appropriate and to modify
care as based on the age related characteristics and needs of our clients. These assessments include
the physical, cognitive and psychosocial stages of growth and development.

Cognitive Development: Jean Piaget

Jean Piaget's levels of cognitive development from birth until 12 years of age are used for the
assessment of children up to this age, after which the cognitive development of the child is
complete.
In the correct sequential order, Jean Piaget's levels of cognitive development include:

 Sensorimotor thought: Infancy to About 2 Years of Age

The sensorimotor thought level has 6 sub stages; this level includes the development of the infant's
and young child's ability to manipulate concrete objects.

 Preoperational and symbolic functioning: From 2 to 7 Years of Age

Language and vocabulary progressively develop.

 Concrete operations: 7 to 11 Years of Age

Between these ages, the child is able to use logic and reasoning; they have also developed their ability
to solve concrete problems.

 Formal operations: 12 Years of Age

Under normal circumstances, the child at 12 years of age should have developed the ability to solve
abstract problems and to use complex thinking, logic and reasoning.

Psychosocial Development: Erik Erikson

Erik Erickson proposed 8 major stages of psychosocial development and expected tasks along the
life span from infancy to old age. People, including our own clients, who are able to resolve their age
related tasks are successfully able to progress to the next task; however, psychosocial development
can become arrested when a person is not able to achieve their age related developmental task.
Nurses must incorporate these developmental tasks and challenges into the plan of care and they
must also modify the plan of care according to these age related tasks.
Eric Erikson's stages, developmental tasks and signs of their lack of resolution are listed below.

 Age Group: Infant

Task: Trust
Failures to Resolve the Task: Mistrust and a failure to thrive

 Age Group: Toddler

Task: Autonomy, self-control and will power

Failures to Resolve the Task: Shame, doubt and a poor tolerance of frustration

 Age Group: Preschool

Task: Initiative, a sense of purpose, self-confidence, and self direction

Failures to Resolve the Task: The fear of punishment and guilt

 Age Group: School Age Child

Task: Industry, competence and self-confidence

Failures to Resolve the Task: Feelings of inferiority and fears that one cannot meet the expectations
of others

 Age Group: Adolescent

Task: Identity formation and a sense of self as an individual

Failures to Resolve the Task: Role confusion, lowered self-esteem and a poor self concept

 Age Group: Young Adult

Task: Intimacy, love and affection

Failures to Resolve the Task: Isolation and the avoidance of relationships including intimate
relationships

 Age Group: Middle Aged Adult

Task: Generativity, productivity, and genuine concern for others

Failures to Resolve the Task: Stagnation, self-absorption and a lack of concern about others

 Age Group: Older Adults

Task: Ego integrity, wisdom and the ability to participate in life with a sense of satisfaction
Failures to Resolve the Task: Despair and feelings that life is without any meaning and without any
sense of satisfaction

Psychosexual Development: Sigmund Freud

Sigmund Freud, often referred to as the father of psychotherapy, developed the concepts of id, ego
and superego, the psychological defense mechanisms such as sublimation and suppression, as well as
the 5 stages of psychosexual growth and development.
The id is an unconscious mechanism that operates in terms of instant gratification and instant
pleasure. Some say that infants are nothing more than a bundle of id. The ego is the person's sense
of self that provides the person with the ability to control oneself and one's behaviors. The superego
is the person's conscience.
The 5 stages of Sigmund Freud's stages of psychosexual development are:

 The oral stage

 The anal stage
 The phallic stage
 The latency stage
 The genital stage

Some of the lesser known theories of growth and development include those of Stella Chess and
Alexander Thomas, Roger Gould, Robert Havighurst, and Robert Peck.

The Development of Temperament: Stella Chess

and Alexander Thomas
Stella Chess and Alexander Thomas are credited with the development of the 9 temperamental
qualities which include:

1. Activity level
2. Sensitivity and reactions to external stimuli
3. Adaptability
4. Level of Intensity
5. Distractibility
6. Approach/Avoidance and Withdrawal
7. Persistence
8. Regularity and organization
9. Mood

Roger Gould
Roger Gould addresses 7 stages of growth and development that begins at age 16 and progresses to
the older adult.
These stages include:

1. Stage 1 - Ages 16 to 18: The adolescent strives to separate from the parents and to develop autonomy.

2. Stage 2 - Ages 19 to 22: The autonomous young adult has fears and anxiety about having to return to
their family unit and parents.

3. Stage 3 - Ages 23 to 28: This young adult replaces their fears and anxiety about having to return to their
family unit and parents with a more secure sense of self and their abilities. Some may also have a spouse
and children.

4. Stage 4 - Ages 29 to 34: At this age, the young adult no longer feels that they have to prove themselves
and many have a career, marriage and even children.

5. Stage 5 - Ages 35 to 43: This period of time is characterized with self reflection and values clarification.

6. Stage 6 - Ages 44 to 50: The person is well established and stable.

7. Stage 7 - Ages 51 to 60: This period of time is characterized with concerns about one's state of health
and one's own finality.

Robert Havighurst
This theorist developed 6 age groups and the physical, psychological and social tasks associated with
each of these 6 age groups.
These age groups and their associated developmental tasks are:

1. Infancy and Early Childhood: During this period of time the child develops the super ego, or
conscience, and they also develop and maintain emotional stability and relationships with the members of
their family unit and friends in their community.
2. Middle Childhood: The child continues their conscience development, and they also enhance their
value system, their sense of morality, and their values systems. Physical abilities continue to be developed
and refined; and intellectual skills are developed in their school and home environment.

3. Adolescence: Gender related roles are assumed, a personal ethical code emerges, mature relationships
with others are developed, and the adolescent begins to think about their future and desired goals in
terms of employment and/or advanced education.

4. Early Adulthood: Many start a family and relationships within the family and the community are
enhanced.

5. Middle Age: This period of time is typically characterized with stability and the empty nest syndrome as
well as major developmental changes like menopause and aging.

6. Later Maturity: During later maturity, the person adjusts to retirement, aging and the loss of loved ones
including spouses and friends.

Robert Peck
Robert Peck's theory focuses on aging and the aging process. Robert Peck's theory has 3
developmental tasks that somewhat parallel those of Eric Erikson's phase of integrity versus despair
in the later years.
Robert Peck's three developmental tasks associated with aging and the aging process include:

1. Ego Differentiation versus Work Role Preoccupation: The older adult adjusts to retirement and
enjoys leisure activities that they were unable to partake in while they were gainfully employed.

2. Ego Transcendence versus Ego Preoccupation: The individual accepts their own mortality without
fear.

3. Body Transcendence versus Body Preoccupation: The aging person maintains a sense of wellbeing,
happiness and satisfaction despite the physical declines associated with the aging process.
Identifying Expected Body Image
Changes Associated with the Client's
Developmental Age
As with all other nursing care, nurses must be able to identify and report client deviations from what
is expected in terms of their growth and development and they must also be able to modify care and
their approaches to care as based on these deviations.
Nurses also determine the impact of expected body image changes on the client in terms of how the
patient's perceptions are interfering with the patient's quality of life and the continued performance
of their activities of daily living. Again, all maladaptation and/or poor coping skills must be
determined, documented and reported so that the patient's plan of care can be changed to meet
these needs.
The major expected bodily changes and bodily image changes are those that occur with puberty,
menopause, pregnancy and the aging process.

Identifying Family Structures and

Roles of Family Members
Family structures are numerous and becoming more numerous and varied than any other time in the
past.
These family structures are discussed below:

 The Traditional Nuclear Family: This family structure consists of biological children and two marred
parents of different genders.

 The Nuclear Family: This family structure consists of two marred parents of a different gender and
children that can be step children, adopted children and/or foster children.

 The Extended Family: This family structure consists of one or more people with a child who resides
with others who are related biologically. For example, the extended family unit can consist of a
grandparent or grandparents.

 The Foster Family: This family structure consists of one or more foster children and one or two
parents.
 The Adoptive Family: The adoptive family is one that has at least one adopted child and one or two
parents.

 The Binuclear Family: The frequency of binuclear families has significantly increased over the last
several years as more and more divorced parents are sharing custody. This family structure consists of
two parents and at least one child. The parents in legal joint custody arrangements share responsibility for
the child or children.

 The Single Parent Family: This family has one parent and one or more children. These children can be
biological children, step children, adopted children and/or foster children.

 The Childless Family: This family structure consists of two adults with no children whatsoever.

 The Communal Family: The communal family is one that consists of group of unrelated adults who
live in a community with their children and who share responsibility for the children and their care,
among other things.

 The Gay, Lesbian and Transgender Family: This family structure consists of two adults of the same
gender who have one or more children.

 The Blended Reconstituted Family: This family consists of two adults who live in the home with one
or more step children from a previous marriage or another type of union.

Roles in the family have also changed over the past decades. In the past roles within the family were
gender based; now these roles are not usually based on gender. For example, in the past the mother
stayed at home and cared for the children while the father worked as the bread winner of the family.
Now things are very different. For example, some males are "stay at home dads" while the female in
the family works outside of the home as the bread winner of the family.
Other family roles that are assumed by the adults in the family are disciplinarian, teacher,
housekeeper, cook and shopper. Ideally, these roles and responsibilities are equally and equitably
shared by the adults within the family unit.
Like leadership styles, parenting styles also differ among members of the family when the family has
one or more children. For example, parents can be permissive, democratic, participative, laissez faire
and authoritarian.
Comparing Client Development to
Expected Age/Developmental Stage
and Reporting Any Deviations
As with all other nursing care, nurses must be able to identify and report client deviations from what
is expected in terms of their growth and development and they must also be able to modify care and
their approaches to care as based on these deviations.

Assessing the Impact of Change on

the Family System
Families, like all other open systems within the environment including individual clients, are
impacted with changes. Some of these changes are expected and developmentally normal and other
changes are unexpected and often disruptive to the homeostasis of the family. For example, a family
system can be impacted with the empty nest syndrome which is an expected and developmentally
normal change; and the death of a child or a spouse is an unexpected and often disruptive change
for members of the family.
Families, therefore, just like individual clients, often need the care and services of the health care
team to cope with any disruptive changes. Some major life changes that can significantly affect and
impact on the family unit are things like poverty, homelessness, divorce, chronic illnesses and legal
concerns.
Families, like individual clients, often need the assistance of the nurse to cope with these changes.

Recognizing Cultural and Religious

influences That May Impact Family
Functioning
Similar to individual clients, families also have their own beliefs, practices, perspectives, values and
views, some of which are present as the result of their culture, while others may be related to their
religion and still more may just simply result from the family's personal preferences.
Culture impacts on virtually all aspects of the client-nurse relationship. For example, communication
patterns, beliefs about illness, who is the major family decision maker, family dynamics, perspectives
about health and health care, space orientation, time orientation, nutritional patterns, beliefs about
elders and the elderly, parenting, family size, and even death and death vigils are often driven by the
family's culture, as passed on from generation to generation.
Religious influences may also impact on the family and its functioning. Some of the same impacts
that culture has, religion also has. Religion may impact on the family's beliefs about illness,
nutritional patterns, beliefs about elders and the elderly, parenting, birth control, family size, and
even death and death vigils are often driven by the family's religion. For example, in terms of the
perideath period, some religious practices include a clergy person like a Catholic priest to perform
that religion's Sacrament of the Sick.

Assisting the Client to Cope With Life

Transitions
Throughout the life span, there are several significant expected life transitions that require the
person to cope and adjust. Some of these expected life transitions include attachment and bonding
to the neonate, puberty, pregnancy, care of the newborn, parenting, and retirement.
Nurses and other health care professionals assist clients to adapt to and cope with these normally
occurring life transitions and changes. For example, the nurse may also seek out community
resources that could be helpful to an elderly, retired person who needs transportation to and from
doctor's appointments, a nurse could teach the new mother and their partner about how to bond
and attach to the newborn, and the nurse could also conduct newborn care classes for new parents
to assist these new person to cope with the challenges associated with the care of a neonate and
infant.

Modifying Approaches to Care in

Accordance with the Client's
Developmental Stage
As somewhat previously discussed with the "Integrated Process: Communication" and the
"Integrated Process: Teaching and Learning", communication and teaching are modified according
to the client's age, level of cognition, and developmental stage. Physical care, including medication
administration, as will be discussed later in this review, is also modified according to the client's age
and developmental status.
Some of these modified approaches to care, communication, explanations, teaching and diversionary
activities include:

 The provision of parent or legal guardian patient education when an infant and the young child is being
cared for
 The provision of safe and nontoxic, large toys for infants and young children to prevent aspiration and a
foreign body obstructing the young child's respiratory tract
 The use of touch and a soft voice to communicate with an infant
 The use of a graphic pain assessment tool, rather than a numerical pain assessment scale, for young
children and elderly adults who have a cognitive impairment
 Using the vastus lateralis as the muscle of choice for an intramuscular injection among infants

Providing Education to the Client and

Staff Members About Expected Age-
Related Changes and Age-Specific
Growth and Development
Clients and staff members must be knowledgeable and educated about expected age related changes
and age specific characteristics and needs. Registered nurses can identify knowledge deficits and
assess learning needs among staff members by observing how well and how consistently their
nursing care is modified according to their clients' age specific characteristics and needs. Similarly,
registered nurses can identify knowledge deficits and assess the learning needs among their clients
and family members across the life span in terms of their knowledge about expected age related
changes and age specific characteristics and needs.
For example, neonates and infants receive communication with the touch or a coo by an adult and
they enjoy colorful things like a mobile; infants and toddlers must not be given any small toys or
toys that can disassemble into small parts because they are in the oral stage of development where
they place objects in the mouth which places them at risk for aspiration and death; adolescents are
rebellious and they want to be with and accepted by their peers. Adults enjoy socialization and
activities like different sports and an exercise regimen; and older adults may be in need of activities
such as those in an elder day care center and reminiscence therapy.
When a staff or client/family learning need is assessed, the nurse then plans, implements and
evaluates the teaching that is given specific to the learners' needs. For example, a middle aged man
caring for an elderly parent may have the need to learn about the safety needs of the elderly and new
parents may need education related to age appropriate toys and car seats.
Evaluating the Client's Achievement
of Expected Developmental Level and
Milestones
When nurses assess clients they incorporate their knowledge of developmental levels into this
assessment to determine and evaluate whether or not the client is achieving the expected milestones
associated with their age. As previously detailed, these assessments include the clients' assessment of
their physical growth and development, their psychosocial growth and development, their cognitive
growth and development, and their psychosexual growth and development.

Determining the Impact of Expected

Body Image Changes on the Client
In addition to the physical aspects of body image changes, there are also social and emotional
impacts with these changes. With the support of the health care team, the client should be able to
adapt to the changes, alter his or her life style as indicated, discard irrational beliefs and replace these
with realistic expectations, maintain social interactions, and enhance the bodily image with things
like a breast prosthesis and a wig, for example.

Evaluating the Impact of Expected

Body Image Changes on the Client
and Family
Body image changes such as those associated with aging, pregnancy, menopause, disfiguring surgery,
and others place challenges upon the client and the family in terms of coping and adaptation.
Some of the signs that indicate whether or not the client is coping with altered bodily image include
the client's acknowledgment of the changes as well as verbal and nonverbal comments about the
change.
Providing Education to the Client and
Staff Members About Expected Age-
Related Changes and Age-Specific
Growth and Development
Staff members must be educated about the age related changes and the age specific characteristics
and needs of clients across the life span so that they can modify the care of their client's accordingly.
Clients should also be educated about the age related changes and the age specific characteristics and
needs of different age groups as necessary. For example, a young mother may be taught about her
toddler's age appropriate toys and a middle age adult may have a need to learn about depression
among the elderly when the parents are not coping with the normal changes of the aging process.

Evaluating the Impact of Expected

Body Image Changes on the Client
and Family
Nurses also determine and evaluate the impact of expected body image changes on the client and
family in terms of how their perceptions and beliefs may be interfering with the patient's quality of
life and the continued performance of their activities of daily living. Again, all maladaptation and/or
poor coping skills must be determined, documented and reported so that the patient's plan of care
can be changed to meet these needs.
Some of the most stressful expected body image changes that may adversely affect the client and
family include body image changes such as those associated with pregnancy, menopause, puberty,
and aging. These changes may occur with significant reactions and responses in terms of the
person's physical, psychological and social wellbeing.
Health Promotion and
Disease Prevention: NCLEX-
RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of health promotion and disease prevention in order to:

 Identify risk factors for disease/illness (e.g., age, gender, ethnicity, lifestyle)
 Assess and teach clients about health risks based on family, population, and/or community
characteristics
 Assess client's readiness to learn, learning preferences and barriers to learning
 Plan and/or participate in community health education
 Educate the client on actions to promote/maintain health and prevent disease (e.g., smoking cessation,
diet, weight loss)
 Inform the client of appropriate immunization schedules
 Integrate complementary therapies into health promotion activities for the well client
 Provide information about health promotion and maintenance recommendations (e.g., physician visits,
immunizations)
 Provide follow-up to the client following participation in health promotion program (e.g., diet
counseling)
 Assist the client in maintaining an optimum level of health
 Evaluate client understanding of health promotion behaviors/activities (e.g., weight control, exercise
actions)
 Implement and evaluate community-based client care

Health, according to Florence Nightingale, was defined as the absence of disease and illness.
Throughout the years, this definition has changed significantly. At the current time, the World
Health Organization (WHO) defines health as "a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity." The World Health Organization defines
health promotion as "the process of enabling people to increase their control over, and improve
their health". These definitions of health and health promotion have implications for nurses and the
health care profession.
There are a large number of theories and models that facilitate an understanding of health, illness,
and wellness. Some of these theories and models are very specific and highly concrete and others are
more general and more abstract.
Some of these theories and models that nurses find helpful in terms of health, health promotion and
illness prevention include:

Holistic Models of Health and Wellness

Holistic approaches to health and wellness, more consistent with the holistic definition of health put
forward by the WHO as just stated, include the beliefs that the bio-psycho-social-spiritual person is
in the state of constant dynamic interaction with the environment; changes occurring in any of these
aspects create change in all the other aspects of the person and the environment within which the
client is.

Adaptation Models
Adaptation models and theories of health define health as how well able the client is to adapt and
cope with changes. Disease and illness occur when the person is maladapting to the change; and
health is promoted when the client is able to cope successfully and in a healthy manner.

Role Performance Models

Simply stated, a person is considered in good health and healthy when they are able to fulfill their
multiple roles without disruption; and a person is considered ill when they cannot fulfill their roles
and responsibilities. For example, a client who is able to continue to work and to perform their role
as a parent is considered healthy and not ill as they manage a chronic disorder such as heart disease
or diabetes.

The Health-Illness Continuum

The Health-Illness Continuum, put forth by Ryan and Travis, describes health and illness along a
continuum with high level health and wellness at one extreme end of this continuum and high levels
of illness and poor health, including death itself, at the other extreme end of this continuum. Neither
health nor illness is depicted in the middle of this continuum which is sometimes referred to as the
neutral zone.
Clients move along the continuum from illness toward health when they are successfully treated; and
clients move along the continuum from health to illness as the result of an infection or trauma, for
example.

The High Level Wellness Model

The High Level Wellness Model of Halbert Dunn is somewhat similar to the Health-Illness
Continuum of Ryan and Travis which was discussed immediately above this model. Rather than a
continuum, however, the High Level Wellness Model has 2 axes – the horizontal axis and the
vertical axis. As these axes cross each other as shown below, four quadrants are formed.
The four resulting quadrants of this model are the:

 Poor health in an unfavorable environment quadrant

 Protected poor health in a favorable environment
 High level wellness in a very favorable environment and
 Emergent high level wellness in an unfavorable environment

Poor health in an unfavorable environment is present when an ill person is in an unhealthy

environment. An example of poor health in an unfavorable environment is when a person with
severe immunosuppression is subjected to unsanitary conditions and contaminated drinking water;
an example of protected poor health in a favorable environment occurs when a client or a family, for
example, has support systems and accessibility to health care services when they are impacted with
an illness, disease or disorder; emergent high level wellness in an unfavorable environment can occur
when a client is committed to a regular exercise regimen, however, they are unable to do so because
of their multiple roles and responsibilities; and, finally, poor health in an unfavorable environment
occurs when a client with illness does not have the resources and services that they need to manage
and correct their poor health.

The Agent – Host – Environment Model

The Agent – Host – Environment Model, developed by Leavell and Clark, describes disease and
illness as a function of the dynamic interactions and interrelationships among the agent, the host and
the environment. The Agent – Host – Environment Model is helpful for getting a fuller
understanding of diseases and illnesses; however, it is not helpful in terms of health and health
promotion.
The agent in this model is the factor or force that leads to the disease or disorder. The agent can be
a physical, psychological, social, chemical or mechanical force or factor. For example, bacteria, an
agent, can lead to an infectious disease when the host and the environment interact with it and each
other; and toxic chemicals can lead to a disease or disorder when the host and the environment
interact with it and each other.
The host is the person that could be affected with a disease or disorder when the client interacts
with the agent and the environment interacts with the client and each other. As discussed previously
with the Infection Control section, some clients are more susceptible hosts than other clients. For
example, a client's vulnerability and susceptibility to illnesses and diseases increase when they are
affected by risk factors associated with the disease or disorder such as gender, age and life style
choices.
The environment consists of all factors that are external to the client. Some elements of the
environment can place a person at risk for a disease or illness; other environmental factors
predispose the person to wellness. For example, a social stressor, such as the loss of a loved one,
predisposes the host for disease and illness; and a physical environmental force, such as healthy
noise levels and adequate living conditions can facilitate health.

The Systems Model of Neumann

The Systems Model of Neumann is based on the premise that the human being, which is an open
system within the environment, has natural boundaries to protect it against the stressors in the
environment.
These protective boundaries include the lines of resistance, the normal lines of defense, and the
flexible lines of defense which protect the open system from environmental stressors and
penetration of the open system. Health promotion includes the nurses' fortification of these lines of
defense to maintain health and prevent diseases and illnesses.
When the lines become penetrated, as is the case with the occurrence of illness and disease, nurses,
in collaboration with other members of the health care team, provide care and treatments to
reorganize and reconstitute the open system after it has been disrupted with penetrating forces.

The Dimensions Model of Health

The Dimensions Model of Health includes 6 dimensions that impact on the individual client, groups
pf clients, families, populations and communities. This model, unlike other abstract models of health
and wellness such as the Systems Model of Neumann and the holistic models, is relatively concrete
and, as such, is highly beneficial to nurses and others as they care for their clients.
The six dimensions of health are the:

1. Biophysical Dimension: This dimension includes physical risk factors for disease and illnesses such as
the age of the person, their genetics, and the presence of any anatomical structure abnormalities.

2. Psychological and Emotional Dimension: This dimension includes the client's ability to adapt with
and cope with changes, including those related to illness and disease, the client's level of cognition, and
their willingness and motivation to participate in health and wellness activities, for example.
3. Behavioral Dimension: This dimension includes the client's choices in terms of their behaviors and life
style choices. For example, a good exercise regimen, adequate nutrition and the avoidance of harmful
substances are examples of some of the components of the behavioral dimension of health and wellness.

4. Socio-cultural Dimension: The Socio-cultural Dimension includes social forces such as socioeconomic
status, and support systems; the cultural aspect of the Socio-cultural Dimension includes things like the
beliefs, practices, and values of the client as based on their culture.

5. Physical Environment Dimension: This dimension includes factors and forces in the external
environment that positively or negatively impact on clients' health. For example, clean air and clean
drinking water in the environment facilitate health; and air pollution and contaminated drinking water
negatively impact on the health of those who are exposed to it in the environment.

6. Health Systems Dimension: This dimension includes the clients' availability, accessibility, and
affordability of health care and health related resources and services that meet their health related needs.

The Seven Components of Wellness

The Seven Components of Wellness, credited to Anspaugh, Hamrick and Rosato, is similar to the
Dimensions Model of Health except that the Seven Components of Wellness has more components
and some of these components are different.
The Seven Components of Wellness are the physical, intellectual, emotional, social, spiritual,
occupational and environmental components of health.
The physical component, the psychological component, the social component and the
environmental component of this model closely parallel the physical dimension, the psychological
dimension, the social dimension and the environmental dimension, respectively, in the Dimensions
Model of Health.
The other components of the Seven Components of Wellness and their descriptions are described
below.

 The Intellectual Dimension: The Intellectual Dimension reflects the client's level of cognition and
their abilities to solve health care problems, including an adequate level of health literacy in order for the
client to understand, and consent to, procedures, alternatives, and treatments relating to their health care
concerns.

 The Spiritual Dimension: This dimension, in addition to a religious component if religious beliefs are
held by the client, reflects the client's connectedness to their God and/or their higher power. This
dimension gives the client a sense of meaning and connectedness beyond the immediate here and now.
 The Occupational Dimension: The Occupational Dimension includes the client's ability to balance
their work life with their personal and social lives and associated roles and responsibilities.

Pender's Health Promotion Model

Pender's Health Promotion Model emphasizes the relationship of the client's motivation and
commitment to goal directed behavior and the promotion of health. As briefly discussed at the
beginning of this review with the "Integrated Process: Teaching and Learning", the primary purpose
of teaching is to change behaviors.
According to Pender's Health Promotion Model, health and health promotion is impacted with a
wide variety of factors and forces including their personal characteristics, their past experiences with
successes and failures, their perceptions, their level of self efficacy, their support systems and their
emotions.

Health Belief Model

Rosenstock and Becker's Health Belief Model, a somewhat predictive model that is sometimes used
to determine if the particular client will or will not participate in the established and recommended
immunization schedule or another aspect of health maintenance and health promotion, as based on
the clients' perceptions and beliefs.
The Health Belief Model addresses the relationship of the client's perceptions, beliefs and other
factors as they relate to the clients' behaviors and their health and health promotion behaviors. This
model can predict whether or not a person will engage in screening tests, for example, as based on
their personal perceptions and beliefs. Some of these beliefs and perceptions can include the client's
perceptions about the severity of the health related threat and their susceptibility and vulnerability in
terms of it and some of the other factors that can impact on the client's behavior are things like
demographics like gender and culture, structural facilitators and barriers including those related to
the accessibility and affordability of health care services and psychosocial factors such as support
systems and economics.

Identifying Risk Factors for Diseases

and Illnesses
Simply defined a risk factor is an intrinsic or extrinsic factor or force that could lead to an illness,
infection, a disease or disorder. An example of an intrinsic risk factor is the presence of hypertension
which places the patient at risk for other disorders and an example of an extrinsic risk factor is
contaminated food which places the person at risk for foodborne illnesses or infections.
Some risk factors can be decreased or eliminated and other risk factors cannot be changed or
eliminated. For example, genetics, age, ethnicity, and gender cannot be changed, however, other risk
factors, particularly those relating to poor life style choices like poor dietary habits and consumption
patterns can be eliminated.
Data and information about the patient's risk factors are collected during the admission health
history, during the physical examination, and throughout the course of care.

Assessing and Teaching Clients About

Health Risks Based on the Family,
Population, and/or Community
Characteristics
As defined in the beginning of this NCLEX-RN review, "client", according to the National Council
of State Boards of Nursing, is defined as an individual client, a family unit, a group, a population and
a community. In addition to the previous discussion on family and types of families, registered
nurses also care for a group which is further defined as a collection or aggregate of more than one
person who have a common characteristic such as age, gender and medical diagnosis. Groups can be
as small as two people, which are referred to as a dyad, and they can be very large like a group of 7
to 10 year old pediatric clients in a particular county. A population is comprised of a group of people
with two or more subpopulations; populations share some characteristics and they do not share
others. For example, a population may share a common characteristic such as multiple sclerosis but
this population also has subpopulations with shared characteristics such as age and gender, for
example. Unlike a population, a community is a group of interacting people who have shared
concerns and/or interests and they address these concerns, needs and interests as a cooperative
effort.
As emphasized in the "Integrated Process: Teaching and Learning", the registered nurses assess the
educational needs of their clients, including individual clients, families, groups, populations and
communities.
Examples of some educational needs for these clients are:

 Individual clients: The assessment of the individual client's learning needs in respect to their self care of
a surgical wound

The nurse would then plan an educational activity for the client that would include the psychomotor
aspects of wound care and/or the cognitive domain content relating to the signs and symptoms of a
wound infection which is a commonly occurring risk associated with poor wound healing.

 Families: The developmental changes and expected milestones for the children within the family unit

An appropriate educational session may include the normal stages of growth and development as
put forward by Erik Erikson and age appropriate activities in order to prevent the risk of
developmental delays.
 Groups: Patient and spouse educational needs related to a diabetic diet and the diabetic medications that
the patient will receive

Group education for patients and their spouses relating to diabetes, the diabetic diet and diabetic
medications can be given to prevent the short term and long term complications and risks associated
with diabetes.

 Populations: Education relating to the recommended immunizations for the infant would be presented
to a population of new parents to prevent the risk of highly preventable infectious diseases.

 Communities: The assessment of learning needs relating to the quality of education or the availability of
parks and other recreational facilities in their geographic area

The registered nurse may appear and give a presentation to a local government group about the
health related need for adequate recreation in the community.

Assessing the Client's Readiness to

Learn, Learning Preferences and
Barriers to Learning
The effectiveness of learning is based on a number of factors including the client's readiness to
learn, how well the educational activity meets and is consistent with their learning styles and learning
preferences, and how effectively the nurse has planned for and removed all possible barriers to
learning.
The motivation, or readiness, to learn is impacted by a number of things including the clients' locus
of control, their belief in self efficacy, and how the learning will help them solve an immediate
problem. As suggested in the section above on "Holistic Models of Health and Wellness", some of
these theories address a person's self efficacy and their locus of control as a predictor of positive
health behaviors.
Simply said, a locus of control is the location of where the power over the future lies. The two kinds
of locus of control are an internal locus of control and an external locus of control. An internal
locus of control motivates the client to learn because they believe that they have control over their
future and that they can solve their problems. In sharp contrast, a person with an external locus of
control has the deep belief that they have no control over their future and their problems. Their fate,
according to the person with an external locus of control, is a function of others and other things
including the sun, the moon and the stars. For these people, learning is futile because they have no
control. When the nurse is challenged with people who have an external locus of control, the nurse
can promote learning readiness and the motivation to learn by moving the external locus of control
into the client's internal locus of control. For example, the nurse may arrange for the client to meet
another person who is living a full life despite their diabetes or they may refer the client to a self-
help group in the community where the members share the same disease or disorder such as
alcoholism or drug abuse.
Similar to the locus of control, the person's sense of self efficacy also motivates or inhibits learning.
The Theory of Self Efficacy, credited to Albert Bandura, states that self efficacy "refers to beliefs in
one's capabilities to organize and execute the courses of action required to manage prospective
situations. More simply, self-efficacy is what an individual believes he or she can accomplish using
his or her skills under certain circumstances". People with high levels of self efficacy believe that
they can succeed; they have a "can do" attitude, and as such, they are more willing to learn in order
to solve their problems. The converse is also true. People with a low level of self efficacy have the
belief that they cannot succeed; they have an "I cannot do it" attitude.
Nurses can support higher levels of self efficacy by promoting their internal locus of control and
also providing opportunities for the person to succeed with. Nothing breeds success like success.
The positive reinforcement of success is also important.
Learning preferences and learning styles were fully discussed in the "Integrated Process: Teaching
and Learning". As a quick review, the learning styles that were previously discussed are:

 Visual Learners
 Verbal Learners
 Tactile Learners
 Active Learners
 Reflective Learners
 Sequential Learners
 Global Learners
 Sensing Learners

Whenever possible, the nurse should use a variety of methods that meet most learner preferences
when a group presentation is being given and they should employ the individual's learning
preference strategies when one-to-one individual teaching activities are given.
Barriers to learning were also fully discussed in the "Integrated Process: Teaching and Learning". As
a quick review, these barriers can include:

 English Language Barriers

 A Low Level of Literacy
 Poor Health Literacy
 The Presence of Stress and Pain
 Health Beliefs Including Spiritual and Cultural Beliefs
 Cognitive, Psychological and Emotional Challenges
 Physical and Functional Limitations
Planning and Participating in
Community Health Education
At times, registered nurses plan and/or participate in community health educational programs. Some
of these programs are formal and others can be informal; some may include only a few clients and
others may have large groups of participants.
When the registered nurse plans these activities, the nurse assesses the educational needs of the
community group and plans educational activities accordingly. The nurse's participation in these
activities can include an oral educational presentation to a group of community members, it can
include one-to-one guidance and education, and it can include teaching a small group of participants
about the correct method to check their blood pressure, for example. Regardless of the nurse's role
and responsibilities in these community health educational programs, the nurse must be thoroughly
prepared and professional at all times.

Educating the Client on Actions to

Promote and Maintain Health and
Prevent Disease
Similar to the nurse's participation in health screening and health promotion programs, nurses often
assist, instruct and coach clients with disease prevention activities such as an exercise routine and
other life style changes that can prevent disease and enhance the learners' level of health and
wellness.

Informing the Client of the

Appropriate Immunization Schedule
Imunizations can be mandatory and required and others can be voluntary. Childhood immunizations
against communicable diseases are most often required according to the CDC and state laws, and
adult immunizations against pneumonia may be recommended by the CDC but it remains voluntary.
Nurses must be aware of the recommendations and mandates for immunizations as based on the
age group that they are caring for. For example, the nurse must be aware of the CDC's schedule
childhood immunizations when they are working with pediatric patients and they must be aware of
the CDC's adult recommended vaccination when they are caring for adult patients at risk. For
example, the nurse caring for adult patients must be aware of recommended immunizations when
the patient is elderly and when they have a history of respiratory disease. Both the elderly patient and
the adult patient with respiratory diseases, for example, should get the pneumonia vaccine and an
annual influenza vaccine.
The CDC's recommended immunization schedule from the day of birth to 18 years of age can be
viewed at: http://www.aafp.org/patient-care/public-health/immunizations/schedules/child-
schedule.html
The CDC's recommended immunization schedule for adults can be viewed
at: http://www.aafp.org/patient-care/public-health/immunizations/schedules/adult-schedule.html
Old wives tales and myths revolve around immunizations and contraindications to them. These
knowledge deficits also have to be addressed with clients because they not only can adversely affect
the patient's health but they can also adversely affect public health and global health. One example
of misinformation relating to immunizations is the belief by many that vaccinations lead to autism
despite the fact that there is no scientific evidence to support this misinformation. Vaccinations do
NOT lead to autism. Some also believe that a child should not be vaccinated when they have a fever
or a respiratory infection. This also is also NOT true.
Despite these old wives tales and myths, the CDC does have some contraindications and
precautions to specific immunizations. For example, second doses of an immunization to the
hepatitis vaccine and the DTaP are contraindicated when the person has had anaphylaxis after the
first dose and these same vaccinations have precautions when the person has a severe acute illness
with or without a fever.

Integrating Complementary
Therapies into Health Promotion
Activities for the Well Client
The number and variety of nonpharmacological interventions including complementary, alternative
and integrative modalities, are numerous and varied.
Some examples of alternative and complementary therapies that can provide the patient with
comfort are:

 Meditation
 Prayer
 Magnets
 Chiropractic Services
 Homeopathy
 Reiki
 Music
 Acupuncture
 Acupressure
 Massage
 Deep breathing
 Progressive muscular relaxation
 Distraction
 Guided imagery
 Biofeedback
 Hypnosis and self hypnosis
 Mind Body Exercises and
 Herbs and Dietary Supplements

Providing Information About Health

Promotion and Maintenance
Recommendations
Health promotion and disease prevention can be facilitated when the nurse informs the client about
the routine and special things that should be done by the client or by the client in collaboration with
another health care professional like a dietitian, their primary care doctor and their dentist.
In addition to immunizations, as just discussed above, health promotion screening is a highly
important part of the recommendations.
Nurses instruct, prepare and assist clients for screening examinations that can identify diseases in its
earliest stages. The U.S. Preventive Services Task Force and other organizations provide screening
guidelines and schedules similar to those that the CDC does for immunizations. Many are based on
the patient's age because the different age groups are at higher risk for diseases and disorders than
other age groups.
Some of the U.S. Preventive Services Task Force's recommended screening tests are tests for:

 Diabetes
 Breast Cancer
 Cervical Cancer
 Prostate Cancer
 Colorectal Cancer
 Osteoporosis
 Scoliosis among school age children
 Hepatitis B and C
 Human Immunodeficiency Virus
 Hypertension
 Hyperlipidemia
 Glaucoma
 Hearing
 Obesity and
 Depression

Some of these recommendations about health promotion and maintenance, in addition to

immunizations and screenings, according to the age of the client and risk factors include:

 Routine annual physical examinations with the primary care physician

 Breast self examination
 Testicular self examination
 Exercise
 Good nutrition
 Weight management
 Dental and oral care
 Stress management and relaxation techniques
 The prevention of heart disease and strokes with simple interventions such as checking one's own blood
pressure
 Life style changes such as the cessation of alcohol, smoking, tobacco products and other substances
including illicit and illegal drugs
 Community resources that are available during times of crisis

Providing Follow-up to the Client

Following Participation in a Health
Promotion Program
The final phase of the nursing process, as well as the teaching process, is evaluation which was fully
detailed in the "Integrated Process: The Nursing Process" and the "Integrated Process: Teaching and
Learning", this evaluative follow up should be done, and documented, after each nursing
intervention including a health promotion activity.
For example, the registered nurse should evaluate how successful a weight management health
promotion activity was in terms of how the client has reduced their weight, they should follow up
on their clients to determine if the client has decreased or eliminated cigarette smoking after a
smoking cessation health promotion activity, and they can also follow up with a new mother to
determine whether or not the newborn's immunizations are up to date as recommended after their
participation in a health promotion activity relating to immunizations and the importance of them in
terms of their new infants health and disease prevention.
If and when this follow up evaluation indicates that the goal of the educational activity was not met,
the registered nurse must reassess the client and determine whether or not the original assessment
included any barriers to learning which were not addressed during the planning of the activity and
then, after a new teaching plan is devised and implemented, the registered nurse will then, again,
follow up with the client(s) to determine if the expected outcomes and goals related to health
promotion were met or not met.

Assisting the Client in Maintaining an

Optimum Level of Health
The definition of optimum, simply stated, is the best possible, which does not necessarily mean the
best or the highest level of health. An optimal level of health is the best possible level of health for
the client as based on their current health status including their limitations and/or the presence of an
acute or chronic illness, disorder or disease. For example, a client who has had a cerebrovascular
accident and paralysis may be at their optimal level of health despite the fact they have limitations
after this neurological insult.
Registered nurses facilitate the optimum level of health for all of their clients with the full knowledge
that many clients will never achieve the highest level of health.

Monitoring the Incorporation of

Healthy Behaviors into One's
Lifestyle by the Client
As stated just above in the section entitled "Providing Follow-up to the Client Following
Participation in a Health Promotion Program", the nurse should be able to determine whether or
not the client has incorporated healthy behaviors into their life style.
Data and information about the incorporation of these healthy behaviors can be collected during an
interview with the client in terms of the changes and improvements that they have made and by also
observing objective data relating to these changes such as a client's lipid levels, adherence to the
recommended screening schedule, making and keeping appointments with their primary care
physician and monitoring the client's weight, for example.
Evaluating the Client's Understanding
of Health Promotion Behaviors and
Activities
As stated near the beginning of this NCLEX-RN review with the "Integrated Process: The Nursing
Process" and the "Integrated Process: Teaching and Learning", the nurse evaluates these activities by
determining whether or not the client understands health promotion behaviors and activities by
measuring whether or not the client has met and achieved their pre-established goals and expected
outcomes in terms of the care that they receive and the education that they have been provided with.
For example, the nurse may ask the client about how they are controlling their weight or the nurse
may ask the client about the benefits that they are now experiencing as the result of their new
exercise regimen.

Implementing and Evaluating

Community-Based Client Care
Community based client care is based on the Nursing Process and this care is provided for all six
dimensions of health, as discussed below.

 The Biophysical Dimension: The nurse assesses, plans, implements and evaluates the biophysical
needs of the client in the community; and then, based on this assessment, the nurse identifies appropriate
resources in the community with which the client can get the needed services to meet their biophysical
needs, such as those relating to their risk factors, their current acute or chronic diseases and disorders.

 The Psychological and Emotional Dimension: The nurse facilitates the use of resources in the
community to support and care for the client as related to their acute and chronic emotional and
psychological health care needs

 The Behavioral Dimension: These community based client care resources can include strategies to
promote a good exercise regimen, adequate nutrition and the avoidance of harmful substances with a
peer support group such as Narcotics Anonymous, for example.

 The Socio-cultural Dimension: These community based client care resources and interventions can
include economic support, resources like Meals on Wheels, church based volunteers for transportation,
and others.
 The Physical Environment Dimension: The nurse facilitates the use of resources in the community to
support a clean environment without the presence of any environmental risks or hazards, such as toxic
chemicals in the environment and unsanitary drinking water. The nurse's role in this dimension can also
include political activism and community advocacy.

 The Health Systems Dimension: The clients' availability, accessibility, and affordability of health care
and health related resources and services that meet their health related needs are employed with this
dimension.

Health Screening: NCLEX-

RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of health screening in order to:

 Apply knowledge of pathophysiology to health screening

 Identify risk factors linked to ethnicity (e.g., hypertension, diabetes)
 Perform health history/health and risk assessments (e.g., lifestyle, family and genetic history)
 Perform targeted screening assessments (e.g., vision, hearing, nutrition)
 Utilize appropriate procedure and interviewing techniques when taking the client health history

Applying a Knowledge of
Pathophysiology to Health Screening
As somewhat discussed previously with the section entitled "Providing Information About Health
Promotion and Maintenance Recommendations", the U.S. Preventive Services Task Force and other
organizations provide screening guidelines and schedules similar to those that the CDC does for
immunizations. Many of these screening recommendations are based on known pathophysiology
such as the risk factors for some diseases and disorders as based on the patient's age, the client's
personal past medical history and the client's family medical history.
Some examples of recommended screening tests and their relationships with pathophysiology are:

 Chlamydial Infection Screening: Although routine screening for a chlamydia infection should begin
for sexually active women 25 years and younger, as based on the knowledge that this age group is at
 greatest risk for this infection, it is also recommended for clients with an impaired immune system and
among those clients with multiple sexual partners.

 Colorectal Cancer Screening: The U.S. Preventive Services Task Force recommends colorectal cancer
for clients of both genders beginning at 50 years of age, however, this screening may begin at a younger
age and more frequently than normally recommended when the client has a pathological risk factors
associated with this frequently occurring type of cancer.

 Depression Screening: Based on the psychological link between major life events and poor coping skills
with depression, for example, depression screening may be done as based on these client characteristics
and needs.

 Breast Cancer Screening: Although the U.S. Preventive Services Task Force recommends a screening
mammography every one to two years for women over 40 years of age, this governmental body also
recommends a screening mammography at an earlier age and more frequently among women with a
family or personal history of breast cancer and/or the presence of a pathological finding such as a
palpable mass or lump in the breast.

Nurses instruct, prepare and assist clients for screening examinations that can identify diseases,
infections and other disorders in their earliest stages. Nurse check and follow up on the results of
clients' screening tests such as a colonoscopy screening test, a stool for occult blood, a Papanicolaou
test, and a screening mammography. Results are also reported to the patient's doctor and entered
into the patient's medical record, according to the facility's specific policies and procedures.

Identifying Risk Factors Linked to

Ethnicity
The role of ethnicity in terms of risk factors is an area of ongoing research. Although there appears
that they are some correlations between some ethnicities and disease, these correlations may be just
that and not a causal relationship. For example, genetic patterns and abnormalities may place a
person at risk for some diseases but the presence of other factors, such as screening and maintaining
a healthy life style, can help to prevent it from every occurring. Despite the risk factor trends
discussed below, these risk factors can be used as a guideline for assessments; these risk factor
trends should not be considered a hard and fast rule for all members of an ethnic group.

 Sickle Cell Anemia: African and Latin Americans, Saudi Arabians, Southern Europeans and some
clients from some Mediterranean nations
 Hypertension: African Americans, Pacific Islanders , Native Americans, Alaskan natives, Hispanic and
Caribbean clients

 Thalassemia: Clients with a Mediterranean ethnicity

 Diabetes: African Americans, Caribbeans, Native Americans and clients from India, Pakistan and
Bangladesh

 Cancer: Caucasians and clients from Scotland and Ireland

 Tay Sachs Disease: Ashkenazi Jewish people

 Psychiatric Mental Health Disorders: African Americans and Native Americans

 Cystic Fibrosis: Clients with a European ethnicity

Performing A Health History, Health

and Risk Assessments
The purpose of the health history is to collect data and information about the patient's and family's
current and past states of health, their risks, their strengths, weaknesses, and their needs.
This data collected for the health history includes primary and secondary data, subjective and
objective data; and it can also consist of quantitative or qualitative data. As you will now learn, these
classifications of data and information are not always mutually exclusive.
An example of primary data is information that you get directly from the patient and secondary data
is information that you collect from sources other than the patient. An example of primary data is
information that the client tells you about their family history; and an example of secondary data
could be information that a spouse or other family member has told you and it can also include data
and information that is gathered by reviewing the medical records, such as progress notes, of the
client during last acute care hospitalization.
Objective data is empirical data that is measurable and observable with the senses such as feeling,
smelling, and seeing and also amenable to empirical validation. On the other hand, subjective data is
not empirical and it is not able to be objectively measured and observed despite the fact that the
registered nurse can make inferences from it and make conclusions about it when the nurse applies
their critical thinking and professional judgment skills.
Some objective data that can be collected during the client's health history include a skin rash that is
visible to the nurse and some subjective data that can be collected can include statements made by
the client in reference to their chief complaint. For example, the client may state "I have chest pain"
or "I am short of breath even when I am only walking". This subjective data is documented and
recorded using the exact words of the client within quotation marks. As you can see, these subjective
statements are not only subjective data; these statements are also primary data because it comes
directly from the client and not from other sources. These two patient statements about their chief
complaint are an example of how some of these classifications of data are not mutually exclusive.
Some data can be classified in more than one way.
Quantitative data is numerical data like laboratory results and the data that is collected with vital
signs measurements. Qualitative data is narrative information like the patient's description of their
pain in terms of its intensity.
Data and information that is collected for the health history is obtained with an interview process.
Two kinds of questions are used during this interview to collect data. These questions are open
ended and closed ended questions.
Closed ended questions are answered with a simple "no" or "yes" answer. An example of a closed
ended question is "Are you married?" another closed ended question could be "Have you ever been
pregnant before?" The answer will be yes or no to both of these questions. On the other hand, an
open ended question, which elicits more data and information than a closed ended question, requires
more than a simple yes or no.
Examples of open ended question are "Tell me about what you were doing when your pain started"
and
"Which members of your family have had diabetes?" As you can see from these examples, open
ended questions give us fuller and deeper data and information than closed ended questions.
A complete health history consists of:

 Essential demographic data

 The patient's chief complaint
 The patient's past medical history
 The family's current and past medical history
 The client's psychological history
 The client's social history
 Life style choices
 The client's spiritual/religious beliefs and practices
 The client's cultural background, beliefs and practices
 The patient's utilization of and access to health care services including health promotion activities

Some health histories are modified somewhat according to the specific developmental milestones
such as infancy and pregnancy.
Some demographic data and information that are collected during the health history are the patient's
name, address, contact information, health insurance information, age, marital status, and
occupation.
Nurses collect data and information about the patient's chief complaint by asking an open ended
question such as "Why did you come to the emergency room today?" The patient will likely respond
to this question with data and information about their chief complaint. Although the data relating to
the client's chief complaint is subjective data and it may not be completely accurate, it will give you
insight into the client and their concerns, including pain. For example, when the client responds to
your question about why they have presented into the emergency department with a statement like
"I am having a heart attack" or "I have indigestion", it does not necessarily mean that the client is
actually having indigestion or a heart attack; however it provides the nurse with insight into the
client's chief complaint.
The client's past medical history portion of the health history is comprised of data and information
about the client's immunizations, prior surgeries, significant injuries and trauma, childhood illnesses,
previous hospitalizations, a history of any acute or chronic illnesses, all allergies including those to
medications, foods and environmental allergens, current medications, supplements, and over the
counter preparations that they are currently taking as well as a history of adverse events and
reactions such as those associated with latex, medications and anesthesia.
The current medical history is a further exploration of the patient's chief complaint in terms of the
patient's symptoms, when the symptoms began, things that make the symptoms worse, things that
precipitate the symptoms, things that decrease the severity of the symptoms, the location of the
symptoms, how often the symptoms occur, and the characteristics of the chief complaint. For
example, if the client is complaining and/or concerned about wound drainage, the nurse would ask
the client about the amount, color and consistency of the drainage; similarly, when the client
expresses pain, the nurse would further explore this pain with the client in order to assess its
characteristics such as its intensity on a scale of 1 to 10 and other distinguishing characteristics such
as whether or not the pain is crushing, aching, or burning, for example.
During the past and current family history phase of the health history, the nurse collects data and
information about relatives' health histories including the presence of any commonly occurring
chronic and acute diseases which have a familial tendency to run in families. Some of these diseases
and disorders, in addition to genetic diseases and disorders, include diabetes, obesity, heart disease,
psychological disorders, hypertension, and cancer.
These family histories typically cover the history of the client's parents, siblings, children,
grandchildren and grandparents on the maternal and paternal side of the family including either their
current age or their age at the time of death.
At times charts like a genogram are used to compile the family history for a simpler and easier
analysis of this intergeneration data.
The client's psychological history is comprised of the client's past and present stressors, and the
client's coping mechanisms, mood, affect, thought processes, and any history of an acute or chronic
psychological disorder or abuse and neglect; and the social history consists of the client's economic
status, the family unit, their level of education, their interrelationships and their employment status.
Some of the cultural data that is collected include the person's ethnic and cultural customs, beliefs,
practices, and preferences. Religious and spiritual data includes customs, beliefs, practices and
preferences.
Data relating to the patient's utilization of and access to health care services including health
promotion activities are also collected. The patient's patterns of health care are determined in terms
of what type of health care resources they utilize and whether or not these resources and services are
accessible to them.

Performing Targeted Screening

Assessments
As briefly mentioned in the section entitled "Applying a Knowledge of Pathophysiology to Health
Screening", in addition to routine and recommended screenings, some screening is targeted at
populations that have the risk for a particular disorder or disease. Some targeted screenings may
screen for visual, auditory and nutritional deficits and disorders when the client is at risk and/or a
possible impairment has to be ruled out, for example.
Targeted assessments relating to nutritional status may be indicated when an infant or young child is
listless and not gaining weight according the established criteria; an adolescent may be target
screened for visual acuity when a high school teacher reports that the teen does not seem to be able
to read things on the blackboard; and a toddler may be target screened when the parent reports that
the child is not responding to their name.

Utilizing The Appropriate

Interviewing Techniques When
Taking the Client's Health History
In addition to the types of interview questions that are appropriately used to collect health history
data and information, there are other techniques and interventions, such as those below, that should
be employed when taking a client's health history.

 Establish an open, trusting, caring, compassionate, nonjudgmental client-nurse relationship.

 Establish and maintain an environment that is comfortable, private, and without any distractions or
districting noises or sounds.
 Identify and correct any barriers to communication. For example, if the client needs a professional
interpreter, get one.
 Use therapeutic communication techniques and strategies such as clarification, active listening,
summarizing and others and avoid all non-therapeutic communication such as intrusive probing, medical
jargon and false reassurances, all of which were more fully described in the "Integrated Process:
Communication and Documentation".
 Validate all of the collected data and information with the client.
 Document all the collected data in a complete and accurate manner.

High Risk Behaviors:

NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of high risk behaviors in order to:

 Assess client lifestyle practice risks that may impact health (e.g., excessive sun exposure, lack of regular
exercise)
 Assist the client to identify behaviors/risks that may impact health (e.g., fatigue, calcium deficiency)
 Provide information for prevention and treatment of high risk health behaviors (e.g., smoking cessation,
safe sexual practices, drug education)

This section of your NCLEX-RN review will be briefer than other sections of this review because
many of the concepts that will be covered here were already discussed in another context, so here,
we will remind you about these previously learned concepts and apply them to a new context
relating to risks and risk potential.

Assessing the Client's Lifestyle

Practice Risks That May Impact On
Health
As discussed before, some risks are preventable and correctable and others are not. For example,
genetics, age and gender are NOT modifiable risks, but the risks associated with life style choices are
modifiable, correctable and able to be eliminated when the person changes their behavior in
reference to these risky behaviors.
Registered nurses assess their clients in terms of their life style practices that are, or may, impact on
their health. Some of these life style choices that are assessed include:

 Excessive sun exposure

 The lack of regular exercise
 A poor diet
 Cigarette smoking and the use of other tobacco products
 Alcohol use
 Illicit drug use
 Unprotected sex
 Avocational and hobby choices such as rock climbing
 Inadequate sleep and rest

Assisting the Client to Identify High

Risk Behaviors
Registered nurses assist the client in the identification of high risk behaviors and then they teach and
counsel the client how to change and eliminate these risky behaviors. For example, the nurse plans
and provides education relating to safe sexual practices to avoid the transmission of sexually
transmitted diseases including HIV/AIDS; They may teach the client about the importance of
calcium and how a calcium deficit, for example, can lead to osteoporosis; they can also assist the
client in their understanding about the positive correlation between fatigue and illnesses and
accidents; and they may refer the client to a community based smoking cessation class or program.

Providing Information for the

Prevention and Treatment of High
Risk Health Behaviors
Nurses provide their clients with written and oral information about the treatment and prevention
of high risk health behaviors as based on their needs. They also refer clients to online and
community resources.
Again, they may provide the client with information and resources relating to smoking cessation,
safe sexual practices, drug education and other areas of concern such as health impact (e.g.,
excessive sun exposure, lack of regular exercise), assisting the client to identify behaviors/risks that
may impact health (e.g., fatigue, calcium deficiency) and providing information for prevention and
treatment of high risk health behaviors (e.g., smoking cessation, safe sexual practices, drug
education).
Lifestyle Choices: NCLEX-
RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of lifestyle choices in order to:

 Assess the client's lifestyle choices (e.g., home schooling, rural or urban living)
 Assess client's attitudes/perceptions on sexuality
 Assess client's need/desire for contraception
 Identify contraindications to chosen contraceptive method (e.g., smoking, compliance, medical
conditions)
 Identify expected outcomes for family planning methods
 Recognize client who is socially or environmentally isolated
 Educate the client on sexuality issues (e.g., family planning, safe sexual practices, menopause, impotence)
 Evaluate client alternative or homeopathic health care practices (e.g., massage therapy, acupuncture,
herbal medicine and minerals)

Assessing the Client's Lifestyle

Choices
In addition to all of the life style choices discussed above in the previous section, there are also
social and educational life style choices made by individuals and family units. For example, the
individual or family makes choices about whether or not they want to live in an urban, suburban or
rural geographic area, whether or not they will send the children to a public or private school in their
community or they will choose to home school their children.
All of these life style choices have their advantages and their disadvantages, and, when the nurse
assesses that a particular life style choices is adversely affecting the individual, family or group, the
nurse educates the client about some alternative life style choices that may be better for the client.
For example, home schooling may be advantageous for some clients because home schooling gives
the parent(s) the ability to control the flow of the education in order to facilitate a child's movement
beyond their grade level when they are an exceptional and gifted student, but it becomes
disadvantageous when the levels of stress within the home increase as the result of the time and
effort that goes into home schooling. At this time, the nurse will explore alternative options and
choices with the family in terms of this home schooling life style choice.
Similarly, a family may elect to live in a rural area rather than a suburban or urban area. Some of the
advantages of living in a rural area include the fact that there is no traffic congestion or air pollution;
however, there are also disadvantages to urban living. Some of these include social isolation and the
lengthy commute to shopping centers and grocery stores. This life style choice may negatively
impact on the rural living client when they are no longer able to drive to the stores and when the
children within the family unit are not developing in terms of their social relationships with their
peers and other children other than those in the family unit. Again, the nurse will explore alternative
options and choices with the family in terms of this rural living life style choice.

Assessing the Client's

Attitudes/Perceptions on Sexuality
Attitudes and perceptions relating to sexuality vary among individual patients and also among those
with a particular culture and/or religion that promote specific practices, beliefs and values relating to
sexuality and related issues such as same sexual unions, contraception, polygamy, premarital sex and
premarital cohabitation.
Regardless of the source of a patient's attitudes, perception and beliefs relating to sexuality, nurses
identify these things and incorporate them into the plan of care without any judgments and
regardless of the nurse's attitudes and perceptions about sexuality.

Assessing the Client's Need and Desire

for Contraception
When patients have the need and desire for contraception, the nurse must support their choices
regardless of the nurse's own preferences, practices and beliefs. At times, patients will express their
need for contraception in a very direct manner and, at other times, the client may be reluctant to
discuss sexuality and related issues like contraception. Nurse must, in these cases, establish trust with
the patient and facilitate the client's open expression of their thoughts without the fear of
judgements and without embarrassment.
When counseling and educating male and female clients about contraception, the nurse incorporates
information about the benefits of each type of contraception, the risks associated with each, the
costs, the convenience, barriers to compliance with the contraceptive regimen, and possible
contraindications associated with some types of contraception.
Methods of contraception include hormonal agents, physical barrier methods, a physical mechanical
means, personal techniques, and surgical procedures like combination oral contraceptives, a female
condom, coitus interruptus, and a male vasectomy, respectively.
Among the many contraceptive methods are:
 Abstinence
 Coitus interruptus, referred to as withdrawal
 Natural family planning based on the calendar method of calculating ovulation days
 The basal body temperature method to determine days of ovulation
 A male condom
 A female condom
 Injectable depomedroxyprogesterone acetate
 Combination oral contraceptives
 91-day combination oral contraceptives
 Combination transdermal patch contraceptive
 A diaphragm
 Cervical cap
 Spermicidal agent
 Contraceptive vaginal ring
 Intrauterine devices like Copper T380, Skyla, and Mirena - T-shaped, polyethylene IUD with a reservoir
 Female sterilization
 Vasectomy
 Emergency contraceptive pills
 Minipill emergency contraception method
 Progesterone agonist/antagonist pills

Identifying Contraindications to
Contraceptive Methods
Some forms of contraception are contraindicated as based on the client's life style choices, their level
of compliance and their medical conditions.
For example, women who have a history of deep vein thrombosis and who are cigarette smokers
cannot use oral contraceptives because they are at risk for clots and strokes when this method of
contraception is used.
The following contraceptive methods and their typical contraindications are shown below:

 Transdermal contraceptive patches: A history of cigarette smoking, deep vein thrombosis, cardiac
disease and cancers such as estrogen related cancers such as breast cancer

 Diaphragm: A client history of toxic shock syndrome and a latex sensitivity when a latex diaphragm is
used
 Combined oral contraceptives: A history of cigarette smoking, deep vein thrombosis, cardiac disease
and cancers such as estrogen related cancers such as breast cancer

 Emergency contraception: This is contraindicated among women with vaginal bleeding and also
among women who may have been pregnant well prior to taking this emergency contraception.

 Vaginal contraceptive rings: A history of cigarette smoking, deep vein thrombosis, cardiac disease and
cancers such as estrogen related cancers such as breast cancer

Poor rates of compliance and a desire for sexual spontaneity are reasons to discourage the use of
such contraceptive methods such as the use of a diaphragm, condom, and oral contraception that is
taken on a daily basis.

Identifying the Expected Outcomes

for Family Planning Methods
The expected outcomes for family planning methods include the lack of unwanted pregnancies,
having children when the time is right and also having a sexually satisfying relationship.
Some examples of expected outcomes relating to family planning methods include the client will:

 Demonstrate a knowledge of the various methods of contraception specific to their needs and personal
choices
 Not have an unplanned or unwanted pregnancy
 Have a satisfying sexual pattern without the fear of pregnancy
 Be able to plan pregnancy

Recognizing the Client Who is

Socially or Environmentally Isolated
According to the National North American Nursing Diagnosis Association International, isolation is
defined as "Aloneness experienced by the individual and perceived as imposed by others and a
negative or threatening state".
Some of the objective defining characteristics, signs and symptoms of social isolation are the lack of
social supports, sadness, depression, hostility, a flat affect, withdrawal, developmental delays and the
lack of communication with others.
Some of the client's subjective defining characteristics include the client's expressions of aloneness,
rejection, a lack of purpose in life, and an inability to meet the expectations of others.
Social isolation can occur as the result of many factors and forces such as geographic distance,
mental illness, a poor level of self-esteem, poor coping, a physical deformity, the lack of mobility,
alterations in the client's bodily image, and even a medical disease that affects the client or a family
member which leads the client's homebound status.
Registered nurses assess isolation as part of a complete client history, and depending on the etiology
of the isolation, the registered nurse will plan interventions, in collaboration with other health care
professionals, to overcome so that the client will be able to:

 Identify one's feelings in reference to isolation

 Enhance one's level of self-esteem and self worth
 Participate in social interactions that are consistent with one's strengths, weaknesses, and personal
preferences
 Refine their interactive and communication skills in order to prepare the client for increased levels of
social involvement and participation

Educating the Client on Sexuality

Issues
In addition to contraception and family planning, as just discussed, clients often also need education
relating to other sexuality issues like safe sexual practices, changes in sexuality secondary to
developmental milestones like pregnancy and menopause, impotency and sexual dysfunction.
Some of the safe sexual practices that registered nurses educate their clients about, in addition to
birth control to prevent unwanted pregnancies, are ways to prevent sexually transmitted diseases
including the correct use and application of a male and female condom, the dangers associated with
rectal sex, immunizations to protect against sexually transmitted diseases and the avoidance of
substances such as alcohol and drugs that can decrease the person's vigilance in terms of safe sexual
practices.
Sexuality during pregnancy is impacted by a number of different things including the couples'
feelings about the pregnant woman's changing body, maternal fatigue, morning sickness, breast
tenderness, back pain, unsubstantiated beliefs about the dangers of sexual intercourse during
pregnancy, and a decreased or increased libido during pregnancy. Some of the myths revolving
around sex during pregnancy that have to be debunked by the nurse include the unwarranted fear
that sexual intercourse will cause a miscarriage and that sex during pregnancy will harm the
developing fetus. The couple should be advised that, with a normal pregnancy, sexual intercourse is
permissible and encouraged.
Sex during and after menopause may also have some issues associated with it. In addition to the
physical and emotional changes associated with menopause such as vaginal dryness, mood changes
and normally occurring bodily changes, the client may experience a lack of sexual desire. Again, the
nurse should assess the dyad (the woman in combination with the sexual partner) to determine the
etiology of any sexual concerns and problems and then address them. For example, vaginal dryness
can be corrected with vaginal lubricants, low dose vaginal estrogen creams, and higher dose estrogen
hormonal therapy; and the lack of sexual arousal can be treated with a PDE inhibitor, similar to
Viagra, that increases blood flow to the female genitalia and sex therapy and counseling.
Sexual dysfunction and male impotency can result from a number of causes including some
medications diabetes, radiation therapy, terminal disease, some surgical procedures and trauma.
Depending on the etiology of the impotence or sexual dysfunction, the client can be educated about
some alternatives like medication, surgical interventions and alternatives to sexual intercourse.

Evaluating the Client on Alternative

or Homeopathic Health Care
Practices
According to the American Society of Homeopathy, "Homeopathy or Homeopathic Medicine, is
the practice of medicine that embraces a holistic, natural approach to the treatment of the sick.
Homeopathy is holistic because it treats the person as a whole, rather than focusing on a diseased
part or a labeled sickness. Homeopathy is natural because its remedies are produced according to the
U.S. FDA-recognized Homeopathic Pharmacopoeia of the United States from natural sources, whether
vegetable, mineral, or animal in nature."
According to the American Association of Naturopathic Physicians, "Naturopathic medicine is a
distinct primary health care profession, emphasizing prevention, treatment, and optimal health
through the use of therapeutic methods and substances that encourage individuals' inherent self-
healing process. The practice of naturopathic medicine includes modern and traditional, scientific,
and empirical methods."
Like other alternative treatments, some homeopathic approaches may not be substantiated as
effective in the professional literature. The U.S. Food and Drug Administration does research on
these homeopathic treatments and they confirm their safety; however, they do not confirm or
support their effectiveness. Additionally, some of these homeopathic treatments and interventions
can also have adverse side effects.
In addition to homeopathic and naturopathic medicine, chiropractic services are used by many
clients. Chiropractors employ spinal manipulation and deep massage, among other treatments,
particularly for the relief of chronic pain resulting from back and neck injuries. These treatments are
typically safe; however, clients who are adversely affected with a spinal cord compression and/or are
taking anticoagulant medications should avoid chiropractic care.
Other alternative and complementary interventions will be briefly discussed below:
 Magnets: At the current time, the National Institutes of Health (NIH) states that magnets are not
scientifically effective, however, many clients claim that they are effective in reducing pain, particularly
arthritic pain and the pain associated with fibromyalgia.Magnets are not considered a safe treatment for
clients with a pacemaker or insulin pump because these internally implanted devices can be adversely
affected by the magnetic force of the magnet.

 Massage: Massage is done by nurses, nursing assistants and other health care professionals such as a
licensed massage therapist and a physical therapist. Massage is effective for the relief of pain and stress
and it also promotes comfort and sleep.

 Meditation: Meditation, which can be spiritual for some clients, is effective for the relief of stress,
anxiety and pain, particularly when the person is able to move their thoughts and concentration inward
rather than focusing on the pain and other stressors. Meditation is often combined with imagery.

 Prayer: Scientific data now indicates that prayer is effective for the relief of stress, anxiety and pain, and
unlike meditation, prayer is often religious.

 Heat and Cold Applications: Heat and cold are effective for the relief of muscular pain. When heat or
cold applications are done, the heat or cold should remain in place for no longer than 10 minutes because
a longer duration will reverse the effects of the heat or cold that was applied.

 Deep Breathing: Deep breathing and taking deep cleansing breaths are effective for the relief of pain,
muscular tension and stress. As previously discussed, the techniques are shown to be effective with
tension, pain, anxiety and fatigue.

 Progressive Muscular Relaxation: Progressive muscular relaxation, with or without the guidance and
coaching of the nurse, relieves muscular tension, pain and stress. Progressive muscular relaxation
stimulates the parasympathetic nervous system and it decreases the autonomic nervous system
stimulation. This technique is often done in combination with meditation and other alternative therapies.

 Distraction: Distraction entails turning one's focus of attention to something other than the stressor that
the person is experiencing. For example, a person can read a book, watch their favorite television show
or consciously concentrate on something other than the person's pain or anxiety.

 Imagery: This alternative, complementary strategy is done when the person focuses and concentrates on
peaceful and relaxing sights such as a sunset on the beach or the running water of a stream rather than
the current here and now. This strategy is often used with meditation and other alternative,
complementary strategies.
 Biofeedback: Biofeedback helps some clients with their relief of pain and stress. This alternative,
complementary strategy entails the use of a monitoring device that measures things like the client's heart
rate and blood pressure. As the client is performing, progressive relaxation or meditation, for example,
the client is able to see their heart rate and blood pressure reduce.

 Hypnosis and Self Hypnosis: Self-hypnosis and hypnosis done with a hypnotist can provide the client
with relief from anxiety, stress, and pain. The client, which or without the guidance of a hypnotist, moves
into a deep state of relaxation.

 Transcutaneous Nerve Stimulation (TENS): Transcutaneous nerve stimulators transmit low electrical
impulses through the skin (transcutaneous) to the area that is painful. This nerve stimulation alters the
client's pain modulatory pathways, thus decreasing the pain.

 Acupuncture: This eastern medicine technique employs the insertion of thin, sterile needles under the
skin to reduce pain. Like acupressure, this Chinese alternative, complementary strategy has been used
since ancient times.

 Acupressure: Similar to acupuncture, this ancient Chinese therapy uses pressure instead of needles.

 Reiki: Reiki, another eastern medicine technique, is done when the therapist places their hands on or
near the person's body to promote the client's energy field and its own natural healing processes. Some
belief that reiki is effective for a wide variety of things such as the relief of pain, depression and
fibromyalgia.

 Music Therapy: Music therapists interact with clients for singing, movement to music, creating music
and listening to music. Not only is music therapy a form of leisure and diversion, many clients benefit
from it in terms of stress and pain reduction.

 Mind-Body Exercises: Yoga and tai chi are two examples of mind-body exercises. Mind-body exercise
techniques combine meditation, deep cleansing breathing, and bodily movement.

 Herbs, Minerals, and Supplements: Some herbs, minerals and supplements are scientifically deemed
as safe and effective and others are not scientifically effective and they can also lead to harm. For
example, some herbs may interact with and diminish the therapeutic effects of medications. Nurses,
therefore, must assess and determine what herbs, minerals and supplements the client is taking and then
determine whether or not these substances are interfering with the client's therapeutic regimen.
Self Care: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of self care in order to:

 Assess client ability to manage care in home environment and plan care accordingly (e.g., equipment,
community resources)
 Consider client self care needs before developing or revising care plan
 Assist primary caregivers working with the client to meet self-care goals

Dorothea Orem developed the Self Care Deficit Nursing Theory. According to this theory, there are
three nursing systems that are used according to the patient's abilities to perform their own self care.
RELATED: The Ultimate Guide to Self-Care for Nurses
The wholly compensatory nursing system consists of complete care to the patient by the nurse
because the patient is not able to perform any of their self care activities. Infants, neonates and
patients in a coma are patients that need the wholly compensatory nursing system.
The partly compensatory nursing system consists of the provision of some care when the patient can
perform some but not all of the needed self care activities. A patient who is acutely ill and able to
only bathe their genital area and a young child who can brush their teeth but not bathe properly are
examples of patients who need the care of the nurse using the partly compensatory nursing system.
The nurse cares for the needs that the patient cannot do on their own.
Dorothea Orem's third nursing system is the supportive educative, also referred to as the
developmental nursing system. The nurse only provides assistance and education to support the
patient's self care abilities and activities.
Activities of daily living (ADLs) are separated into the basic activities of daily living and the
instrumental activities of daily living.
Examples of basic activities of daily living include things like bathing, mobility, ambulation, toileting,
personal care and hygiene, grooming, dressing, and eating.
The instrumental activities of daily living are more advanced than the basic activities of daily living.
The instrumental activities of daily living include things like grocery shopping, housework, meal
preparation, the communication with others using something like a telephone, and having
transportation. The mnemonic to remember the instrumental activities of daily living is SHAFT
which represents shopping, housekeeping, accounting and managing money, food purchasing and
preparation, and the use of the telephone and needed transportation.
Assessing the Client's Ability to
Manage Care in the Home
Environment and Planning Care
Accordingly
The patient's ability to perform self care can be assessed by the registered nurse by direct
observation as the patient performs their self care activities, and, their ability to perform self care can
also be assessed by using the services of a physical therapist, an occupational therapist and by using a
standardized tool or test that measures the patient's abilities in terms of their basic and instrumental
activities of daily living.
Some of the standardized tests to determine the patient's abilities to perform the basic and the
instrumental activities are the Lawton Instrumental Activities of Daily Living Scale, the Bristol
Activities of Daily Living Scale, the Cleveland Scale of the Activities of Daily Living, and the Katz
Index of Independence in Activities of Daily Living.
The Lawton Instrumental Activities of Daily Living Scale is used to assess the client's ability to shop,
prepare meals, run errands, manage their medications, managing their finances and bills, doing
laundry and other activities like housekeeping and maintaining the household. Katz's Index of
Independence in Activities of Daily Living assesses and measures the client's ability to perform such
basic activities as bathing, feeding, toileting and level of continence or incontinence. The Bristol
Activities of Daily Living Scale contains 20 items which are rated from number 1 to number 5. Some
of the items on the Bristol Activities of Daily Living Scale include time orientation, eating, dressing,
food preparation, space orientation, oral care and using transportation. The Cleveland Scale of
Activities of Daily Living, developed by Patterson and Mack, is somewhat similar to the Bristol
Activities of Daily Living Scale in that both are used to measure the functional abilities of the person
with dementia in terms of their activities of daily living, but the Cleveland Scale is also used to assess
these abilities among those with physical impairments.
Clients' abilities to perform self care and the activities of daily living can be impacted by a number of
things including the patient's motivation, social support, physical and psychological status, their
neurological status, their musculoskeletal abilities and deficits, their cognitive abilities, and their level
of development.
The patient's neurological and musculoskeletal status can also be measured and determined using a
standardized tests and tools like the Barthel Index and the Klein Bell Scale and the Assessment of
Motor and Process Skills.
Range of motion, muscular strength, muscular tone, balance, coordination, gait, reflexes, and the
patient's motor function can also be determined by nurses, physical and occupational therapists.
All efforts are made to support and assist patients with their activities of daily living in order for
them to maintain their highest level of independence.
Nurses support clients with mobility problems, such as ambulation, transfers and positioning
oneself, with interventions such as assisting with and teaching transfer techniques, encouraging
range of motion exercises, and supporting the patient with any assistive devices they need for
ambulation such as crutches or a cane.
Nurses also support and help patients with their personal care and hygiene self care needs as
indicated. Some interventions can include setting the patient up and assisting them as needed and
also by providing the patient with assistive devices and equipment such as a long shoe horn and
adapted toothbrushes to facilitate the greatest possible level of independence. Bathing self care can
be supported with assistance and the provision of devices such as a shower chair, grab bars in the
bathroom, and long handled back brushes. Toileting can be supported with bowel and bladder
training and assistive devices like a raised toilet seat.
Lastly, nurses refer clients to community resources, as indicated.

Considering the Client's Self Care

Needs Before Developing or Revising
the Care Plan
The client's level of self care and their functional abilities in relationship to the activities of daily
living are an integral part of a complete assessment. When basic and/or instrumental self care needs
are identified, the nurse plans care, or revises the plan of care, as based on these needs. Some of
these needs may be simply met with some assistance by nurses or other health care providers and
many may have to be completely met by another, including a nurse or a caregiver in the home.

Assisting the Primary Caregivers

Working with the Client to Meet Self-
Care Goals
After the nurse assesses the client and their self care needs, the registered nurse will assist and
educate the client's primary caregivers so that they can assist the client with their self care activities
or provide the client with their necessary care.
Techniques of Physical
Assessment: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of techniques of physical assessment in order to:

 Apply knowledge of nursing procedures and psychomotor skills to techniques of physical assessment
 Choose physical assessment equipment and techniques appropriate for the client (e.g., age of client,
measurement of vital signs)
 Perform comprehensive health assessment

Applying the Knowledge of Nursing

Procedures and Psychomotor Skills to
the Techniques of Physical
Assessment
Baseline data that is collected after the health history and before the complete head to toe
examination includes a general survey of the client. The general survey includes the patient's weight,
height, body build, posture, gait, obvious signs of distress, level of hygiene and grooming, skin
integrity, vital signs, oxygen saturation, and the patient's actual age compared and contrasted to the
age that the patient actually appears like. For example, does the patient appear to be older than their
actual age? Does the patient appear to be younger than their actual age?
Nurses prepare and position clients for physical examinations. Nurses provide privacy, explain and
reinforce the procedures to the client and insure that the client is as comfortable as possible during
the physical examination.
As with all other aspects of nursing care, all data and information that is collected with the health
history and the physical examination are documented according to the particular facility's policies
and procedures. Some facilities use special forms for this data and information.
Registered nurses, advanced practice nurses such as nurse practitioners, and doctors typically do the
complete head to toe physical assessment and examination and document all of these details in the
patient's medical record; however, licensed practical nurses review these details and compare this
baseline physical examination data and information to the current patient status as they are
providing ongoing care. They also report and document all their significant physical examination
results to the supervising registered nurse and/or the patient's health care provider.
The four basic methods or techniques that are used for physical assessment are inspection,
palpation, percussion and auscultation. Inspection is a visual examination of the patient; palpation is
done when the person doing the assessment places their fingers on the body to determine things like
swelling, masses, and areas of pain. Palpation can include light and deep palpation. Deep palpation is
cautiously done after light palpation when necessary because the client's responses to deep palpation
may include their tightening of the abdominal muscles, for example, which will make the light
palpation less effective for this assessment, particularly if an area of pain or tenderness has been
palpated.
Percussion is tapping the patient's bodily surfaces and hearing the resulting sounds to determine the
presence of things like air and solid masses affecting internal organs. The sounds that are heard with
percussion are resonance which is a hollow sound, flatness which is typically hear over solid things
like bone, hyper resonance which is a loud booming sound, and tympany which is a drum type
sound.
Lastly, auscultation is listening to an area of the body using a stethoscope. For example, bowel
sounds, lung sounds and heart sounds are auscultated with a stethoscope. The sounds that are heard
with auscultation are classified and described according to their duration, pitch, intensity and quality.
For example, the duration of a breath sound can be described in terms of seconds of duration or it
can be described as having a longer duration of inspiration than expiration. The intensity can be
describe as loud or soft and quiet; the pitch is described as a high pitched sound to a dull and low
pitched sound.
A thorough physical assessment consists of the following:

 Vital signs
 The assessment of the thorax and lungs including lung sounds
 The assessment of the cardiovascular system including heart sounds
 The assessment of the head
 The assessment of the neck
 The integumentary system assessment
 The assessment of the peripheral vascular system
 The assessment of the breast and axillae
 The assessment of the abdomen
 The assessment of the musculoskeletal system
 The assessment of the neurological system including all the reflexes
 The assessment of the male and female genitalia and inguinal lymph nodes and
 The assessment of the rectum and anus
Choosing Physical Assessment
Equipment and Techniques
Appropriate for the Client
Although the routine and the equipment needed for a complete physical assessment are similar for
both the adult and the pediatric client, there are some differences. For example, the pediatric client
will require that the nurse use a neonatal, infant or pediatric blood pressure cuff, respectively, and
techniques such as the assessment of the vital signs which vary among the age groups.

Performing a Comprehensive Health

Assessment
A comprehensive health assessment includes:

 A complete medical history

 A general survey
 A complete physical assessment

The medical history and the general survey were previously detailed. In this section, you will review
the components of the complete physical assessment.

Vital Signs
The pulse, blood pressure, bodily temperature and respiratory rate are measured and documented.

Assessment of the Thorax

Inspection: The anterior and posterior thorax is inspected for size, symmetry, shape and for the
presence of any skin lesions and/or misalignment of the spine; chest movements are observed for
the normal movement of the diaphragm during respirations.
Palpation: The posterior thorax is assessed for respiratory excursion and fremitus.
Percussion: For normal and abnormal sounds over the thorax

Assessment of the Lungs

Auscultation: The assessment of normal and adventitious breath sounds.
Percussion: For normal and abnormal sounds. Normal breath sounds like vesicular breath sounds,
bronchial breath sounds, bronchovesicular breath sounds are auscultated and assessed in the same
manner that adventitious breath sounds like rales, wheezes, friction rubs, rhonchi, and abnormal
bronchophony, egophony, and whispered pectoriloquy are auscultated, assessed and documented.

Assessment of the Cardiovascular System

Inspection: Pulsations indicating the possibility of an aortic aneurysm
Auscultation: Listening to systolic heart sounds like the normal S1 heart sound and abnormal clicks,
the diastolic heart sounds of S2, S3, S4, diastolic knocks and mitral valve sounds, all of which are
abnormal with the exception of S2 which can be normal among clients less than 40 years of age.

Assessment of the Peripheral Vascular System

Inspection: The extremities are inspected for any abnormal color and any signs of poor perfusion
to the extremities, particularly the lower extremities. While the client is in a supine position, the
nurse also assesses the jugular veins for any bulging pulsations or distention.
Auscultation: The nurse assesses the carotids for the presence of any abnormal bruits.
Palpation: The peripheral veins are gently touched to determine the temperature of the skin, the
presence of any tenderness and swelling.
The peripheral vein pulses are also palpated bilaterally to determine regularity, number of beats,
volume and bilateral equality in terms of these characteristics.

Assessment of the Musculoskeletal System

Inspection: The major muscles of the body are inspected by the nurse to determine their size, and
strength, and the presence of any tremors, contractures, muscular weakness and/or paralysis. All
joints are assessed for their full range of motion. The areas around the bones and the major muscle
groups are also inspected to determine any areas of deformity, swelling and/or tenderness.
Palpation: The muscles are palpated to determine the presence of any spasticity, flaccidity, pain,
tenderness, and tremors.

Assessment of the Neurological System

Of all of the bodily systems that are assessed by the registered nurse, the neurological system is
perhaps the most extensive and complex.
Some of the terms and terminology relating to the neurological system and neurological system
disorders that you should be familiar with include those below.
Acalculia: Acalculia is the client's loss of ability to perform relatively simple mathematical
calculations like addition and subtraction.
Agnosia: Agnosia is defined as the loss of a client's ability to recognize and identify familiar objects
using the senses despite the fact that the senses are intact and normally functioning. The different
types of agnosia, as based on each of the five senses, are auditory agnosia, visual agnosia, gustatory
agnosia, olfactory agnosia, and tactile agnosia.
Agraphia: Agraphia, simply defined, is the Inability of the client to write. Agraphia is one of the
four hallmark symptoms of Gerstmann's syndrome. The other symptoms of Gerstmann's syndrome
are acalculia, finger agnosia, and an inability to differentiate between right and left.
Alexia: Alexia, which is a type of receptive aphasia, occurs when the client is unable to process,
understand and read the written word. This neurological disorder is also referred to as word
blindness and optical alexia.
Anhedonia: Anhedonia is a loss of interest in life experiences and life itself as the result of the
neurological deficit.
Anomia: Anomia is a lack of ability of the client to name a familiar object or item.
Anosagnosia: Anosagnosia is characterized with the client's inability to perceive and have an
awareness of an affected body part such as a paralyzed or missing leg. Anosagnosia is closely similar
to hemineglect and hemiattention
Anosdiaphoria: Anosdiaphoria is an indifference to one's illness and disability
Aphasia: Aphasia includes expressive aphasia and receptive aphasia. Expressive aphasia is
characterized by the client's inability to express their feelings and wishes to others with the spoken
word; and receptive aphasia is the client's inability to understand the spoken words of others.
Asomatognosi: Asomatognosia is the inability of the client to recognize one or more of their own
bodily parts.
Astereognosia: Astereognosia is the client's inability to differentiate among different textures with
their sense of touch and also the inability of the client to identify a familiar object, like a button, with
their tactile sensation.
Asymbolia: Asymbolia is the loss of the client's inability to respond to pain even though they have
the sensory function to feel and perceive the pain. Asymbolia is also referred to as pain dissociation
and pain asymbolia.
Autotopagnosia: Autotopagnosia is the inability of the client to locate their own body parts, the
body parts of another person, or the body parts of a medical model.
Balint's syndrome: Balint's syndrome includes ocular apraxia, optic ataxia and simultanagnosia,
which consist of impaired visual scanning, visusopatial ability and attention.
Boston Diagnostic Aphasia Examination: The Boston Diagnostic Aphasia Examination is a
standardized comprehensive assessment tool that assess and measures the client's degree of aphasia
in terms of the client's perceptions, processing of these perceptions and responses to these
perceptions while using problem solving and comprehension skills.
Broca's aphasia: Broca's aphasia entails the client's lack of ability to form and express words even
though the client's level of comprehension is intact.
Color agnosia: Color agnosia reflects the client's lack of ability to recognize and name different
colors.
Conduction aphasia: Conduction aphasia is the client's lack of ability to repeat phrases and/or
write brief dictated passages despite the fact that the client has intact speech abilities, comprehension
abilities, and the ability to name familiar objects.
Constructional apraxia: Constructional apraxia is the inability of the client to draw and copy
simple shapes on paper.
Dressing apraxia: Dressing apraxia occurs when the person is not able to appropriately dress
oneself because of some neurological dysfunction.
Dysgraphaesthesia: Dysgraphaesthesia impairs the client's ability to sense and identify a letter or
number that is tactily drawn on the client's palm.
Dysgraphia: Dysgraphia is similar to agraphia; however, dysgraphia is difficulty in terms of writing
and agraphia is the client's complete inability to write.
Environmental agnosia: Environmental agnosia is the lack of ability of the client to recognize
familiar places, like the US Supreme Court, by looking at a photograph of it.
Finger agnosia: Finger agnosia occurs when the person is not able to identify what finger is being
touched by the person performing the neurological assessment.
Geographic agnosia: Geographic agnosia is the lack of ability of the client to recognize familiar
counties, like Canada or Mexico, when viewing a world map.
Gerstmann's Syndrome: Gerstmann's Syndrome consists of dyscalculia or acalculia, finger agnosia,
one sided disorientation and dysgraphia or agraphia.
Hemiasomatognosia: Hemiasomatognosia is the neurological disorder that occurs when the client
does not perceive one half of their body and they act in a manner as if that half of the body does not
even exist.
Homonymous hemianopsia: Homonymous hemianopsia occurs when the person has neurological
blindness in the same visual field of both eyes bilaterally.
Ideomotor apraxia: Ideomotor apraxia is a neurological deficit that affects the client's ability to
pretend doing simple tasks of everyday living like brushing one's teeth.
Misoplegia: Misoplegia is a hatred and distaste for an adversely affected limb.
Motor alexia: Motor alexia occurs when the client is not able to comprehend the written word
despite the fact that the client can read it aloud.
Musical alexia: Musical alexia is a client's inability to recognize a familiar tune like "The National
Anthem" or "Silent Night".
Movement agnosia: Movement agnosia is a neurological deficit that is characterized with a client's
lack of ability to recognize an object's movement.
Ocular apraxia: Ocular apraxia is the neurological deficit that occurs when the person is no longer
able to rapidly move their eyes to observe a moving object.
Optic ataxia: Optic ataxia is characterized with the client's inability to reach for and grab an object.
Phonagnosia: Phonagnosia is the client's lack of ability to recognize familiar voices such as those of
a child or spouse.
Prosopagnosia: Prosopagnosia is a lack of ability to recognize familiar faces, like the face of a
spouse or child.
Simultanagnosia: Simultanagnosia is a neurological disorder that occurs when the client is not able
to perceive and process the perception of more than object at a time that is in the client's visual
field.
Somatophrenia: Somatophrenia occurs when the client denies the fact that their body parts are not
even theirs, but instead, these body parts belong to another.
The Two-Point Discrimination Test: This test measures and assesses the client's ability to
recognize more than one sensory perception, such as pain and touch, at one time.
Visual agnosia: Visual agnosia is the client's lack of ability to recognize and attach meaning to
familiar objects.
Wechsler Memory Scale IV: Wechsler Memory Scale IV: This measurement tool is a standardized
comprehensive method to assess verbal and visual memory, including immediate memory, delayed
memory, auditory memory, visual memory and visual working memory..
The neurological system is assessed with:

Inspection
Balance, gait, gross motor function, fine motor function and coordination, sensory functioning,
temperature sensory functioning, kinesthetic sensations and tactile sensory motor functioning, as
well as all of the cranial nerves are assessed.
Balance is assessed using the relatively simple Romberg test. The Romberg test is the test that law
enforcement use to test people for drunkenness. Gait can be assessed by simply observing the client
as they are walking or by coaching the person to walk heal to toe as the nurse observes the client for
their gait.
Gross motor functioning is bilaterally assessed by having the client contract their muscles; and fine
motor coordination and functioning is observed for both the upper and the lower extremities as the
client manipulates objects.
Sensory functioning is determined by touching various parts of the body, bilaterally, with a pen or
another blunt item while the client has their eyes closed. The client is prompted to report whether or
not they feel the blunt item as the nurse touches the area. Similarly, a hot and cold object is placed
on the skin on various parts of the body to assess temperature sensory functioning. The client will
then report whether they feel heat, cold or nothing at all.
Kinesthetic sensations are assessed to determine the client's ability to perceive and report their
bodily positioning without the help of visual cues.
Tactile sensory functioning is assessed for the client's ability to have stereognosis, extinction, one
point discrimination and two point discrimination. One and two point discrimination relates to the
client's ability to feel whether or not they have gotten one or two pin pricks that the nurse gently
applies. Stereognosis is the client's ability to feel and identify a familiar object while their eyes are
closed. For example, the nurse may place a pen, a button or a paper clip in the client's hand to
determine whether or not the client can identify the object without any visual cues. Extinction is the
client's ability to identify whether or not they are being touched by the person doing the assessment
with either one or two bilateral touches. For example, the nurse may touch both knees and then ask
the client if they felt one or two touches while the client has their eyes closed.

Reflexes
Reflexes are automatic muscular responses to a stimulus. When reflexes are absent or otherwise
altered, it can indicate a neurological deficit even earlier than other signs and symptoms of the
neurological deficit appear.
Reflexes can be described as primitive and long term. Primitive reflexes are normally present at the
time of birth and these reflexes normally disappear as the baby grows older; neurological deficits are
suspected when these primitive reflexes remain beyond the point in time when they are expected to
disappear. Reflexes, other than the primitive reflexes remain intact and active during the entire life
span, under normal conditions.
The primitive reflexes are the:

 Rooting reflex: The infant will turn their head in the direction of the side of the face that is being gently
stroked and, then, the infant will begin a sucking action.

 Sucking reflex: The sucking reflex is demonstrated when the infant performs sucking actions when
anything like a nipple or a finger tip comes in contact with the infant's mouth.

 Tonic neck reflex: The tonic neck reflex, also referred to as the fencing reflex, is demonstrated when
the infant's body takes on the appearance of a fencer's position when the infant's head is turned to the
right or to the left.

 Galant or truncal incurvation reflex: This reflex is seen when the infant moves their hips toward the
direction of gentle tap on their back near the spine when the infant is in the prone position.

 Grasp reflex: Newborns grasp fingers and other objects that are placed in their palm. They will also
tighten their grasp as the finger or another object is slowly removed.
 Moro or startle reflex: This reflex normally occurs with a sudden noise such as clapping of hands. The
infant will jerk when the sound is heard. The infant's head and legs will extend and the arms will move
upward.

 Step reflex: Newborns will perform walking like movements when the soles of the infant's feet touch a
surface such as a floor. The reflex disappears in about six to eight weeks of age.

 Parachute reflex: The baby extends their arms forward as if to break a fall when a person holds the
infant and rotates their body rapidly.

The other reflexes are the:

 Pupil reflex: Pupil reflexes include pupil dilation and pupil accommodation. The "PERLA" mnemonic
for pupil reflexes stands for Pupils Equally Reactive to Light and Accommodation which is a normal
finding. The pupil reflexes for their reactions to light are assessed by using a flash light in a darkened
room. Pupils will normally dilate as the light is withdrawn and they will normally constrict when the light
is brought close to the pupils. The pupils are assessed not only for their reaction to light, they are also
assessed in terms of their accommodation. Normally, the pupils will dilate when an object is moved away
from the eye and they will constrict as the object is being brought closer to the eye.

 Plantar reflex: The plantar reflex is elicited when the person performing this assessment strokes the
bottom of the foot and the client's toes curl down. The Babinski sign occurs when the foot goes into
dorsiflexion and the great toe curls up; this sign is an abnormal response to this stimulation and it can
indicate the presence of deep vein thrombosis.

 Biceps reflex: This reflex is assessed by placing the thumb on the biceps tendon while the person is in a
sitting position and then tapping the thumb with the Taylor hammer.

 Triceps reflex: This reflex is elicited by tapping the triceps tendon with the Taylor hammer above the
elbow while the client has their hands on their legs when the client is in a sitting position.

 Patellar tendon reflex: This reflex, often referred to as the knee jerk reflex, is elicited by tapping the
patellar area with the Taylor hammer.

 Calcaneal reflex: This reflex, often referred to as the Achilles reflex, is assessed with tapping on
the calcaneal reflex on the ankle with the Taylor hammer.

 Gag reflex: The gag reflex is elicited when the back of the mouth and the posterior tongue is stimulated
with a tongue blade.
 Sneeze reflex: Sneezing occurs to rid the nasal passages of irritants.

 Blinking reflex: This reflex is elicited when the eyes are touched or they are stimulated a sudden bright
light or an irritant.

 Cough reflex: Coughing occurs when the airway is stimulated.

 Yawn reflex: Yawning occurs as the result of the body's increased need for oxygen.

All reflexes should be done bilaterally in rapid succession so that all differences between the right
and the left reflexes can be determined and assessed. For example, when the person who is
performing these assessments should assess the biceps reflex of the right arm and then immediately
assess the biceps reflex of the left arm so that any differences or inequalities can be assessed and
documented.
Lastly, the nurse assesses the twelve cranial nerves. Some of these twelve cranial nerves are only
sensory or motor nerves, and others have both sensory and motor functions.
The twelve cranial nerves can be easily remembered using this mnemonic: On Old Olympus Tippy
Top, A Fat Armed German View A Hop, as below:

1. Olfactory
2. Optic
3. Oculomotor
4. Trochlear
5. Trigeminal
6. Abducens
7. Facial
8. Acoustic
9. Glossopharyngeal
10. Vagus
11. Spinal accessory
12. Hypoglossal

Each of these twelve cranial nerves, their function and their classification as sensory, motor or both
sensory and motor are shown in the table below.

Name of the Cranial Classification Function

Nerve
Number

1. Olfactory Nerve Sensory This nerve transmits the sense of smell from the olfactory
nose.

2. Optic Nerve Sensory This cranial nerve transmits the sense of vision from the re

3. Oculomotor Nerve Motor The oculomotor nerve controls eye movements, the sphin
the ciliary body muscles.

4. Trochlear Nerve Motor This cranial nerve innervates eye ball movement and the su
muscle of the eyes.

5. Trigeminal Nerve Motor and The trigeminal nerve controls the muscles that are used fo
Sensory

6. Abducens Nerve Motor This cranial nerve innervates and controls the abduction o
lateral rectus muscle.

7. Facial Nerve Motor and The facial nerve controls facial movements, some salivary
Sensory sensations from the anterior part of the tongue.

8. Acoustic Nerve Sensory This cranial nerve senses and transmits the sense of hearin
gravity and maintains balance and equilibrium.
1.

9. Glossopharyngeal Motor and This nerve gives us the sense of taste from the posterior to
Nerve Sensory innervates the parotid glands.

10. Vagus Nerve Motor and The vagus nerve controls laryngeal and pharyngeal muscle
Sensory cranial nerve can lead to swallowing disorders.

It also controls the parasympathetic nervous system to the

abdominal organs and it controls the resonance of the voic
11. Spinal Accessory Nerve Motor The spinal accessory nerve, in interaction with the vagus n
trapezius and sternocleidomastoid muscles.

12. Hypoglossal Nerve Motor The hypoglossal cranial nerve controls the tongue, speech

Assessment of the Head (The Face and Skull, Eyes,

Ears, Nose, Mouth, Throat, Neck, Trachea and
Thyroid)
Face and Skull
Inspection: The size, shape and symmetry of the face and skull, facial movements and symmetry
are inspected.
Palpation: The presence of any lumps, soreness, and masses are assessed.

Eyes
Inspection: Pupils in reference to their bilateral equality, reaction to light and accommodation, the
presence of any discharge, irritation, redness and abnormal eye movement are assessed.
Standardized Testing: The Snellen Chart for visual acuity

Ears
Inspection: The auricles are inspected in terms of color, symmetry, elasticity and any tenderness or
lesions; the external ear canal is inspected for color and the presence of any drainage and ear wax;
and the tympanic membrane in terms of color, integrity and the lack of any bulging is also assessed.
Standardized Testing: The Rinne test and the Weber test for the assessment of hearing can be
done using a tuning fork.

Nose
Inspection: The color, size, shape, symmetry, and any presence of drainage, flaring, tenderness, and
masses are assessed; the nasal passages are assessed visually using an otoscope of the correct size for
an infant, child and adult; the sense of smell is also assessed.
Palpation: The sinuses are assessed for any signs of tenderness and infection.

Mouth
Inspection: The lips are visualized for their symmetry and color; the buccal membranes, the gums
and the tongue are inspected for color, any lesions and their level of dryness or moisture; the tongue
is inspected for symmetry of movement; teeth are inspected for the presence of any loose or missing
teeth; the uvula is assessed for movement, position, size and color; the salivary glands are examined
for signs of inflammation or redness; the oropharynx, tonsils, hard and soft palates are also
inspected for color, redness and any lesions. Lastly, the gag reflex is assessed. The mouth and the
throat are assessed using a tongue blade and a light source.

Neck
Inspection: The neck and head movement is visualized; the thyroid gland is inspected for any
swelling and also for normal movement during swallowing.
Palpation: The neck, the lymph nodes, and trachea are palpated for size and any irregularities
Auscultation: The thyroid gland is assessed for bruits

Assessment of the Integumentary System (Hair,

Skin and Nails)
Inspection: The color of the skin, the quality, distribution and condition of the bodily hair, the size,
the location, color and type of any skin lesions are assessed and documented, the color of the nail
beds, and the angle of curvature where the nails meet the skin of the fingers are also inspected.
Palpation: The temperature, level of moisture, turgor and the presence or absence of any edema or
swelling on the skin are assessed.

Assessment of the Breast and Axillae

Inspection: The breasts are visualized to assess the size, shape, symmetry, color and the presence of
any dimpling, lesions, swelling, edema, visible lumps and nipple retractions. The nipples are also
assessed for the presence of any discharge, which is not normal for either gender except when the
female is pregnant or lactating.
Palpation: The nurse performs a complete breast examination using the finger tips to determine if
any lumps are felt. The lymph nodes in the axillary areas are also palpated for any enlargement or
swelling.

Assessment of the Abdomen

Inspection: The abdomen is visualized to determine its size, contour, symmetry and the presence of
any lesions. As previously mentioned, the abdomen is also inspected to determine the presence of
any pulsations that could indicate the possible presence of an abdominal aortic aneurysm.
Auscultation: The bowel sounds are assessed in all four quadrants which are the upper right
quadrant, the upper left quadrant, the lower right quadrant and the lower left quadrant.
Palpation: Light palpation, which is then followed with deep palpation, is done to assess for the
presence of any masses, tenderness, pain, guarding and rebound tenderness.
Assessment of the Male and Female Genitalia
Inspection: The skin and the pubic hair are inspected. The labia, clitoris, vagina and urethral
opening are inspected among female clients. The penis, urethral meatus, and the scrotum are
inspected among male clients.
Palpation: The inguinal lymph nodes are palpated for the presence of any tenderness, swelling or
enlargements. A testicular examination is done for male clients.

Assessment of the Rectum and Anus

Inspection: The rectum, anus and the surrounding area is examined for any abnormalities.
Palpation: With a gloved hand, the rectal sphincter is palpated for muscular tone, and the presence
of any blood, tenderness, pain or nodules.