Top 10 Examinees of July 2011 Nursing Licensure Exam

1. Jomel Garcia Lapides (University of the Philippines - 88.40%
2. Hazel Cortes Crisostomo (University of Santo Tomas) - 87.40%; Beverly Lynne Yao Ong (Univeristy of Santo Tomas) -87.40%
3. Ivy Grace Cuadra Lim (Far Eastern University - Manila) - 87.20%
4. Ameera Sarah Niebres Baylon (Camarines Sur Polytechnic College-Nabua) - 87.00%; Kim Carmela Dee Co (University of the Philippines-Manila) - 87.00%; Ralph Jarilla de Leon (Metropolitan Hospital School of Nursing) - 87.00%; Patricia Teodoro Pintac (Cebu Doctors University) - 87.00%; Nadine Cedeno Sameon (University of Saint LaSalle) - 87.00%
5. Mary Bianca Doreen Fernandez Ditching (University of Santo Tomas) - 86.80%; Channiel Pauline Mijares Luciano (University of Santo Tomas) - 86.80%; Patrick Ranier Agupitan Latoza (Our Lady of Fatima University - QC) - 86.80%; Raymark Domingo Salonga (University of the Philippines-Manila) - 86.80%
6. Maria Theresa Daclan Bido (Lourdes College) - 86.60%; Princess Samantha Valencia Buban (University of Santo Tomas) - 86.60%; Johnel Carlo Cristobal Estrella (Far Eastern University-Manila) - 86.60%; Florence Jill Dela Victoria Polina (STI College Cebu, Inc) - 86.60%; Jacob Cabrera Reyes (Cebu Normal University Nicole Marie Tiglao Severino (Angeles University Foundation) - 86.60%; Maria Jalyssa Pascua Tan (University of the Philippines-Manila) - 86.60%
7. Frances Mae Tupas Baquillos (Riverside College) - 86.40%; Amparo Marie Medina Bayongan (University of Santo Tomas) - 86.40%; Rose Ann Labrague Canlapan (Holy Angel University) - 86.40%; Dee Zyrie Alli Divina (Far Eastern University-Manila) - 86.40%; Catherine Joyce Distor Go (Saint Louis University) - 86.40%; Angela Nicole Rago Ocio (Xavier University) - 86.40%; Bianca Malilay Velando (University of the Philippines-Manila) - 86.40%
8. Argee Abunda Alonsabe (University of Saint LaSalle) - 86.20%; Lowel Andrew Andales Batomalaque (Cebu Normal University Lora Enriquez Jarabelo (University of Santo Tomas) - 86.20%; Mishael Kate Ilagan Mendoza (De La Salle University-Health Sciences Institute) - 86.20%; Jan Joel Lalic Simpauco (University of Santo Tomas) - 86.20%; Alvin Duke Roberto Sy (University of the Philippines-Manila) - 86.20%; Cherryl Joyce Cabatingan Tan (Velez College) - 86.20%
9. Ruth Marie Dela Cruz Andoque (West Visayas State University-La Paz) - 86.00%; Paolo Holandez Andrade (Univeristy of Santo Tomas) - 86.00%; Thea Mae Medalla Baronda (Velez College) - 86.00%; Emmanuel Arianne Mendoza Bastasa (Manila Doctors College) - 86.00%; Maria Katrina Mitra Capellan (University of Santo Tomas) - 86.00%; Emmanuel Demigillo Debuque (University of Santo Tomas) - 86.00%; Katherine Alegre Flores (University of Santo Tomas) - 86.00%; Maria Reylan Magallanes Garcia (West Visayas State University-La Paz) - 86.00%; Debby Grace Tabugo Jardiolin (Saint Paul University-Iloilo) - 86.00%; Josephine Ann Jablo Necor (Far Eastern University-Manila) - 86.00%; Royce Jasper Uy Ong (University of Santo Tomas) - 86.00%; Rochelle Realino Perlas (Emililo Aguinaldo College-Manila) - 86.00%; Jann Marvin Posada (Catanduanes State Colleges-Virac) - 86.00%; Kyle Nicole Torrila Teruel (West Visayas State University-La Paz) - 86.00%
10. Shane Alexis Allanigue Abella (Saint Paul University-Manila) - 85.80%; Christine Corintha Daway Almora (University of Santo Tomas) - 85.80%; Jan Briane Fabie Astom (Saint Paul College-Bantay Jasper Joseph Carag Ballecer (Saint Paul University-Manila) - 85.80%; Gloria Isabel Labrador Baltazar (University of Santo Tomas) - 85.80%; Maria Ronallaine de Leon Bello (University of Santo Tomas) - 85.80%; Ma. Aileen Bianca Real Bose (Bicol University-Legazpi) - 85.80%; Jane Febe Booc Cabatingan (Cebu Normal University Deo Robert Bodiongan Castro (Cebu Doctors University) - 85.80%; Angela Valerio Coronado (Far Eastern University-Manila) - 85.80%; Judith Pajigal Cuadra (Holy Name University April Luz del Mundo (Central Colleges of the Philippines) - 85.80%; Khris Chan Dy (University of Pangasinan) - 85.80%; Mei Joy Castillo Flaminiano (Our Lady of Fatima University-Valenzuela) - 85.80%; Kelci Mae Tan Francia (University of Santo Tomas) - 85.80%; Jayvie Bacud Gacutan (Medical College of Northern Philippines) - 85.80%; Sarah Agnes Mary Reyes Lim (University of Santo Tomas) - 85.80%; April Wine Yogi Sayas Manigbas (Lyceum of the Philippines University-Batangas,Inc) - 85.80%; Eirene Joy Louise Noveza Ocampo (Far Eastern University-Manila) - 85.80%; Mary Jane Turno Ocampo (Saint Louis University) - 85.80%; Iris Mae Belgado Relles (Bicol University-Tabaco) - 85.80%; Gee Blossom Barba Robino (Saint Paul University-Iloilo) 85.80%; Ability-Ann Gayoma Tacaisan (West Visayas State University-La Paz) - 85.80%

JULY 2011 NURSING LICENSURE EXAM RESULT

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Therapeutic Exercise

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Definition

Therapeutic exercises are activities that are prescribed by the physician and are performed with the assistance and guidance of a physical therapist or a nurse. The ultimate goal of therapeutic exercises is to help and aid the patient or injured individual gain independence in functional activities and make the activity as much as possible comfortable and pain-free.

Goals:

• Enable ambulation
• Release contracted muscles, tendons, and fascia
• Mobilize joints
• Improve circulation
• Improve respiratory capacity
• Improve coordination
• Reduce rigidity
• Improve balance
• Promote relaxation
• Improve muscle strength and, if possible, achieve and maintain maximal voluntary contractile force (MVC)
• Improve exercise performance and functional capacity (endurance)

Physiological Aspects of Physically Fit Person

• Higher oxygen consumption (mL/min)
• Greater cardiac output per minute
• Higher stroke volume and total blood volume
• Greater oxygen extraction by the tissues
• Greater cardiac volume
• Lower resting pulse rate
• Greater muscle strength
• Lower pulse rate on exercise
• Lower blood pressure on exercise
• Better adaptation of circulation and respiration to effort

Benefits of Therapeutic Exercises

When correctly performed, therapeutic exercises will have the following outcomes:

1. Improve or maintain muscle strength. It is only through the execution of these exercises that muscle strength is built and reinforced.
2. Enhancing joint function.
3. Helps in preventing deformities.
4. Assists in stimulating blood circulation.
5. Developing a person’s endurance.
6. Promoting relaxation.
7. Helping to restore motivation and well-being of the patient

Approach Considerations
Therapeutic exercises aimed at achieving and maintaining physical fitness fall into the following major categories, each of which has a specific purpose:

• Endurance training
• Resistance training
• Flexibility training

Endurance Training
An endurance training program has 3 variables: frequency, intensity, and duration. The American College of Sports Medicine (ACSM) recommendations are as follows:

• Frequency - Aerobic exercise 3-5 days a week
• Intensity of training - 64/70-94% of maximum heart rate (HR max), or 40/50-85% of maximum oxygen uptake reserve (VO2 R) or heart rate reserve (HRR)
• Duration of training - Continuous or intermittent aerobic activity for 20-60 minutes (minimum of 10-min bouts accumulated throughout the day). Duration is dependent on the intensity of the activity; thus, lower-intensity activity should be conducted over a longer period of time (≥30 min), and, conversely, individuals training at higher levels of intensity should train at least 20 minutes or longer. Moderate-intensity activity of longer duration is recommended for adults not training for athletic competition, because total fitness is more readily attained with exercise sessions of longer duration and because potential hazards and adherence problems are associated with high-intensity activity.

Application to healthy individuals
Exercises that use large muscle groups that can be maintained continuously and are aerobic in nature are recommended. These exercises include walking, running, jogging, dancing, stair climbing, cycling, swimming, rowing, skating, aerobic dance/exercise classes, jumping rope, and cross-country skiing.

The HR max can be determined by the following: HR max = 220 – Ag

The exercise session should consist of the following:

• A warm-up period of approximately 10 minutes: This should combine calisthenic-type stretching exercises and progressive aerobic activity that should increase the heart rate close to the prescribed heart rate for the session.
• Endurance training (20-60 min)
• A cool-down period of 5-10 minutes

Application to patients
For at-risk patients, especially those with cardiac or respiratory disease, a less intense training regimen must be used, with the training heart rate not exceeding that attained at 50-60% of maximum O2 uptake (VO2 max).

In the absence of data regarding maximum attained heart rate measurements, it is prudent not to allow a patient to exceed a heart rate of 130 beats per minute (bpm). In elderly patients and patients at risk, the intensity, frequency, and duration of therapeutic exercise should be established for each patient individually through prior medical evaluation (see Medical evaluation).
Using the following equation, the HRR method, otherwise known as the Karvonen method, should be employed to determine the target heart rate for the ill or elderly patient: Target HR = (220 - age - resting heart rate × % intensity selected) + resting heart rate

Progression

Progression must be a part of an exercise program to ensure continued results. With endurance training, progression can occur by increasing the duration or the intensity. Several factors contribute to the optimal rate of progression; current activity levels, exercise goals, age, and physiologic limitations should be considered. Most importantly, a rate of progression should be used that results in long-term participation. Being too aggressive with progression can lead to increased dropout rates as a result of injuries and/or perceived excessive discomfort.


Resistance Training

Resistance training increases strength, walking speed, stair-climbing power, balance, and lean body mass and decreases regional and total fat mass. This form of exercise has been shown to bring about favorable changes in risk factors for coronary artery disease, osteoporosis, diabetes mellitus, and cancer. For example, resistance training has been proven to lower systolic blood pressure, increase bone mineral density, increase mechanisms involved with blood glucose metabolism (glucose tolerance and insulin resistance), and increase bowel transit time, which decreases the risk of colon cancer in healthy men and women who are middle-aged or older. Back pain and work-related back injuries also have been shown to decrease with resistance training.


Factors Affecting the Adherence to Therapeutic Program

A therapeutic exercise program is beneficial to the patient. However, some individuals do not adhere to the program. The following are some of the identified factors that affect the performance of therapeutic exercise:

• Lack of knowledge about the exercise program
• Lack of Skill. Explaining and demonstrating the methods or techniques of exercise execution may be helpful in assuring adherence to the exercise program. Though the patient may indicate familiarity with the exercise, the technique execution might be wrong. An exercise is ineffective if done incorrectly. Thus, it is ideal to demonstrate the techniques and skill to the patient beforehand and let the patient perform the complete set of exercise while watching to correct improper technique execution. Correcting errors can be easily provided by positive reinforcement and suggestions.
• Lack of Risk Taking Ability. An individual’s fear of feeling increased pain, discomfort or possible reinjury sometimes limits the individual’s motivation to exert full effort and thus it prevents the patient from sticking to the therapeutic exercise program. Emotions are one factor that may motivate or block the individual to deal successfully with the challenges of the exercise program. Nurses should provide constant positive feedback to deal with this.
• Lack of Social support. When an individual feels alone or isolated, he or she might lose the motivation to meet the challenges of the exercise program. Assuring and acknowledging that value of a patient in an activity and encouraging socialization are the key steps in handling this problem.
• Confidence. One of the most essential factors that affect the completion of the exercise program is the confidence of the person.  Timely recovery will be delayed when a person has low confidence because focus is interfered with negative thoughts.
• Motivation. The greatest influence in the completion of the exercise program is based on how motivated an individual is. Low motivation results to the following:

1. Low effort and intensity
2. Poor attention
3. Lack of attentiveness to instructions
4. Undefined goals
5. Insupportable excuses to avoid the exercise program

IELTS Writing

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Grading System for Essays

• Task Response
• Coherence and Cohesion
• Lexical Resource
• Grammatical Range and Accuracy

“Task Response”
Means that your essay shows that you understood and covered the topic from all its sides, aspects, etc. Let’s take this topic for example – “Internet: connecting or isolating people?”. Those who chose to write about how Internet connects people – loose marks, those who chose to write about how Internet isolates people – loose marks, those who compare and contrast both sides of the Internet and give arguments for and against – gain marks.

“Coherence and Cohesion”
Means how well you connected the paragraphs and sentences inside each paragraph. You see, all of your paragraphs need to be logically connected. For example, if paragraph 1 explains the advantages of the Internet, and paragraph 2 explains its disadvantages, then paragraph 1 should have last sentence saying something like this: “In spite of Internet being such a help in communication, its drawbacks can not be overlooked”. This sentence creates the connection between 1st and 2nd paragraphs. If it wasn’t there, examiner could think that you jumped from advantages to disadvantages without a reason. The same rule applies to sentences inside the paragraph. Every sentence should lead to the next one.

“Lexical Resource”
Means vocabulary and different types of sentences, simple and complex. You should be able to use words and their synonyms.

“Grammatical Range and Accuracy”
Means spelling and grammar of sentences. You should be able to spell the words correctly, do not forget articles “a” and “the”, punctuations is also important, etc.

WRITING

W – Work with a coach.

Practice is one way to enhance your writing skills. However, it would be ideal if you practice with a teacher or IELTS coach that will correct your output. You can never be prepared to combat the IELTS writing tasks without receiving feedbacks on your writing errors. For those who are in a tight budget and cannot afford to hire an IELTS coach, you can work on your own but be sure to have a good IELTS preparatory manual that will serve as your guide in honing of that writing ability.

R – Read through the instructions and questions carefully.

Aside from the main question, the point of issue often will ask you to address three or four things. Make sure to get these queries and discuss them in your answer.

I – Inspect your watch!

Keep track of your time! Monitor your own progress! Remember you only have one hour to finish both writing tasks. For those who have difficulty hitting the 60-minute mark for tasks 1 and 2, speed is developed by practicing constantly.

T – Think and write it out.

While rehearsing your writing ability, sit and write out tasks 1 and 2. Some people are not actually writing the brilliant ideas they were thinking while reading the question. Thus, a structured format approach should be utilized in this case. Repetitive writing can also be avoided if you practice, practice and practice.

I – Inscribe those words legibly!

Messy writing is not a criterion in marking your written output. However, if the examiner cannot read what you have written, then, you are not getting any mark either. Before taking the examination, my coach kept on reminding me about my writing because the words are too small and she had difficulty reading them. Keep in mind than an unreadable output means no mark at all!

N – No reason to start writing immediately for task 1.

Yes, I told you to keep track of your time. But don’t start writing immediately after looking at the graph or table and understanding what is asked and given. Before writing, make sure that you know what each axis represents and the units that are used. Even if you finished writing task 1 for 10 minutes but the data written is incorrect you will never hit your target mark.

G – Go for task 2 first!

Task 2 in the IELTS writing section is easier to compose and is worth more mark than task 1. I am not saying that you should ignore the other component in this section, but making sure you completed the part which weighs more points to your mark is a wise choice.

Phlebotomy

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Phlebotomy is a procedure that consists of venipuncture and withdrawal of blood. It is a safe outpatient method where blood is extracted from the vein through a cut or puncture. This procedure is performed by a nurse or technician called phlebotomist.

Purpose

Phlebotomy is performed for many reasons which include the following:

1. To obtain sample for analysis and diagnosis.
2. To treat polycythemia. Polycythemia is a condition where elevation or red blood cell volume is noted. Part of the treatment of this disorder is carrying out therapeutic phlebotomy.
3. To decrease the total blood volume of patients with pulmonary edema.
4. To remove blood from the body during blood donation.
5. To analyze blood substances contained in blood before clearing a person for blood donation.

Safety Guidelines

• Universal precautions are used with this procedure. Gloves should be worn when performing this procedure.
• Prior to blood collection it is important that the one performing the procedure is properly trained and identified as licensed phlebotomist.
• Properly identify your patient. Check the name tag and verify with the patient or nurse on duty.
• Supplies should be checked for their integrity.
• Label vials and tubes properly. Indicate date and time of extraction with the name of the patient clearly indicated.
• Needles should be immediately disposed in an approved sharps container. They never be recapped and should only be used once.
• Assess the patient for complications associated with the phlebotomy procedure.

Venipuncture Site Selection:

Although the larger and fuller median cubital and cephalic veins of the arm are used most frequently, the basilic vein on the dorsum of the arm or dorsal hand veins are also acceptable for venipuncture. Foot veins are a last resort because of the higher probability of complications.

Certain areas are to be avoided when choosing a site:

• Extensive scars from burns and surgery - it is difficult to puncture the scar tissue and obtain a specimen.
• The upper extremity on the side of a previous mastectomy - test results may be affected because of lymphedema.
• Hematoma - may cause erroneous test results. If another site is not available, collect the specimen distal to the hematoma.
• Intravenous therapy (IV) / blood transfusions - fluid may dilute the specimen, so collect from the opposite arm if possible. Otherwise, satisfactory samples may be drawn below the IV by following these procedures:
  
  • Turn off the IV for at least 2 minutes before venipuncture.
  • Apply the tourniquet below the IV site. Select a vein other than the one with the IV.
  • Perform the venipuncture. Draw 5 ml of blood and discard before drawing the specimen tubes for testing.
• Lines - Drawing from an intravenous line may avoid a difficult venipuncture, but introduces problems. The line must be flushed first. When using a syringe inserted into the line, blood must be withdrawn slowly to avoid hemolysis.
• Cannula/fistula/heparin lock - hospitals have special policies regarding these devices. In general, blood should not be drawn from an arm with a fistula or cannula without consulting the attending physician.
• Edematous extremities - tissue fluid accumulation alters test results.

Description of Procedure

In this procedure, blood is extracted from a vein on the back of the hand or over the antecubital fossa. However, some tests require blood to be taken from an artery. In blood transfusion, donors are placed in a semirecumbent position and the skin over the antecubital fossa is carefully cleansed with an iodine preparation or antiseptic solution. A tourniquet or elastic band is applied around the arm to retain blood in the area and make the veins visible. After the phlebotomist selects an appropriate vein for blood extraction, venipucture is performed. – A needle is inserted into the vein and the tourniquet is released.

The appropriate amount of blood to be withdrawn widely varies. Blood donation and therapeutic phlebotomy require larger amount of blood than blood analysis. Blood donors usually give about 450 to 500 ml of blood per session. For laboratory analysis, the volume of blood needed depends on the type of test performed. Approximately, one or more 5 to 10 ml tubes of blood are withdrawn.

Withdrawal of 450 ml of blood takes less than 15 minutes. After the needle is removed, the donor is asked to hold the involved arm straight up and apply firm pressure on the site with sterile gauze for about 2 to 3 minutes or until the bleeding stops. The phlebotomy technician then places a bandage on the site.

Instructions After the Procedure

• Within 1 to 2 minutes the donor is asked to remain in the position until they feel able to sit up. If weakness or faintness is experienced, the donor should rest for a longer time.
• Foods and fluids are given when the donor sits up and is asked to remain for another 15 minutes.
• Heavy lifting should be avoided for several hours.
• Smoking should be avoided for an hour.
• Alcoholic beverages should be avoided for 3 hours.
• For 2 days, fluid intake should be increased and balanced diet should be practiced for 2 weeks.

NOTE: Always observe aseptic technique to protect your patient and yourself.

Health Assessment

A. Health Assessment in General
1. Purposes of Health Assessment

• Data collection 
• Supplement, confirm or refute historical data 
• Identify changes in client’s status 
• Evaluate the outcomes of care 

2. Components of Health Assessment: history and physical exam
History:
I. Chief complaint

• Location 
• Quality 
• Quantity 
• Precipitating or aggravating factors 
• Duration 
• Associated findings 

II. General health status
III. Medical history
IV. Family history
V. Social history
VI. Occupation
VII. Activity level
VIII. Sleep
IX. Nutrition
X. Medications; including substance use/abuse
XI. Psychosocial factors

Physical Exam: Skills
I. Inspection

• Process of observing the differences between normal physical signs and deviations 
• Requires knowledge of normal physical signs throughout the lifespan 

Principles of inspection

• In good lighting and with whole body partly visible 
• Observe each area for size, shape, color and position 
• Compare body parts bilaterally for symmetry 

II. Palpation

• Use touch to assess resistance, resilience, roughness, texture and mobility 
• Palpation may be either light or deep in pressure:

1. Use light palpation to determine tenderness 
2. Deep palpation usually depresses the area by 1 to 2 inches; use it to examine specific organs 

•  Use palmar surface of fingers to determine position, texture, size, consistency and pulsation; also presence and shape of mass 
• Use back of hand to test temperature 
• Use palm of hand to sense vibration 

III. Percussion

• Tap the body with fingertips: to detect fluid or to assess location, size, density and borders of organs 
• Tapping the body produces vibration and sound waves which you hear as percussion tones 

Methods

• Direct: striking the body surface with two fingers 
• Indirect: striking the middle finger of the non-dominant hand on the back surface with the fingers of the dominant hand rather than the body surface, while keeping the palm and remaining fingers of the body 
• Character of percussion sounds depends on the density of the tissue being percussed 

Percussion Sounds:

• Tympany: drum like, loud, high pitch, moderate duration; usually found over space containing air such as the stomach 
• Resonance: hollow sound of moderate to loud intensity; low pitch, long duration; usually heard over the lungs 
• Hyperresonance: booming sound of very loud intensity; very low pitch, long duration; usually heard in the presence of trapped air (such as emphysematous lung) 
• Flatness: flat sound of soft intensity; high pitch, short duration; usually heard over muscles 
• Dullness: thud-like sound of soft intensity; high-pitch, moderate duration; usually heard over solid organs (such as heart, liver) 

IV. Auscultation

• Listening (with unassisted ear or stethoscope) to sounds made by the body 

Assess presence of sound and their character 

• Frequency (high or low pitch) 
• Loudness (loud or soft) 
• Quality (blowing, gurgling, booming, thud-like, hollow or flat) 
• Duration (short, moderate or long) 

V. Olfaction

• Use of sense of smell to differentiate common body odors from abnormal ones 

Common odors include:

• Urine: ammonia 
• Skin: body odor 
• Body wastes: feces, vomitus 
• Mouth: halitosis 

VI. Physical exam 

1. Equipment 

2. Client positions 

3. Reporting general appearance and behaviors 

• Gender and race 
• Age 
• Obvious signs of distress 
• Body type 
• Posture 
• Gait 
• Body movements 
• Hygiene 
• Dress 
• Affect and mood 
• Speech 

4. Vital signs 

5. Height and weight

6. Body temperature 

• Range: 36 to 38 degrees Celsius (98.6 to 100.4 degrees Fahrenheit) 
• Measure core temperature: rectum, tympanic membrane, esophagus or urinary bladder 
• Measure surface temperature: skin, axilla or mouth 

Body temperature normally varies with:

• Age 
• Exercise 
• Hormone level 
• Circadian rhythm (time of day) 
• Stress 
• Environment 

Equipment needed for physical exam

• Client gown 
• Drapes 
• Stethoscope 
• Gloves 
• Percussion hammer 
• Sphygmomanometer (blood pressure gauge and cuff) 
• Thermometer 
• Tape measure 
• Cotton swabs 
• Flashlight 
• Tongue depressor 
• Scale 
• Lubricant 
• Eye chart 
• Miscellaneous: safety pin, ruler, paper towels

Health and Health Promotion

HEALTH
A. Definitions of health vary

• Traditional definition: freedom from disease 
• 1958 World Health Organization definition: “state of complete physical, mental and social well-being and not merely the absence of disease and infirmity” 

B. Health belief model

• Psychological and behavioural theory 
• Attempts to explain individual health behaviours 
• Health behaviours

1. The individuals perception of susceptibility of illness 
2. The individuals perception of seriousness of the illness 
3. The likelihood that the person will take preventive action 

• Modifying Factors

1. Cultural beliefs 
2. Economics 
3. Political factors 
4. Social factors 
5. Personal beliefs 

Health Promotion
A. Definitions

1. Health Promotion Behaviour is a behaviour in which the client views health as a goal and engages in behaviours designed to achieve or maintain that goal 
2. Health Care includes prevention, early detection, treatment and rehabilitation for clients with potential for or existing illness or disability 
3. Healthy Lifestyle can increase or maintain client’s level of wellness and functional ability 
4. Health Screening (for risk factors or illness) can prevent or minimize illness and disability 
5. Disease Prevention Behaviors are behaviours designed to decrease the likelihood/risk of illness 

• Primary prevention 

1. Health promotion and disease prevention 
2. Applied to clients considered physically and emotionally healthy
3. Example: exercise programs, healthy diet 

• Secondary prevention 

1. Early detection of illness 
2. Focuses on individuals who are experiencing health problems and illness and who are at risk for problems and illnesses and who are at risk for complications 
3. Activities are directed at diagnosis and prompt treatment 
4. Example: breast self examination, cholesterol screening 

• Tertiary prevention 

1. Prevention of further deterioration in disease or disability 
2. Occurs when a defect or disability is permanent and irreversible
3. Activities are directed at rehabilitation 
4. Example: alcoholics anonymous 

B. Primary Health Care

• Accessible, community-based or work-based health care services based on principle of universal access, which ensures health care for all individuals regardless of employment or insurance status
• Health Security Act of 1993 offered universal access to basic hospital, preventive, physician and long-term services. It included these seven services:

1. Physical examinations
2. Screening tests 
3. Diagnosis and treatment of common acute illness 
4. Management of chronic illnesses 
5. Liaison with community resources 
6. Provision of prenatal care 
7. Identification of need for specialty referrals 

• Providers include physicians and advanced practice nurses such as: nurse midwives and nurse practitioners
• Services provided through a managed care model
• Specialty services provided and reimbursed only after referral from the primary care provider
• Primary care settings include:

1. Health maintenance organizations (HMOs) 
2. Public health departments 
3. Occupational health clinics 
4. Schools 
5. Nurse managed clinics 
6. Collaborative practice settings 

C. Health Promotion Model

• Developed by Nola Pender 
• Health promotion depends on seven factors of cognition-perception

1. Importance of health to the person 
2. Perceived control of health 
3. Perceived self-efficacy 
4. Definition of health 
5. Perceived health status 
6. Perceived health benefits from the health-promoting behaviour 
7. Perceived barriers to the health-promoting behaviour 

D. Risk Factors – probability of acquiring a particular health problem

• Varies with age, race, ethnicity, gender 
• Risk increases with certain lifestyle choices, such as smoking, occupation, diet, environment 
• Modifiable risk factors include occupation and diet 
• Non-modifiable risk factors include race and age 
• Examples: Risk factors are important in

• Coronary artery disease 
• Cancer 
• Colon cancer 

1. Over 50 years of age 
2. Family history of colon polyps or cancer 
3. Urban living 
4. Diet high in fats and low in fiber

• Tuberculosis 

1. History of exposure to person with TB 
2. History of travel or living outside United States 
3. History of prison time 
4. HIV infection 
5. Cancer chemotherapy 
6. Malnutrition 
7. Homelessness 
8. History of IV drug use 
9. Medical workers

• Diabetes: candidates for screening 

1. Strong family history of diabetes mellitus 
2. Markedly obese 
3. Obstetrical history of babies weighing over nine pounds at birth 
4. Obstetrical history of miscarriage or fetal death 
5. Pregnant women between 24-48 weeks gestation 
6. History of gestational diabetes

E. Screening recommendations for the average American

• Cholesterol – once every five (5) years if normal age 45 and older 
• In women: mammography 
• In women: the first Papanicolau smear at the onset of sexual activity and/or over age 19, annually
• In men: prostate-specific antigen – annually 50 years of age or at age 40 for those at risk
• For colon cancer:

1. Digital rectal exam every year after the age of 40
2. Guiac test for occult blood every year after the age of 50
3. Proctoscopy every three (3) to five (5) years after the age 50 after two negative annual exams
4. Colonoscopy

• Tuberculosis skin tests: intradermal injection of antigen
• Diabetes: fasting plasma glucose, ideally eight (8) to twelve (12) hours fast
• Vision: after age 39, medical eye exam every three (3) to five (5) years
• Hearing: candidates for screening include:

1. Family history of childhood hearing impairment
2. Perinatal infection (rubella, herpes, cytomegalovirus)
3. Low birth weight infants
4. Chronic ear infection
5. Down syndrome

HEALTH PROMOTION PROGRAMS AND HEALTH SCREENING

I. Blood Pressure Screening

• Screening should be done annually beginning at age 21 for both males and females
• Screening for children and adolescents is also recommended but optimal interval has yet to be determined
• Auscultatory method with a properly calibrated and fitting cuff should be used
• Person should be seated quietly in a chair for at least five minutes with feet on the floor and arms supported at heart level
• At least two measurements should be done, two minutes apart
• Pre-hypertensive individuals (SBP 120-139 and DBP 80-89) should be counseled on lifestyle modifications such as weight reduction, exercise, diet and smoking cessation
• SBP >140 and/or DBP >90 should be referred to a health care provider for antihypertensive drug therapy

II. Breast Self-Examinations

• Should be started by age twenty
• Done at the same time of the month - preferably seven days after onset of the menstruation cycle; if no menstruation cycles, do at the same time of each month
• Technique should be reviewed by a health care provider to ensure effectiveness
• Limited effectiveness, but when done regularly helps a woman understand how her breast normally feel
• Most changes are benign, but unusual or spontaneous changes should be checked by a health care provider without delay. These include:

1. lump or thickening (breast or underarm)
2. red or hot skin
3. orange peel skin
4. dimpling or puckering
5. itch or rash, especially in nipple area
6. retracted nipple
7. change in direction of nipple
8. bloody or spontaneous discharge
9. unusual pain
10. a sore on the breast that does not heal

III. Risky Behaviors - assist in assessment of behaviors that impact the health of individuals in the following developmental stages

• Adolescents (age 13-19)
• Eating disorders
1. Anorexia Nervosa - restrictive eating
2. Bulimia Nervosa - binge eating followed by purging
• Injury prevention
1. wearing of seat belts
2. wearing of helmets
3. sports injuries
4. homicide and suicide
• Substance abuse
1. tobacco
2. underage drinking
3. illicit drug use
• Sexual  behavior
1. number of sex partners
2. use of contraception
3. unintended pregnancy
4. exposure to sexually transmitted diseases
• Young Adult (age 20-35)
• Eating disorders - onset of obesity
• Injury prevention
1. Motor vehicle accidents
2. Occupational hazards
3. Homicide and suicide
• Substance abuse
1. tobacco
2. alcohol use
3. illicit drug use
• Sexual behavior
1. sexually transmitted disease - use of condoms
2. unintended pregnancy
• Stress
1. depression
2. Changing roles
• marriage
• beginning a new family
• starting a new job
• Middle Adult (age 35-65)
• Obesity
• Lack of exercise
• Substance abuse
1. tobacco
2. alcoholism
3. illicit drug use
• lack of preventative health care
• stress
1. job
2. family/divorce
3. acceptance of aging
• Older Adult (age 65 and older)
• Obesity
• Lack of exercise
• Substance abuse
1. tobacco
2. alcoholism
3. illicit drug use
• Injury prevention
1. falls
2. seatbelts
3. suicide
4. multiple medications

IV. Scoliosis Screening

• Recommendations vary but generally accepted to perform screening at onset of adolescence
• Significantly more prevalent in girls than boys
• Early intervention important because untreated scoliosis can lead to disfigurement, impaired mobility, and cardiopulmonary complications
• Technique - clothing should be removed from upper body

1. While standing, check adolescent for asymmetry of shoulders, scapula, hips or waist
2. Assess for misalignment of spinous processes - lateral curvature and convexity of thoracic spine indicate scoliosis
3. With feet together and legs straight, have adolescent bend forward until back is parallel to floor; check for prominence of ribs on one side only and hip and leg asymmmetry - chest wall on side of convexity is prominent and scapula on side of convexity is elevated

• Abnormalities are to be followed up by a health care provider and referral to orthopedist may be necessary for severe curvatures

V. Testicular Self-Examinations

• Monthly self-examination should begin in adolescence, since this is the highest risk group
• Best time to perform exam is during or after a bath or shower when the scrotum is relaxed
• Limited research to determine if regular examinations reduce death rate but they are strongly encouraged for men with risk factors such as

1. family history of testicular cancer
2. cryptochidism
3. previous germ cell tumor in one testicle

• Findings that should be reported to a health care provider include

1. hard lumps or nodules
2. change in size, shape or consistency of the testes

F. Compliance

• Definition: adherence to primary or secondary prevention recommendations
• Factors influencing compliance

1.  Personal meaning and perceptions: knowledge, values, beliefs, outcome expectations
2. Social factors: environmental context, social relationships, social support, societal norms, economic resources
3. Deficiencies in the health care system: access, costs, wait time, monolingual services

 G. Noncompliance

•  An individual’s informed decision not to adhere to a therapeutic recommendation
• Individual unable or unwilling to alter habitual behaviours or adopt new behaviours necessary to a prescribed therapeutic regimen 

TIMING OF MAMMOGRAMS 

• The National Cancer Institute (NCI) and the American Cancer Society differ in their recommendations for scheduling of mammograms 
• NCI recommends (2002): 

1. Women in their 40s should be screened every one (1) to two (2) years with mammography 
2. Women aged 50 and older should be screened every one (1) to two (2) years 
3. Women who are at higher than average risk of breast cancer should seek expert medical advice about whether they should begin screening before age 40 and the frequency of screening 

• The ACS guidelines for the detection of breast cancer in asymptomatic women (2002): 

1. Women 40 years of age and older should have a mammogram every year 
2. Women 40 years and older should have a physical examination of the breast every year, performed by a health care professional, such as a physician, physician assistant, nurse or nurse practitioner. This examination should take place near and preferable before, the annual mammogram 
3. Women 20-39 should have a physical examination of the breast every three (3) years, performed by a health care professional such as physician, physician assistant, nurse or nurse practitioner 

• BSE is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away 

POINTS TO REMEMBER:

• 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