NCLEX RN GUIDE                                                                                   the best of NCLEX

Health Promotion and Maintenance Part 5

  1. Client/Family Education
    1. Adult learning theory
    2. Self-directed

    3. Reservoir of experience

    4. Adults prefer mutual planning/goal setting

    5. Internally motivated

    6. Established orientation to learning

    7. Educator is facilitator of learning

    8. Experiential rather than didactic

    9. Must be immediately applicable to life

  2. Teaching/learning process

    1. Assessment

    2. Identification of learning needs

    3. Outcome (goal) setting

    4. Educational offerings

    5. Evaluation of outcomes

  3. Learning styles

    1. Vary with individuals

    2. Learners can be visual, auditory, or tactile (kinesthetic)

  4. Teaching strategies

    1. Demonstration / return demonstration

    2. Programmed instruction

    3. Role playing

    4. Simulation

    5. Case study analysis

    6. May be individualized or in groups

    7. May be computerized

    8. May be media-based or print

    1. Legal implications

      1. American Hospital Association issued the Patient Bill of Rights in 1972 that guaranteed clients the right to information necessary to give informed consent before treatment begins.

      2. Individualized teaching must be documented in client's chart

      3. Alterations for geriatric clients

        1. make sure client has glasses or hearing aid

        2. face the client and use a lower pitched voice

        3. supplement oral presentation with print materials

        4. use large print

        5. provide good lighting

        6. some clients have a hard time seeing color; use black on white or yellow paper

        7. keep sessions short and work with survival-level information initially

        8. repeat often for clients prone to memory loss

        9. break down learning into small steps

        10. use specific, step-by-step directions and have the client redemonstrate them

        11. get frequent feedback regarding client's level of understanding

      4. Health Insurance Portability and Accountability Act (HIPAA)- signed into law in 1996. This law includes important new protections for millions of working Americans and their families who have preexisting medical conditions or might suffer discrimination in health coverage based on a factor that relates to an individual's health. HIPAA places requirements on employer-sponsored group health plans, insurance companies and health maintenance organizations (HMOs). HIPAA includes changes that:

        1. limit exclusions for preexisting conditions

        2. prohibit discrimination against employees and dependents based on their health status

        3. guarantee renewability of health coverage to certain employers and individuals

        4. protect many workers who lose health coverage by providing better access to individual health insurance coverage.

      5. The first-ever federal privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers took effect on April 14, 2003. Developed by the Department of Health and Human Services (HHS), these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed.

      6. The new privacy regulations ensure protection for patients by limiting the ways that health plans, pharmacies, hospitals and other covered entities can use protected medical records and to other individually identifiable health information, whether it is on paper, in computers or communicated orally. Key provisions of these new standards include:

        1. access to medical records

        2. notice of privacy practices

        3. limits on use of personal medical information

        4. prohibition on marketing

        5. stronger state laws

        6. confidential communications

        7. complaints

Before Birth

  • Early and regular antepartal (before-birth) care is critical. First trimester health directly influences the development of organs in embryo and fetus.

  • To identify risks, nurses need both subjective (client's) and objective (the nurse's own) assessment data.

  • Prescribed medications, over-the-counter drugs, alcohol and tobacco may lead to problems for the fetus and woman.

  • Pregnancy diet must include increased calcium, protein, iron and folic acid.

  • If the client's situation warrants, suggest ways to adapt activity, employment, and travel.

  • It is helpful if the woman can have the same support person throughout pregnancy and birthing classes.


  • Maintain safety and asepsis (sterilize instruments; wear gown, gloves, mask) through the labor and birth process to reduce risks to mother and fetus/newborn.

  • Ideally, same caregivers stay through all stages of labor.

  • Recognize urgent signs and act promptly.

  • Constantly assess and analyze problems to prioritize actions.

  • Reinforce the childbirth preparation techniques practiced by the couple during pregnancy.

  • Effective teaching during labor must be flexible. Mother will have shorter attention span, increasing discomfort, and emotional responses to labor.

  • Promote privacy of the woman and support person as much as possible.

  • Respect the cultural and religious beliefs of the woman and partner.

  • Involve the family in the birth process as noted in their birth plan or special requests.

  • Provide for the woman's needs and comfort.

  • Communicate caring and concern to the woman and her family through therapeutic techniques.

  • Document assessments, changes in condition and care as promptly as possible.


  • Teach (by demonstration and praise) self assessment and care. Start soon after birth.

  • The newborn is first of all a family member.

  • Share your assessments and plans with parents; welcome their input.

  • Respect culture and religious beliefs of the family.

  • Praise the parent's skills.

  • Media and pamphlets are useful teaching aids if the parent has a chance to discuss them.

Visits and Teachings

  • Mothers are discharged quickly, so you must teach accordingly.

  • Home visits and follow-up telephone calls let the nurse and parents discuss adaptations, questions and concerns.

  • Postpartum teaching should include women's health promotion.

  • The adolescent mother benefits from developmentally appropriate teaching and referral to community resources, including parenting classes.

Growth and Development

  • Normally proceed in a regular fashion from simple to complex and in cephalocaudal and proximodistal patterns.

  • Are orderly, directional, predictable, interdependent and complex processes.

  • Are unique to individuals and their genetic potential.

  • Occur through conflict and adaptation.

  • Growth and development are impacted by genetics, environment, health status, nutrition, culture, and family structures and practices.

  • Growth should be measured and evaluated at regular intervals throughout childhood.

  • Deviations from normal growth and development should be thoroughly investigated and treated as quickly as possible.

  • In the care of children, key concepts are anticipatory guidance and prevention of disease.

  • Major developmental tasks of infancy are: increase in mobility, separation, and establishment of trusting relationships.

  • In both toddlerhood and adolescence, hallmarks are development of independence and further separation.

  • Children and adolescents grow rapidly, so nurses must stress optimum nutrition and give anticipatory guidance related to nutrition.

  • In children over one year of age, the leading cause of death is injuries.

Elder Adults

  • Elder adults must adjust to lessening physical and cognitive abilities. Over 85% have some type of chronic disease.

  • When elder adults experience cognitive changes, check for possible substance abuse or polypharmacy.

  • Cognitive impairment can be acute and reversible, or it can be chronic and irreversible.

  • Up to 60% of older adults have some impairment in performance of activities of daily living.

  • Some physiologic changes are a normal part of the aging process and do not signal disease.

  • Elder adults need more time to complete tasks.

  • Age is a weak predictor of survival in traumatic injury and critical illness.


Health Risks in Elder Adults

  • Major health problems typically include cardiovascular, cerebrovascular, and respiratory diseases; diabetes; and cancer.

  • The elder adult will change social roles, and these changes may affect psychological health, leading to depression.

  • Elder adults need the same nutrition as other adults, but more bulk and fiber, calcium, and vitamins C and A.

  • Contraindications for estrogen replacement therapy include

    • hypertension

    • thrombophlebitis

    • cardiac dysfunction

    • family history of breast or uterine cancer

  • Elder adults clear drugs from kidney and liver more slowly; so medications have longer half-lives, and they can bring on side effects and toxicity at lower doses.

Health Promotion: Health Assessment

  • Measure vital signs when the client is at rest

  • Compare both sides of the body for symmetry

  • Assess the systems related to the client’s major complaint first

  • Offer rest periods if client becomes tired

  • Culture and religious beliefs may play a role in observed differences

  • Warm hands and equipment such as stethoscope before touching client

  • Tell client what you are going to do before touching client

  • Normal variations exist among clients and there is a range of normalcy for all physical findings

  • Maintain the client’s privacy throughout the examination

  • Control for environmental factors which may distort findings

  • Check equipment prior to exam for functioning

  • Consider growth and developmental needs when assessing specific age groups

  • Integrate client teaching throughout the exam


  • Compare blood pressure in arms left versus right

  • Compare blood pressure with client lying, sitting and standing

Lungs - Airway

  • Anemic patients may never become cyanotic

  • Polycythemic patients may be cyanotic, even when oxygenation is normal

  • Cough results from stimulation of irritant receptors, with implications of either acute or chronic etiology.

  • Cyanosis indicates decreased available oxygen. Etiology can be either peripheral or central in origin.

  • Wheezes indicates narrowing/inflammatory process of lower airways

  • Stridor harsh sound produced near larynx by vibration of structures in upper airway. Classic "barky cough"

  • Crackles or rales adventitious sounds, usually on inspiration and indicating inflammation


  • Breast tissue shrinks with menopause

  • Teach client breast self examination (illustration )

Abdomen - Reproductive System

  • Auscultation should be performed before palpation to prevent distortion of bowel sounds

  • Tightening of abdominal muscles hinders accuracy of palpation and auscultation

  • Warm hands before touching client’s abdomen.

  • Men breathe abdominally; women breathe costally.

  • Auscultate all four quadrants for bowel sounds

  • Auscultate abdomen between meals


  • Older adults walk with smaller steps and need a wider base of support


  • Glasgow Coma Score

    • not valid in patients who have used alcohol or other mind-altering drugs

    • possibly not valid in patients who are hypoglycemic, in shock, or hypothermic (below 34C)

    • should be compared to total of 10 when client is intubated

  • Reflexes are normally less brisk or even absent in older clients

  • Reflex response diminishes in the lower extremities before the upper extremities are affected

  • Absent reflexes may indicate neuropathy or lower motor neuron disorder

  • Hyperactive reflexes suggest an upper motor neuron disorder

Teaching client and family

  • Teaching-learning process mirrors the nursing process

  • Select teaching strategies that are compatible with the client’s learning style, age, culture, level of education

  • Client teaching should be multi-sensory

  • Always confirm the client’s understanding of the information presented

  • Teaching must be geared to the level of the learner

  • Repeat key information and summarize main points at intervals

  • Explain medical terminology in lay terms

  • Determine the client’s learning style and gear teaching methods to using that style

  • Sequence information the way the client will use it

  • Be concrete and use the simplest words and the shortest sentences when teaching low literacy clients, or any client under stress