NCLEX RN Study Guide Module 3 | The promotion of health and maintenance

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In this section of the NCLEX RN study guide, we cover a range of subjects including immunization, family education, pain assessment, and more.

Immunizations

The concept of immunization is having the body build up its defenses against a certain disease.

This defense comes in the form of antibodies which are introduced to the body via a vaccine.

In turn, these antibodies will stop the patient from getting the disease or if they do, a milder form of it.

By introducing some of the antigens of the disease through vaccination, the body will begin to produce the antigens needed to fight it.

The goal is herd immunity.

This is when the vast majority of the population is immune to a specific disease.

Vaccine types

There are numerous types of vaccines available today including:

Conjugated vaccines
Killed virus vaccines
Live virus vaccines
Recombinant vaccines
Toxoid vaccines

You can read up on these in more detail in your coursework.

Now let’s look at a few specific vaccines that a nurse will come across during their daily activities.

Hepatitis A vaccine

Two doses of this vaccine are given to young infants as protection against Hepatitis A, which is a contagious virus that results in liver disease.

These are given at:

12 months
18 months (or a six month period following the first dose)

It can be given to older children as well.

Hepatitis B vaccine

Three monovalent HepB injections are necessary to ensure immunity against Hepatitis B which is passed on through body fluids and blood.

This is a necessity as Hep B can also cause liver problems and even cancer.

The vaccine is administered:

At birth
1-2 months thereafter
At 24 weeks

Those who haven’t been vaccinated and are older can receive two doses (adolescents). The second should be administered within four to six months of the first.

Rotavirus vaccine

This vaccine is to prevent Rotavirus, which causes severe diarrhea.

It’s administered in three doses in infants:

2 months
4 months
6 months

Inactivated Poliovirus vaccine

This protects against poliomyelitis, a viral infection that before the vaccine was introduced in 1955, resulted in 20,000 cases per year.

IPV (injectable polio vaccine) is administered in four doses:

2 months
4 months
6-18 months
4-6 years as a booster

MMR vaccine

This protects against measles, mumps, and rubella and is given in two doses:

12-15 months
4-6 years

There are a few other vaccines that you can work through which will appear in your coursework:

Varicella
DTaP and Tdap
HPV
PCV-7
PPV
Meningococcal
Hib

Summary of the schedule for infant immunization

Here’s a handy schedule that breaks down how the time frame of when these vaccines should be administered to infants:

Hep B: Administered at birth, 1-2 months, and then last dosage at 6-18 months
Diphtheria/pertussis/tetanus: Administered at 2, 4, and 6 months with the last dosage at 15-18 months
Hib: Administered at 2, 5, and 12 months but the last dosage can be later
Poliovirus vaccine: Administered at 2, 4, and between 6-18 months
MMR vaccine: Administered between the ages of 12-18 months
Varicella: Administered at 12 months

When giving immunizations, the immunization status of the child receiving them should be evaluated.

It’s a requirement in states across America that children are immunized before they go to a licensed daycare center or school.

When it comes to vaccines themselves, they must always be stored correctly.

Administering the vaccines should be carried out as per guidelines while consent should be obtained from the parent/guardian of the child.

Vaccine side effects

There are a number of side effects that can result from the administration of these vaccines.

These include:

Fever
General irritability
Loss of appetite
At the site of the injection – swelling, and redness

Should any of these last for more than two days, the parents should contact a healthcare provider.

Education theory

In this section, we cover various forms of education theory.

Theory of social learning: Bandura model

This model proposes that learning is the result of observing, organizing, and rehearsing modeled behavior.

For modeling to occur, four conditions are required:

Attention: A range of variables (physical, social, and environmental) play a role in modeling and the degree of attention paid to it
Retention: In order to retain models, people create mental images, make use of symbolic coding, organize their thoughts, and mental or physical rehearsing. The degree they carry this out determines their capacity to remember models
Reproduction: Depending on their physical and mental capabilities, this is their ability to reproduce a model they’ve been exposed to
Motivation: People feel motivated when they have previous performance, rewards, or vicariously modeled others’ behavior

Transtheoretical model for change

The model conveys concepts that can be applied to both family members and patients in the process of educating them.

The stages of this model involve the following:

1st stage – precontemplation: The patient is unaware that their health behavior needs to change
2nd stage – contemplation: Realization that change is necessary. Patients do so after recognizing that the current behavior is unhealthy. Additionally, they have considered the consequences of carrying on as they are currently
3rd stage – preparation: In this stage, the patient visualizes the change in the future and formulates a plan to achieve it
4th stage – action: The patient begins to note positive changes in their health behavior after making the required changes
5th stage – maintenance: The patient is able to maintain changes over time by using strategies to avoid returning to their former behavior
6th stage – termination: The patient will not resume their previous unhealthy behavior because they’ve incorporated change behavior into the way they function daily

Force field analysis: Kurt Lewin

This is the brainchild of social psychologist Kurt Lewin and attempts to analyze the driving and restraining forces when it comes to change.

Leaders, incentives, and competition are all examples of driving forces that encourage and motivate change.

Poor attitudes, hostility, inadequate equipment, and a lack of funds are all examples of restraining forces that resist change.

A force field analysis diagram is used to talk about the variables related to a proposed process change.

This is done by:

A middle column should be used to write down the proposed change
Brainstorm driving and restraining forces
Provide scores to these forces
Evaluate the proposed change’s value
Reduce or eliminate restraining forces by developing a relevant plan

Model of change theory: Kurt Lewin

This can be used to help in the decision-making process that patients will need to go through to make changes.

It proposes a three-part procedure:

Unfreezing: In this phase, the patient recognizes the need for change and removes all barriers to it
Actual change: In accordance with expected outcomes and goals, the patient put the change into effect
Refreezing: This is sustaining the change so it eventually becomes a habit

Education principles

Adult learning principles

When planning strategies for teaching patients, parents, families, and staff, the following principles of adult learning should be considered.

Goal-orientated and practical: Always keep the goal in focus while using problem-solving exercises and collaborative discussion. Overviews and examples should be provided too
Self-directed: Participating actively and seeking input. To achieve goals, different options are allowed. Responsibilities given
Knowledgeable: Respect must be shown to the education and life experiences of participants, while they should be validated and feedback asked of them. New material should be related to things they are familiar with
Relevancy-oriented: How the information will be applied must be explained while objectives must be defined clearly
Motivated: Whenever possible, award staff certificates of professional advancement or continuing education

Styles of learning

Not everyone learns in the same way.

A range of teaching methods may be required that tie in with all three learning styles should be used.

These learning styles are:

Visual: Here, picture guides, written directions, charts, photos, diagrams, or demonstrations are necessary for people who learn easiest by reading and seeing
Auditory: Here, the best learning is achieved through talking and listening. So procedures should be explained, with the learner repeating them following a demonstration. Question and answer sessions are also necessary, while if audio lessons are available, they can be provided too
Kinesthetic: Here, a more hands-on approach that includes practicing and handling is the way to go. Allowing people to demonstrate what they have learned is an excellent idea, while they should be encouraged to handle supplies, for example.

Teaching approaches

Let’s quickly touch on the types of teaching approaches that can be used.

They include:

Educational workshops
Lectures
Discussions
One-on-one discussions
Learning online

What often dictates the approach is the number of people that need to be taught.

Factors that affect readiness to learn

These can include:

Physical factors
Overall experience
Emotional and mental status
Overall knowledge and education

Teaching older patients

In some situations, a nurse will have to teach something to an elderly patient.

Before doing so, it’s best to determine their overall level of functioning.

The following can be influenced by illness and aging:

They struggle to retain information due to short-term memory loss
There could be an overall decrease in their ability to concentrate
They could be a delay in their reaction times
They may have problems hearing or seeing properly

While teaching, the family should be present so they can hear what needs to be learned as well.

The pace at which the teaching takes place is ultimately governed by the pace at which the patient understands.

Teaching those with learning disabilities

The starting point here is to focus on the actual learning disability the patient has:

For those with visual problems, the preferred method of teaching is verbal with lots of repetition. If the session can be recorded and played back to the patient at a later point, it should be
For those with auditory perception problems, the preferred method of teaching is visual. Role-playing, demonstrations, and trying out the procedure are all excellent methods to use when teaching. Computers are particularly useful here
For those with expressive problems, the patient needs time, first to process what has been taught and then to ask questions. Utilizing the senses, carrying out demonstrations, and using hand gestures are all useful tools when teaching this group

Teaching disabled patients

Here’s some ideas for teaching patients that have disabilities

The key is to empower patients so they have a sense of control and coping. This is easily achievable by providing them with the information they need but never overwhelming them
Your plan of action should take into account the patient’s learning readiness and priorities
Keep track of what they’ve learned using a skills checklist
Always provide feedback, support, and praise
Lastly, patients should be provided with resources that can be used after they are discharged

Theories: Human development and growth

Human development issues

Below are some human development issues that can be analyzed by theory.

Universally vs context specificity: Universality says that people will develop the same way regardless of their culture while context specificity says that culture influences development
Assumptions regarding human nature: There are three doctrines regarding this – original sin (children need to be taught good because, by nature, they are bad), innate purity (children are, by nature, good), and tabula rasa (children are neither good nor bad when born but must be taught wrong from right)
Behavioral consistency: No matter what the situation is, depending on who is interacting with them, children will behave in the same way
Nature vs nurture: In the first, development is linked to genetic influences while the second says that development is influenced by social influences
Continuity vs discontinuity: Continuity says development proceeds steadily and changes have cumulative effects. Discontinuity says that later development is not influenced by the effects of early development while progress thereof is in a stair fashion
Passivity vs activity: With passivity, outside forces can have an impact on development. Activity is more of how a child reacts to these outside forces as well as how their development is influenced by them
Critical v sensitive period: The critical period is when a child will be able to pick up new behaviors and skills. The sensitive period is more flexible in terms of the time frame and here, the child is susceptible to learning new skills, regardless of the normal learning curve.

Erik Erikson: Developmental tasks

Let’s look at the developmental tasks model as put forward by Erik Erikson

Trust vs mistrust: This takes place from birth to 1-year old. Here, should the needs of the child be met, they will develop faith, trust, and optimism but if not, mistrust develops
Autonomy vs shame/doubt: This takes place from 1 to 3 years old. Here, a child is looking for choice while becoming independent, handling tasks around basic self-care. Doubt and shame can result if this new independence (which develops willpower and self-control) is not fostered
Initiative vs guilt: This takes place from 3 to 6 years old. Without outside influence, a child will begin self-directed play on their own. Based on the support they receive while showing initiative, this could result in direction/purpose or guilt
Industry vs inferiority: This takes place from 6 to 12 years old. Pride and self-worth develop when a child feels competent and capable with a mindset that looks to do what’s right. Peer social interaction is important where feelings of inferiority or pride can result when achievements are compared
Identity vs role confusion: This occurs between the ages of 12-18. Youth are expected to take on certain behaviors as role models and are pressured by their ethnicity, culture, family, peers, parents, teachers, and religion. Ultimately, they have to find their own identity
Intimacy vs isolation: This takes place between the ages of 40 and 65. Here, roles related to work, community, and family are defined while adults carry out a number of tasks as they look to find their own niche as well as interests in the world of work
Integrity vs despair: The final stage is for the age group 65 and older. Here overall life experience is put into perspective while the aging process is accepted

Other theories of human development include Freud’s Stages of Psychosexual Development, Piaget’s Theory of Cognitive Development, and Maslow’s Hierarchy of Needs.

These will be all covered in your coursework, so make sure you go through them there.

Disease prevention and the promotion of health

Health promotion

Healthy People 2030 is a program driven by the U.S. Public Health Service.

It has five main goals:

Achieving a healthy, thriving life for all without preventable diseases, disabilities, injuries, or premature deaths
Improving health literacy, eliminating health disparities, and achieving health equality
Promoting health through the creation of conducive environments
Assuring good health throughout the various life stages
Designing policies that improve health and well-being in collaboration with leadership and key stakeholders

In all this program includes 62 areas with 355 total objectives.

It is divided into 5 sections:

Health conditions
Health behaviors
Populations
Systems and settings
Social determinants of health

When we talk about the promotion of health, four areas are key:

Lifestyle and choices
Good nutrition
Stress
Physical fitness

Self-management of health

Health maintenance, disease prevention, and health promotion are all parts of health self-management.

When we talk of disease prevention, it can be broken down into three parts:

Primary prevention: Here, prior to the onset of disease, measures are put in place to prevent it
Secondary prevention: This involves screening, detecting, and treating diseases at an early stage in order to prevent their progression or occurrence of other complications
Tertiary prevention: In this case, measures are taken to prevent comorbid conditions or complications from developing

Health screening

Let’s break this down into various age groups:

First, we have young adults screening (20 to 39 years).

Full body physical: Every 5 years
Blood pressure: Every 3 to 5 years if normal, more often if not
Cholesterol: Ever 5 years
Dental check-up: Annually
Thyroid: Every 3 years
Depression assessment: At every visit
Breast exam: Every 3 years although self-examination should be every month
Testicular self-assessment: Every month
Pap smear: Every 3 years
Vaccination for influenza: Every year
Td immunization: Every 10 years

Then there are adult screenings (40 years and older).

Full body physical: Every year
Blood pressure: Every year
ECG: Annually if know cardiac risks exist
Breast exam: Annually with a mammogram every second year
Colorectal cancer screening: Every year
Prostate-specific antigen screening: Upon request

Illness prevention: Pediatrics

There’s quite a bit to cover in this section, so let’s jump straight in.

Disease prevention and the part that risk analysis plays in it

Risk analysis plays a critical role in not only disease prevention but health promotion too.

That’s because, based on the age and sex of the child, it helps identify their risk of current as well as future diseases, especially based on family history.

Risk analysis areas could include the following:

Nutrition
Exercise
Cardiovascular
Diabetes
Hypertension
Cancer
Osteoporosis
Vision
Behavior
Lifestyle

Risk factors then help identify the chance of developing the disease in terms of a low, medium, or high risk.

Risk factors: Neonates linked with maternal disease

An infant’s overall risk factors can be increased by several maternal factors:

Diabetes mellitus: This can lead to hypoglycemia, macrosomia, birth defects, and even stillbirth
HIV/Hepatitis B: These infectious diseases can be passed on to the infant. This can take place during pregnancy as well as during delivery

Fetal drug exposure and the implications thereof

Some prescribed drugs, but mostly those taken illicitly can have a massive effect on an unborn child.

These can include:

Low birth weights
Poor sucking and dysphagia lead to them failing to thrive
Risk of HIV, hepatitis, and other congenital infectious diseases
Risk of SIDS
Withdrawal symptoms
Problems associated with development and cognition that vary with age

Fetal alcohol syndrome and the implications thereof

Children born with FAS often have a range of birth defects as a result of their mothers drinking while pregnant.

These include:

Facial abnormalities
Neurological defects
Growth retardation
Behavior problems

Fetal nicotine/carbon monoxide exposure and the implications thereof

A fetus whose mother smokes during pregnancy is exposed to not only nicotine but carbon monoxide too.

This can lead to:

Growth retardation
Vasoconstriction as a result of nicotine which, along with oxygen transport interference caused by carbon monoxide, can result in fetal hypoxia. This could also lead to a chance of spontaneous abortion, premature birth as well as low weight at birth
High risk of SIDS and perinatal death
Learning disorders and cognitive deficiency
Cancer risk increasing

Poverty-related risk factors

Sadly, when children are raised in poverty there are numerous risk factors that could affect them.

These include:

No or incomplete immunizations
Infections that occur frequently
Not enough sleep
Deficiencies in nutrition
Problems with dental care
Depression
Injuries

Overall wellness evaluation

A completed assessment of a child is carried out during a wellness evaluation.

Part of this is securing the information to draw up a health profile which includes the following information:

Measurements such as height and weight but also the circumference of their head
Vital signs
Temperature
Nutrition profile
Level of activity/mobility
Screen test results (if carried out) and why the test took place
Activities around health promotion and the prevention of disease

Injury prevention

Young nurse in uniform prevention from an Injury

Environmental assessment

A number of aspects should be considered in this regard including:

Environmental health history
Pediatric patient’s health and the environmental influences that play a role in it
Environmental aspects to consider when the child patient returns home
General aspects of environmental safety

Social situations and recommendations for parents/children

These include;

Dealing with strangers
Dealing with violence
Dealing with bullying
Overall automobile safety

Sports and recreation recommendations

These include:

Risks regarding concussion
Using helmets in sport where necessary

Youth Risk Behavior Surveillance System (YRBSS)

Six different facets of health-risk behaviors are monitored in this program which is conducted through the CDC:

Violence and injury-causing behavior
The use of tobacco
The use of alcohol
The use of drugs
High-risk sexual behavior
Unhealthy eating
Lack of physical activity

Trends are assessed from data secured from states participating in the program as well as from local surveys that are carried out and include youngsters from grades 9-12.

STD prevention

There are five strategies that the CDC has implemented to prevent STD transmissions:

Education
Identification of infected persons, both symptomatic and asymptomatic who haven’t gone for treatment
Diagnosing and treating those infected with STDs
Infection prevention in partners
Pre-exposure vaccination

The 5-P approach is also used to assess risk by looking at the sexual history of a patient:

Partners
Pregnancy prevention
Protection
Practices
Past history when it comes to STDs

Prevention methods when it comes to the transmission of sexually transmitted diseases:

Abstinence or if not, reduction in sex partners
Pre-exposure vaccination
Condoms (both male and female)
Spermicides
Other non-barrier contraceptive methods

Injury prevention mentions for toddlers, preschoolers, school going children as well as adolescents are covered adequately in your coursework, so we won’t go into great detail here.

Just make sure you are aware of the various measures depending on the age group specified.

Family education

Fit Family Doing Home Online Stretching Yoga Fitness Exercise

In this section, we focus mainly on education for expectant and new mothers who are having/have had their first baby.

New mothers and their educational needs

These needs are never the same from mother to mother.

They will vary based on a range of factors including background, education, experience, expectations, and their age.

It’s not easy to assess what these needs might be, especially during a short hospital stay and it’s for this reason why, on the whole, education covers a variety of topics.

Let’s cover what this education should entail.

Care of the umbilical cord

The following should be taught to mothers when it comes to umbilical cord care:

It should be protected from moisture. This is easily achieved by, instead of covering it with the diaper, fold the diaper under the cord
Wash the cord with mild soap and water, rinse and then dry if it becomes soiled
Irritation may result if the cord stump is covered by clothing
Until the cord falls off – usually between 10 and 14 days – the infant should only receive sponge baths
Any signs of infection should be dealt with immediately

Infants and safe positioning

When sleeping, an infant should always be placed on their back as this cuts the risk of SIDS which is more prevalent if they sleep on their stomach.

When positioned on their back, the position of their head should be changed from one side to the other. This stops flattening from occurring
Once a day, the infant should be turned to allow them to lie on their abdomen. This should only take place on a firm surface as a way to stop positional molding and strengthen both neck and head muscles
Rather than leaving an infant in their carrier, they should be held
Along with additional support, babies can be positioned on their sides but this should alternate after a period of time

Fecal and urinary elimination

A baby will usually pass a very black and tarry-looking stool during the first 24 hours.

This will change as the baby takes on formula or milk from their mother.

By day 5, babies are producing around five stools a day.

Any abnormalities should be reported and this could include stools that are watery, contain various colors, or are very hard.

Mild soap and water should be used to clean the skin when cleaning up following a stool while the skin should also always be checked for any signs of irritation.

By day 6 following their birth, a baby will have around 6-8 wet diapers a day.

Diapers should always be checked often, especially after feeding.

The skin should always be cleaned with mild soap and water or baby wipes.

Diaper rash is also something to consider.

To prevent this:

Diapers should be changed when necessary
The skin should always be cleaned
The skin should be exposed to air from time to time. This can be done for a few minutes when diapers are changed
Barrier cream can be used to help prevent diaper rash

Gagging/choking in infants

Infants are extremely susceptible to choking or gagging.

New mothers should be educated regarding the following in this regard:

Babies should never be fed using a propped up bottle
All small, hazardous items should be kept out of their reach
When babies are being fed, they should be regularly burped. Usually this is after they have taken in about 2 to 3 ounces of milk. To burp the infant, place them on the shoulder, and rub or pat their back gently. A burg cloth should be put under their head. Should they not burp, the position can be changed, for example, to the opposite shoulder.
While feeding, they should have their head elevated and kept in an upright position
The nipple of the bottle should never run freely, but instead, it should provide a drip feed to the baby when drinking

Should an infant choke, they should be placed face down on a forearm while their body is tilted downwards.

The heel of the hand should then be used to thump them in the middle of their back and repeated until the item is dislodged.

CPR should be started should the child stop breathing while a call is placed to emergency services.

Neonatal CPR is covered in your coursework and you should know the procedures to carry it out.

Infant bathing

Once the umbilical cord has fallen off, an infant may receive a full bath in an infant tub.

Here’s what new mothers should be educated about in this regard:

The environmental temperature in the bathroom should be warm
The infant tub only needs to be filled to around 3 inches of water
The water temperature should be warm and never hot and should be checked before the infant is placed in the tub
The baby should be held to provide support. This is achieved by supporting the neck and hand by placing one arm under the upper back
The free hand is then used to pour water over the infant. It is also used to wash their body and hair
When drying the infant, care must be taken to ensure that this is done in a thorough manner
No lotions or creams should be used on the infant

Car seats

During transit, infants should be placed in a car seat.

There are a few rules to follow in this regard:

The seat should always be in the back of the car, but never positioned near any airbags and with the seat facing towards the rear
The child should always be secured in the seat using the seat buckle
To stop the head of the child from falling forward, the seat should be put in a reclined position
Padding can be placed on the insides of the seat to stop the infant from falling to the side

Health history

A nursing health history includes several elements.

These are:

Biological element: This covers details regarding the patient
Main complaint: The reason why they are at the medical facility
Present illness history: Details about the current health problem
Prior medical history: Details about past problems, surgeries, etc
Family history
Systems review: To obtain a full subjective symptom report from the patient, this is necessary
Lifestyle details: Including sleep, habits, diet, etc
Social history: This includes ethnicity, family history, economic status, level of education, and more
Psychological status
Normal access to healthcare

The process of obtaining a health history from a patient is something that you should also know for the exam.

It’s adequately covered in your coursework, so there’s no need to go into any great detail here.

The same can be said for techniques used for physical examination.

These include palpitation, percussion and auscultation.

Assessment of pain

Pain pathophysiology

Pain can be broken down into different types.

Nociceptive pain

The term refers to pain that is caused by stimulation of neuroreceptors as a direct result of tissue injury or damage with pain severity determined by the degree of injury.

There are two subclassifications of this pain:

Visceral pain: Related to the layer of viscera that protects the organs and can be related to genitourinary, cardiovascular, respiratory, or gastrointestinal systems
Somatic pain: Related to bone joints, muscle tissue, and cutaneous tissue

Opioids are used to treat both these pain types.

Neuropathic pain

When the nervous system is injured in some way, neuropathic pain is the result.

An example of this is the spinal cord being compressed by cancer cells.

Nerves damaged by chemotherapy are also an example of pain that’s described as neuropathic.

Opioids and NSAIDs are used to treat this type of pain while nerve blockers can help as well.

Pain: Adverse systemic effects

Many systems in the body can be significantly affected by pain.

Cardiovascular: As a response to pain, tachycardia and increased blood pressure will occur. This results in systemic vascular resistance as well as raised cardiac output. A decrease in cardiac output, however, may be seen in people with cardiovascular disease
Respiratory: Pulmonary function may be compromised, while the ability to clear secretions or cough is impaired.
Gastrointestinal: Pain can result in a decrease in motility but an increase in sphincter tone and because of that, Ileus may result as well as urinary retention. The gastric lining can be irritated by higher gastric acid secretion resulting in ulcerations. Other occurrences can include constipation, nausea, or vomiting. Aspiration pneumonia can result because of reflux while on some occasions, abdominal distention can occur
Endocrine: Pain will affect hormone levels in different ways. For example, there will be a rise in catabolic hormones and a decrease in anabolic hormones. Other effects include carbohydrate intolerance, an increase in lipolysis, and retention of sodium which can result in fluid retention
Hematologic: Pain can result in increased blood coagulation as well as platelets becoming more adhesive. Fibrinolysis generally reduces.
Immune: The risk of infection increases due to the likelihood of leukocytosis and lymphopenia
Emotional: Emotionally, pain can have an effect in various ways, including causing depression, anger, anxiety, lack of appetite, and struggling to sleep

Tools for pain assessment

One of the tools in this regard is the ABCDE method:

Asking about the level of the pain and then systematically assessing it
Believing the reported degree of pain the patient is experiencing is genuine
Choosing, depending on the circumstances and the patient, the correct pain control method
Delivering appropriate pain interventions
Empowering both patients and their support structures to help control treatment

There are five elements that can be used when it comes to pain assessment:

Quality: Here, ask the patients to describe the type of pain they are experiencing. For example, is it a burning pain, or a stabbing pain
Intensity: Have the patient describe on a scale of 1-10 how intense the pain is
Location: Have the patient explain exactly where the pain is located
Duration: Have the patient explain how long the pain lasts. Is it continuous, or does it come and go
Aggravating/alleviating factors: Is there anything that offers relief from the pain, or aggravates it?

While we won’t cover them here in great detail – you will find them in your coursework – you should understand the various tools for assessing pain in nonverbal or cognitively impaired patients as well as neonates/infants and pediatric patients.

Optimal pain assessment barriers

Let’s look at some barriers that can affect pain assessment.

These include:

Professional
System
Patient
Family
Society

There are other influential factors that can affect pain perception including:

Attitude/overall emotional state
Cultural expectations
Pain threshold

Psychological factors play a role in pain experience as well which include:

Fear
Depression

Medical record: Pain documentation

When it comes to pain documentation, medical records should include the following:

The time the pain started, where it is located, the nature of the pain, and the overall degree the patient is experiencing using a pain assessment instrument
All interventions should be documented (both non-pharmacological and pharmacological)
Based on the expected response time, assess the first response to the medication
Based on the expected duration of the medication, assess and document the duration of the response
Any adverse effects should be noted

Assessment: Cardiovascular

As part of a patient’s cardiovascular assessment, they should be asked about cardiovascular diseases within their family.

Questions should focus on:

Chest pains
Edema
Dyspnea
Vertigo
Fatigue
Changes in consciousness (like fainting or passing out)
Leg cramps
Weight gain
Other pain

Should a patient report experiencing chest pains, they should be asked about the intensity, timing, and location.

Also, anything that aggravates that pain, or brings relief should be documented too.

As part of their physical assessment, their vital signs should be taken, their heart and lungs listened to and a range of other tasks carried out which is covered in your coursework.

Any risk behaviors pertaining to the patient, such as smoking, obesity, inactivity, stress, and others should be brought to their attention and they should be helped to modify their actions.

Electrolyte levels and lipid profiles should be established by taking blood from the patient.

Heart sound assessments

Different cardiac disorders can be diagnosed by listening to the sounds a patient’s heart makes.

Areas to listen to include the following:

Aortic area
Pulmonary area
Tricuspid area
Apical area
Erb’s point

The closing of the valves of the heart are represented by normal heart sounds.

The closure of the mitral and tricuspid valve will present as the first heart sound (S1) or “lub”
The closure of the aortic and pulmonic valves will present as the second heart sound (S2) or “dub”

Other heart sounds include:

Gallop rhythms
Opening snap
Ejection click
Friction rub
Murmur

Electrocardiogram

This is a display graphically of the heart’s electrical activity using intervals, complexes, and waveforms.

It comprises of:

P wave
QRS complex
T wave
U wave

Your coursework will have explanations of what each of these refers to as well as how and where the ECG leads should be placed on a patient.

Cardiac monitoring

On an electrocardiogram, various intervals and segments are evaluated as part of cardiac monitoring.

This includes:

QT interval: The time it takes for the ventricles to depolarize and repolarize
ST segment: During this period, the ventricles are in a plateau phase, depolarized, then recovering and repolarizing

Your coursework will contain the equations you should know to work out mean arterial pressure (MAP) as well as overall cardiac output and stroke volume.

Also remember that for proper cardiac function, oxygen saturation levels must be monitored with an understanding of what it means if these levels are increased or decreased.

Jugular venous pressure assessment

This is the use of the neck vein of the patient to assess pressure in the right heart as well as cardiac output.

This isn’t that accurate if the pulse is above 100, however.

To carry out this assessment, the following steps should be taken:

The head of the patient should be elevated between 45 and 90 degrees and turned to the right
Use a light, positioned at an angle to shed light on shadows and veins
Use a ruler to measure the height of the jugular vein pulsation above the sternal joint (a normal height is less or equal to 4 cm above the sternal angle)

If it’s higher than this, this shows raised pressure in the right atrium which indicates right heart failure, pericarditis, and/or tricuspid stenosis.

Assessment: Respiratory system

a nurse observing the Respiratory x-ray of a patient

Getting information about a patient’s respiratory history is the place to start with this but obviously, a patient should first be stabilized if they are suffering respiratory distress.

Finding the correct information includes asking questions about:

Risk factors such as smoking, if they have inhaled toxins, smoke exposure, any allergies they may have and if they have had lung problems in the past
The symptoms of their current respiratory problems should be established as well as their duration

Physical assessments should include checking vital signs, pulse oximetry, posture check, clubbing on nails, a skin assessment, looking for anxiety signs, edema as well as listening to the lungs.

Arterial blood gasses, electrolytes, and CBC can be determined by drawing blood from the patient while, depending on their symptoms, a sputum culture can also be taken.

Physiological airway clearance

Various aspects of respiratory failure lead to normal airway clearance.

Mucus, which is found in airways where it presents as a thin layer, helps to prevent foreign objects from reaching the lower airways by trapping them.

Usually, these foreign objects will either be swallowed and digested or coughed up.

Ventilation/perfusion ratio

A balance needs to be maintained between the respiratory and cardiac systems to ensure homeostasis.

The fact that the ventilation and perfusion of the lungs are balanced is indicated by the ventilation/perfusion ratio with a figure of 0.8 showing a normal ratio.

If it is higher, this shows that ventilation is too high and perfusion is too low usually which could be a result of hyperventilation, hypotension, or a pulmonary embolism.

Also, this is a clear indication that when compared to perfusion, there is more ventilation.

If it is lower, this shows that ventilation is too low and perfusion is too high which could result from atelectasis, lung disease, or pneumonia.

This is a clear indication that when compared to ventilation, there is more perfusion.

Breathing sounds: Normal and abnormal

When it comes to normal breathing sounds, there are three types:

Sounds that are low and soft and heard above peripheral lung space are known as vesicular breath sounds
Moderate pitch breath sounds, known as bronchovesicular breath sounds, occur in the upper lung fields
Higher pitch breath sounds, known as tracheal breath sounds, occurs in the trachea
An excessive amount of secretions within the airway, heard on both inspiration and expiration, will cause coarse crackles
When peripheral airways open up again, this will result in fine crackles heard in the late expiratory phase

Pulmonary assessment: Diagnostic procedures and tools

This will depend on the injury/disease of the specific patient, but includes:

A full on physical exam
Electrocardiogram
Chest x-ray
Computerized tomography
Oximetry
Atrial blood gasses
Electrocardiogram
Echocardiogram

Capnography involving an end-tidal C02 detector

An end-tidal CO2 detector is used to measure the concentration of that gas in expired air during a capnogram using a capnometry.

This will provide the following information:

PaCO2 levels
Bronchial obstruction type and degree
Ventilation air leaks
In response to the demand for a new CO2 absorber, rebreathing will be precipitated
Cardiac arrest
Reduced metabolism
Hypothermia

Arterial blood gasses

The effectiveness of ventilation, oxygenation, and acid-base status as well as determining oxygen flow rates are the information provided by ABGs.

Normal values for these readings include:

Acidity/Alkalinity (pH): 7.35 to 7.45
Carbon dioxide partial pressure (PaCO2): 35-45 mmHg
Oxygen partial pressure (PaO2): ≥ 80 mmHg
Concentration of bicarbonate (HCO3): 22-26 mEg/L
Oxygen saturation (SAO2): ≥ 95%

Assessments: Endocrine, immunologic and oncologic

a nurse assessing the Endocrine x-ray of a patient

Endocrine disorders

Any changes related to growth, sexual development and metabolism may indicate an endocrine disorder.

Symptoms vary, but there are some generalized ones to look out for.

They include fatigue, the capacity to carry out ADLs, intolerance to heat and cold, sexual libido changes, sexual functioning problems, fluctuation in weight, problems sleeping, loss of memory, concentration problems, and mood swings.

Things to note while conducting a physical exam include:

Assessments for edema
A patient having a “buffalo hump” or “moon face”
Exophthalmos
Hair loss
Facial hair in female patients
Think of extremities with an enlarged trunk

Cancer

Irregular cell growth and reproduction are what cause cancer in humans and we know that this is a life-threatening disease.

While there is no cure for cancer, if left untreated, this cell growth can result in a tumor while cancer cells can extend through the body via their ability to metastasize.

Should the immune system not be able to deal with cancer cells and destroy them, they will reproduce, eventually forming a tumor.

Cancer development: Stages

When it comes to cancer development, there are three stages:

Initiation: The cancer causing substance enters the body, reacts with, and causes DNA to mutate. Examples of this would be exposure to radiation or cigarette smoke
Promotion: With this stage, the body is exposed to the substance that causes cancer over and over again, causing the likelihood of cancer cell reproduction
Progression: When healthy normal cells are outnumbered by malignant cancer cells, this stage occurs. From this point on, the DNA damage done by the cancer cells means that it’s as cancer cells that normal cells will continue to replicate as

Immunology

The field of medicine that deals with infection and the ability of the body to fight it off is known as immunology.

In addition, it studies treatments and ways to improve the immune system’s ability to prevent cancer cell formation.

Tumor grading and staging

Tumor severity assessment is carried out in two ways – tumor staging or tumor grading.

The size and spread of the tumor is a measurement known as tumor staging which uses three parameters, commonly called TMN.

T = tumor size (for the original local tumor)
N = Show if there is the regional lymph nodes are involved
M = indicates a distance metastatic spread has occurred

Tumor grading deals with the extent of differentiation of the tumor and is a histopathologic evaluation thereof.

This looks at the surrounding tissue compared to the tumor and the differences between the two.

Well differentiated tumors are those rated Grade 1 and when compared to normal tissue, there is not much difference in appearance.

Tumors graded 3 and 4 will see a significant difference between the tumor and the normal tissue.

These are said to be poorly differentiated and compared to a grade 1 tumor are significantly more aggressive in nature.

Other important terms

Let’s look at other important terms that you should know from this section, if you are unsure what they are exactly, you can find them in your coursework:

Invasion
Angiogenesis
Metastasis
Tumor heterogeneity
Hyperplasia
Metaplasia
Dysplasia
Anaplasia

Assessment: Neurological system

When assessing the neurological system, there’s a few things to focus on:

The health history of the patient focusing on if they have abused drugs, suffered from alcoholism, what medication they are taking, if there is any history of neurological problems in their family, if they’ve suffered any trauma or fallen lately
The patient should also be asked about any neurological symptoms that may have presented themselves lately

Consciousness and cognition are also assessed, while abnormalities in posture and movements should be checked too along with noting both facial movement and expression.

Assessment of the cranial nerve should be carried out while the patient should be checked for their ability to carry out ADLs along with checking overall strength, coordination, and balance.

There are a few other tests that can be carried out, but your coursework will cover them in detail.

Functional status assessment

Acts that form part of daily living activities as well as meeting basic needs fall under functional abilities.

They also include those acts that are essential to daily living.

To determine where a patient stands in terms of a functional assessment, the patient should be observed carrying out both ADLs and IDLs and the following should be recorded:

How much independence they exhibit
If they need to rest before completing the activity
Overall nerve function
Overall strength displayed and muscle function
Their motion
Their coordination
Their cardiac and respiratory status
To complete the activity, did they require any assistance

Functional Independence Measure (FIM) is the tool most commonly used to record a functional assessment.

NIHSS

Careful attention to direction is necessary when administering the National Institute of Health Stroke Scale (NIHSS).

The person should never be coached at any time and the person administering the test should never repeat any requests that they make.

There are 11 sections to the scale, with scores ranging from 0 (normal) to 4.

The scale sections are as follows:

Level of consciousness
Best gaze
Visual
Facial palsy
Motor, arm
Motor, leg
Limb ataxia
Sensory
Best language
Dysarthria
Distinction and inattention

You can find out how the scale is applied to each of these sections in your coursework.

It will contain information on the Glasgow Coma Scale as well, which you should look through for the exam.

The scale has three main sections:

Eye opening
Verbal
Motor

Each of these sections has four responses to choose from when assessing a patient.

Other brain injury complications are often a result of intracranial pressure (ICP) and here, the Monroe-Kellie hypothesis comes into play.

Be sure to understand how this can be used as well.

Cerebral blood flow, CPP and MAP

Cerebral perfusion pressure (CPP) can be worked out using an equation.

This takes mean arterial pressure (MAP) and subtracts ICP, which we mentioned above.

Normal CPP: 60-100 mmHg
< 60 mmHG sees focal or global ischemia as a result of hypoperfusion
< 30 mmHG sees marked Hypoperfusion
> 100 mmHG sees cerebral edema and hypertensive encephalopathy occurring

Assessment: Gastrointestinal system

a nurse assessing Gastrointestinal system of a patient

When assessing this, the following should be asked of the patient:

Their personal and family history of problems related to the gastrointestinal system
What risk factors do they partake in? Do they smoke, drink, use drugs or have a poor diet?
Focus on specific gastrointestinal problems they may have, for example, diarrhea, abdominal pain, GI discomfort, and others
Ask if they have had fluctuations in their weight
Ask about their pattern of defecation and how it relates to their GI problems

The following should be examined during a physical assessment:

Oral mucosa
Teeth
Tongue
Pharynx
Thyroid gland
Parathyroid gland
Skin: color, moisture, turgor, nodules or lesion present, or bruises
Abdominal shape
Bowel sounds
Anal region: For dimples, tears, inflammation, fissures

Gallbladder/Pancreatic disease assessment

Should the patient display symptoms of gallbladder disease, they would include the following:

Following eating fatty foods, the patient would experience epigastric discomfort
Distention of the abdomen
Pain in the right upper quadrant
Nausea
Vomiting

Pancreatitis symptoms can include:

Severe pain in the abdominal region
Back pain
Vomiting extensively
Dyspnea

Because pancreatitis is linked to alcoholism as well as gallstones, the patient’s history related to alcohol should be established and gallstones checked for.

Liver disease assessment

Abnormalities in the liver will only show in lab tests when this organ is 70% damaged or more.

Early disease, however, can be identified by assessing various risk factors which include:

Alcoholism
Drug abuse
Risky sexual history
Infection exposure
Environmental toxin exposure
Visiting countries with insufficient/poor sanitary facilities

Liver diseases symptoms should be discussed with patients to assess if they have experienced any which include:

Abdominal pain
Itching
Fatigue
Weight gain
Anorexia
Black stools
Blood in stools
Fever
Problems sleeping
Menstruation problems in women
Lack of sexual libido

Physical assessment will include:

Checking vital signs
Checking the skin: for scratches, pallor, jaundice, dryness, bruising, petechiae, spider angiomas, and abdominal veins
Red palms

Blood tests can be carried out as well.

While we won’t cover it here, your coursework will include assessing a patient’s nutritional status as part of this section, so be sure to go through that.

Assessment: Genitourinary

Kidneys and urinary tract assessment

This includes:

Assessing the health history of a patient as well as that of their family specifically related to urinary system diseases, immobility, diabetes, exposure to chemicals, chronic diseases, having the pelvis exposed to radiation, alcohol abuse, drug abuse, STDS
Identifying the amount of fluid they consume
Ask if they have had any of the following symptoms: pain in the abdomen, hesitancy, urgency, straining while voiding, problems emptying their bladder, incontinence, fatigue, anemia exercise intolerance, chills or fever, blood when they urinate, and GI symptoms

A physical assessment includes:

Taking vital signs
Palpation of the kidneys and bladder
After urination, percussion over the kidneys
Checking herniation, irritation, or tears in the urethra or vagina
Measuring DTRs
Checking gait to see if they can walk heel-to-toe
Ascites and edema palpitations

Fluid balance and kidney regulatory functions

Maintaining fluid balance is one of the kidney’s regulatory functions.

Three things are important here and while we will name what they are, you can follow up a little more on this section in your coursework.

Osmolality: Urine’s electrolytes and molecules per kilogram.
Specific gravity: Here, distilled water is used to compare the weight of the urine (the particles found in it).
Antidiuretic hormone: Assists in the regulation of water excretion in the renal tubule by adjusting water absorption

Assessment: Musculoskeletal

a medical officer assessing the Musculoskeletal problem of a patient

A musculoskeletal injury assessment includes the following steps:

Asking questions and listening to the answers from the patient, first responders, family, or friends. This can help determine how, when, and where the injury happened
Observation of the general appearance of the patient, any obvious injuries they have, and more will provide an overall picture of what their living situation may be as well as their overall general health
Physical examinations should look for injury patterns that are characteristic of a particular injury mechanism

Risk of falling assessments

To determine the risk of fall status of a patient, there are several factors that need to be taken into consideration.

These include:

If they have sensory defects
Their age
If they have mobility problems
If they have neurological disorders
If they have a past history of falling
If they are cognitively impaired
If they suffer from depression
What mediation they are on

Patients that are at risk of falls should be noted in a manner that other healthcare workers are aware.

Each medical facility will do this in its own way, a wristband is an example of how this can be carried out.

If a patient that’s considered a fall risk does fall, the cause of that fall should be evaluated.

Patients with disabilities assessments

Due to inaccessibility, those with disabilities can struggle when it comes to a health screening.

When carrying these assessments out there’s a few things to consider:

Together with the patient, find the easiest way to get the necessary healthcare information needed on a regular basis, for example, weight, bone density tests, etc
At all times, make sure you ask the patient if they need assistance during the assessment
Note nonverbal communication coming from the patient, for example, they might see they are in pain through a grimace
When sensation will be affected on a specific test, always make sure that you warn the patient beforehand
All areas of the health history of a patient should be addressed
Always give a patient enough time to respond, and if necessary, use an interpreter (but not a family member, if possible)
The ability to perform ADLs will be impacted by a disability, so the impact thereof should be addressed. Also discuss how their disability impacts other areas of their lives, for example, their emotional status, their financial status, their work life, their family well-being, and more

Assessment: Geriatric/Elderly

Carrying out proper assessments when dealing with the elderly is essential.

To start, they are three groups in which they can be placed depending on their age.

Young old: from 65 to 74
Middle-old: from 75 to 84
Old-old: from 85 and older

Presentation of illness in the elderly and the factors that influence it

These three factors, which in combination with each other and even alone can make an assessment difficult, are:

Underreporting the illness/symptoms: Many elderly people simply don’t want to go to hospital and therefore don’t always report accurately what’s wrong with them
Pattern of distribution of the illness: This relates to problems/diseases that are more common to the elderly. It may be difficult to identify and differentiate the primary diagnosis in this regard
Altered response to illness: Diagnoses and treatments can be difficult when this occurs as due to other problems, symptoms can be exaggerated or even in some cases, completely absent.

Changes related to the aging process

These changes take place biologically, psychologically, and socio-culturally.

Biological changes: There is a decline in many organs, such as the kidneys, liver, and heart as well as in tissue and in some of the senses
Psychological changes: These can happen in the following areas: memory, capacity to learn, and overall cognition. This can influence relationships between the person and their family, for example, while continued development will decrease. Attention span and concentration can decrease too, which results in poor performance when assessing patients. Memory loss can occur as well
Sociocultural changes: This takes the form of changes in their overall independence, employment as well as social interaction with family and friends. Things they used to be able to do for themselves, which they might not be able to do anymore, include basic ADLs.

Evaluating a patient: Basic safety assessments

Four basic assessments should be carried out in this regard:

Mobility assessment
Level of awareness
Their overall current condition
Mental status

Assessment: Postpartum management

There are several aspects of a postpartum assessment to carry out including:

Vital signs
Temperature
Alertness
Fundus
Lochia
Perineum
Bladder
Rectum
Level of pain
Legs/feet
Anesthesia

The procedures for all of these checks are covered in your coursework, so we won’t go into great detail about them now.

Wound care

Wound care is essential for any patient that’s undergone a Cesarean, or episiotomy, or who has lacerations.

Analgesia should be provided to them when necessary.

Your coursework will cover the exact details of how to provide wound care to someone who has had a Cesarean as well as how to deal with episiotomy/lacerations.

Management of a Cesarean section

The first hour of postoperative care includes:

Checking VS every 5 minutes until the point the patient is stable. Thereafter, they are checked every 15 minutes for a period of an hour and then every 30 mins until the patient leaves the recovery area
Checking the abdominal dressing and perineal pad every 15 minutes for the first hour. The thing to look out for is signs of bleeding
Contraction of the uterine muscles is encouraged by having IV oxytocin administered to the patient
In the case of the patient receiving a general anesthetic, they should be turned on their side and over a 24-hour period, they should be turned every two hours
The level of anesthesia should be monitored every 15 minutes if the patient received an epidural or spinal anesthesia
Monitoring of intake and output should occur. All urine samples should be checked for the presence of blood. If present, this could suggest bladder trauma
As needed, analgesia can be given to help with pain management