Sinclair Nursing Program Requirements

SINCLAIR COMMUNITY COLLEGESINCLAIR COMMUNITY COLLEGE
Associate Degree Nursing Program
NSG 1130
COURSE REQUIREMENTS
PREPARATION
Nursing courses are demanding in time and effort. The expectation is that the student will prepare by
reading and utilizing other learning resources before the topic/concept is discussed in class. Preparation
and familiarity with the content enhances learning and assimilation of information in the clinical setting.
Bring questions and be prepared to discuss concepts during class time. Develop a study schedule the
first week to follow throughout the semester.
ALL BEEPERS AND CELL PHONES MUST BE TURNED OFF DURING CLASS SESSIONS.
LEARNING RESOURCE PACKET (LRP)
• The student is responsible for the entire content of the packet.
• It contains the terminology, required learning resources, learning outcomes, unit objectives, content
outline, learning activities/opportunities, and study guides.
• Terminology, study guides and other learning exercises must be completed by the student. The
instructor may request to see completed work.
NURSING SKILLS LABORATORY
LOCATION: Nursing has five skills laboratories, 3313, 3333, 3322A, 3231, and 1012.
Students enrolled in NSG 1130 will use 3313 or 3333 for practice.
PURPOSES: Each lab is used for class, college lab, independent study, and simulation
evaluation.
The skills laboratories are designed to provide
− opportunities to reinforce and practice the technical assessment skills of
NSG 1130.
− resources to support and supplement the content.
− resources to implement the learning activities of NSG 1130.
− a place to interact with peers to study and discuss class and lab content.
ATTENDANCE: Each student is expected to use the lab for independent practice and study
each week. To verify attendance in the lab, the student must sign in each time
the lab is used and must indicate the purpose for being there (i.e., class,
practice, etc.).
HOURS: Laboratory hours will be announced and posted in Angel beginning of each
term.
ASSISTANCE The lab supervisor and student workers are available to help when needed.
NO FOOD, DRINKS, OR CHILDREN PERMITTED IN THE SKILLS LABS

MULTIMEDIA RESOURCES
LIBRARY LIB GUIDE
The supplemental videos by Nursing Education in Video that can be viewed from a computer is accessed
through the library via ANGEL. Open up ANGEL and under MyCollege (lower right corner of screen) click
on Library. Under the Welcome to the Library screen click on Life and Health Sciences. Next click on
Nursing and then click on the tab Nursing 1130 LPN/RN Transition. This lists the videos available for
viewing for the course. Click on the title of the video and it will start to play.
The student is responsible for obtaining and reading articles and viewing multimedia materials that are
required for independent study. Nursing 1130 students can access a list of these audiovisuals through
LRP and ANGEL.
HINTS FOR SUCCESS
1. NSG 1130 is demanding in time and effort as it is a four (4) credit hour course involving class and
college lab experience.
2. Allow approximately 13 hours per week in addition to scheduled class and college lab times to read the
textbook, review lecture notes, view audio visuals, practice skills, and prepare for college lab.
3. Lectures are to amplify and clarify the material. It is the student's responsibility to seek guidance or
counseling, when there is difficulty in understanding content or when achieving a low grade.
EVALUATION
The faculty of NSG 1130 believes that evaluation is a vital part of the learning process. Written
quizzes/exams and assignments along with an assessment performance exam are all part of the evaluation.
These are all tools for student learning and an indication whether or not learning outcomes are being met.
In order to pass NSG 1130, the student must achieve:
• 80% on exams, quizzes, and written assignments.
• A satisfactory rating on performance head to toe exam and IV exam.
• A satisfactory on portfolio completion.
1.Written exams
• Quizzes
• Unit exams
• Comprehensive final exam
• Dates are listed on the course calendar
• Exams items will be selected from: textbook, readings, required multimedia resources, LRP study
guides, key terms, lecture, and college lab content. The exam items are based upon unit learning
outcomes and will emphasize knowledge, comprehension, application and analysis of data.

• Each unit exam will cover the specific content of the unit(s). The student is responsible for all previously
learned material.
• Exams and quizzes will begin promptly as scheduled and there will not be time allowances for
latecomers.
2.Written assignments
• Nursing Process Tool / Care Plan Scenario
• LPN to RN Transition Topic Paper
3.Assessment Performance Exams
• Student will perform head to toe assessment on a peer for the faculty member during the final weeks of
the course.
• Course Requirement
• Must pass with a satisfactory to pass the course. No points assigned.
4.IV Skill Performance Exam
•Student will demonstrate converting saline lock to maintain along with math calculations, &
documentation.
•Course requirement
•Must pass with a satisfactory to pass the course. No points assigned.
PORTFOLIO
• The student will bring as directed by the faculty member the first week of class the purchased portfolio
notebook and content pages. The student will be instructed how to put the portfolio together and
utilize each section throughout the program. It is the student’s responsibility to keep all sections of the
portfolio current throughout the term. The student will bring the portfolio the last week of class for
review by the faculty and to receive a satisfactory or unsatisfactory grade regarding thoroughness and
current status of the portfolio. The student needs to receive a satisfactory grade to pass the course in
this section.

Nursing Process Tool/Care Plan Scenario Written Assignment
• A patient scenario will be given to you in class for utilization in filling out a nursing process
tool including the development of a care plan.
• Rubric for grading will be given to you in class.
• Due date will be on the course calendar.
• Worth 50 points.
LPN to RN Transition Paper
• Write a five page narrative response to your transition from LPN to RN.
• Specific directions and grading rubric will be given to you in class.
• Due date will be on the course calendar.
• Worth 40 points.
Head to Toe Assessment Performance Examination
• Performance exam criteria on the next page.
• It is graded satisfactory / unsatisfactory rating.
• Need to receive satisfactory to pass NSG 1130.
• Bring all the equipment you will need to perform the assessment.
• Takes place in one of the nursing skills labs.
• Specific time and date will be provided towards the last few weeks of the course.
• The faculty member is there only to observe and evaluate your performance, not to coach and teach.
• You may address comments or communicate with the instructor as a member of the patient’s health
care team.
• During the examination, if you make an error, call it to the instructor’s attention at that time.
Otherwise, it will be counted as a mistake and an unsatisfactory performance.

HEAD-TO-TOE ASSESSMENT PERFORMANCE EXAM CRITERIAHEAD-TO-TOE ASSESSMENT PERFORMANCE EXAM CRITERIA
DATE _________________ STUDENT _____________________________________
TIME ALLOWED 10 MINUTES
S = Satisfactory U = Unsatisfactory
___ Determined LOC _____ Oriented x4
___ Hair
___Pupils (PERRLA) ____Pupil size _____Convergence
___ Ears (drainage, obstruction, lesions)
___Nasal cavity (mucous membranes; internal/external lesions,drainage)
___ Oral (mucous membranes; internal/external lesions; midline tongue)
___ Neck assessment
____JVD ___Carotid pulse palpation ___ Carotid pulse auscultation ___ Midline trachea
___ Skin assessment
___Turgor ____Temperature/moistness compare extremities to trunk ___Color
___ Upper extremities
___ Grip ___Capillary refill ___ ROM
____ Chest symmetry
___ Breath sounds (auscultate all lobes anterior & posterior)
___ Heart sounds
____Apical pulse
____Identified landmarks – A, P, T & M
___ Abdomen
___Inspection ____Auscultated 4 quadrants _____Palpation
___ Lower extremities
______Skin temperature compared to trunk
______Capillary refill
______Pedal pulses
______Edema
______Homan’s sign
______ROM
______Foot strength (dorsiflexion and planter flexion)
Passed Redo

IV SKILL PERFORMANCE EXAMINATION
The performance examination is pass/fail based on achieving a satisfactory rating for the assessment,
planning, implementation and documentation of the skill included in the examination. The psychomotor
skill included in the examination is converting a saline lock to a mainline IV. Psychomotor skill criteria are
based on the skill criteria on the next page and in your NSG 1130 LRP IV skills section. You will be
expected to communicate with the mannequin as if it were an actual patient. Individual times for the
performance examination will be assigned by the instructor towards the end of the semester for the last
week of class/clinical. You will have three attempts to complete the skill satisfactorily.
The performance examination takes place in one of the nursing skills laboratories at school. The
examination is completed with your NSG 1130 faculty member. The faculty member is there only to
observe and evaluate your performance, not coach and teach. You may address comments or
communicate with the instructor as a member of the patient's health care team. During the examination, if
you make an error, call it to the instructor’s attention at that time. Otherwise, it will be counted as a
mistake and an unsatisfactory performance.
You will be given a patient scenario requiring math calculations. You will then proceed to the nursing skills
interventions followed by documentation. There will be 20 minutes to complete the examination.
Approximate times are: 5 minutes for math calculations, 10 minutes for skill implementation and 5 minutes
for documentation.
Feedback on your performance will be provided later the day of the performance. The expectation is to
come prepared and pass the performance examination successfully the first time. However, there is an
opportunity to redo the examination up to two more times for a satisfactory passing grade if you are
unsuccessful on the first attempt. If still unsatisfactory after 3 attempts, the result is failure of the
performance examination and NSG 1130.
A satisfactory performance does not add points to the theory grade. A passing grade must
be achieved on the performance examination in order to pass NSG 1130.

CONVERTING SALINE LOCK TO INFUSING IV MAINLINE
Objective:
 To maintain fluid and electrolyte balance.
 Administer medication by the intravenous route.
Equipment:
 Alcohol swabs
 Gloves
 Infusion set
 IV pole or IV pump
 IV solution as ordered by physician
 Tape or time tape
INTERVENTION Sat. UnSat.
ASSSESSMENT:
1. Assess the laboratory data.
2. Assess the patient history of allergies.
3. Assess the type and duration of IV therapy as ordered by physician.
4. Assess the vital signs for baseline data.
5. Wash hands.
PLAN:
6. Organize the equipment in the medication room.
7. Check the IV solution and the medication additives with the MAR and /or physician’s
order.
8. Calculate the IV flow rate.
INTERVENTION:
9. Remove the outer wrap around the IV bag
 Check the solution for color, clarity and expiration date.
 Time tape the container by securing adhesive tape or fluid indicator tape along the
side of the volume markings.
 If the IV is not prelabeled by the pharmacy, place adhesive tape at the top of the
container and label with the date and time, patient’s name, room number, hourly
rate of infusion and student initials. Do not occlude the name of the IV solution.
10. Hang the IV container on an IV pole and open the infusion set package maintaining
aseptic technique.
 Remove the tubing from the package and straighten it. Maintain aseptic technique
while removing and straightening the tubing.
 Do not allow tubing to dangle down or touch the floor.
 Slide the tubing (roller) clamp upward until it is just below the drip chamber and
close tubing (roller) clamp.
Example Narrative Charting for Converting a SL into a Continuous IV Infusion
10/3/14 0800 - A&O X4, denies history of allergies & verbalizes understands new order to add 0.9% NS IV to maintain
hydration. Assessed labs and baseline VS. RFA #20 ONC SL IV site intact without signs of infiltration (cool, pale, pain,
swelling) or phlebitis (redness, warmth, tenderness, drainage). Tegaderm/Opsite drsg dry, clean, & intact. Cleansed
RFA SL with alcohol swab. Per hospital P&P, flushed RFA SL with 3ml NS. SL patent without signs of infiltration. Per
physician order, added IV bag of 0.9 N.S. 1000 ml at 17 gtts/min, 100ml/hr to RFA SL. IV infusing without signs of

infiltration. Patient denies pain or discomfort during RFA SL flush and 0.9% NS IV infusion.
---------------------------------------------------------------------------------------------------------V. Jackson SNS

NURSING 1130
IV PERFORMANCE EXAMINATION
STUDENT NAME______________________________ DATE______________________
Attempt - 1 2 or 3
Critical Thinking YES NO COMMENTS
All three math calculations are correct.
Psychomotor Component
Converting SL to mainline IV (see skills checklist)
Documentation
Date
Time
Assessment
Flushed SL and was patent.
IV site without S & S of infiltration (cool, pale, pain,
swelling) or phlebitis (redness, warmth, tenderness,
drainage
Dressing dry and Tegaderm/Opsite intact
Intervention
Started infusion of 0.9 N.S. at ______gtts/min or ml/hr
Site location
Evaluation
IV site infusing without difficulty or complications
All entries signed – Signature SNS

UNIT I: FOUNDATIONS OF ASSESSMENT
LEARNING OUTCOMES LEARNING/CLINICAL OPPORTUNITIES
At the end of this unit, the learner will be prepared to:
1. Describe the purposes of assessment
2. Describe the process of assessment
2.1 Database development
Reading Summary:
Berman & Snyder: Chap 11, pp. 178-197 (Assessment), Chap. 23, pp. 412-
431 (Older Adult), Chap. 30, pp. 574-584 (Health Assessment), Chap. 26, pp.
462-482 (Communication)
− Types of data
− Subjective Participate in classroom discussion.
 Objective
 Constant
 Variable
− Sources of data
° Primary
− Patient
° Secondary
− Family
− Health care team members
− Health records
− Electronic
− Hard copy
Compare and contrast the essential heath history assessment information that
must be available in a common database (electronic vs hard copy) to support
patient care.
3. Discuss preparation of the patient for assessment Participate in discussion.
3.1 Approach
− Manner – assertive, task oriented
° Confident, open body posture
° Eye contact
° Adaptation to patient
Role play approaches for assessment.
° Control
− Explanation
° Who, what, why, how
3.2 Comfort
− Privacy
− Confidentiality
4. Discuss assessment techniques Participate in classroom discussion.
4.1 Interview Phases
- Preparatory/Planning
- Charts
 Timing
 Environment
- Orientation
 Introduction/Opening

 Tone/Purpose
 Patient’s primary needs
- Working/Development
 Information gathering
 Communication techniques
 Termination/Closing
 Thanks
 Summarize
 Conclude
Interview a peer related to experience in extended care facility during NA
training.
4.2 Health History
- Biographical
- Reason for seeking health care
- History of present illness
- Past history
- Family history
- Environmental
- Lifestyle
- Psychosocial
- Patterns of health care
4.3 Assessment Techniques
- Inspection – Vision
- Systemic observation
- Palpation – Touch
- Percussion –Hearing
- Auscultation – Hearing
- Sound characteristics
- Olfaction – Use of smell
4.4 Utilize strategies to minimize the risk of harm during assessment.
- Positioning
Complete Exercise on Positions in the LRP.
5. Discuss therapeutic communication skills utilized during assessment Participate in lecture/discussion.
5.1 Thought process
− Orientation
5.2 Listening
5.3 Verbal Communication
- Terminology
- Pacing
- Intonation
- Clarity
- Timing and Relevance
5.4 Communication Techniques
- Open ended questions
- Closed ended questions
Identify typical questions used to gather data (assess).

- Focusing
- Clarifying
- Paraphrasing
- Summarizing
- Supplementary statements/Back channeling
5.5 Nonverbal communication
- Appearance
- Posture and gait
- Expressions
- Eye contact
- Gestures
-- Space
5.6 Identify the multiple dimensions of providing patient-centered care when
communicating with diverse patients.
- Language differences
- Visually/Hearing impaired
- Cognitively impaired
- Speech difficulties
- Unresponsive
6. Define and describe four approaches to assessment
Identify personally held attitudes about caring for a diverse patient.
6.1 Initial
- General Information/baseline data -subjective
− Use/purpose/rationale
− Establish database
− Nursing admission history
− Head to Toe – objective data
− Vital signs
− Body systems
6.2 Problem Focused/Problem Oriented
− Rationale
− Requirements
° Medical diagnosis (stressor)
° Knowledge of stressor
° Needs created by stressor
° Reason in agency, requiring home visit
° Prioritization for essential assessment
− Components
° Responses (signs/symptoms) created by stressor
° Treatments
° Additional information based on data finding

Questions about preliminary data
Do I know about this person’s medical diagnosis?
Do I know expected treatments?
What is unique about the assessment of a person with this
diagnosis?
6.3 Daily/Ongoing – General Survey
− Use/purpose/rationale
− Physiological component
° Oxygenation - respiratory status
° Circulation - color, LOC
° General appearance
° Physical integrity-assistive devices
° IV’s, catheters, O2, NG tubes
° Mobility
° Assistive devices
− Environment
° Temperature
° Lighting
° Floor
° Cleanliness
° Bathroom
° Other persons present
6.4 Emergency
- Life threatening situations
- Evaluate ABC’s (airway, breathing, circulation)
- Status of life sustaining physical functions
7. Discuss adaptations of assessment for the elderly
7.1 Hearing and vision changes
7.2 Decreased energy
7.3 Psychosocial changes
7.4 Assistive devices
7.5 Safety, time
8. Identify evidence-based principles of asepsis that apply to assessment. Participate in discussion.
8.1 Medical asepsis
8.2 Review of Standard Precautions
9. Describe assessment of cognitive abilities
− Ability to learn
− Level of orientation

10. Describe caring behaviors used during assessment
10.1 Respect, acceptance
10.2 Empathy
10.3 Genuineness
10.4 Concreteness
10.5 Unhurried approach

FORM FOR PEER INTERVIEW
(OPTIONAL)
Name
Focused interview--have the peer relate a memorable experience from LPN clinical or an experience from
other health care that tells good or bad experience.
Summarize what the experience was.
Use some closed ended questions as well as open ended and also use focusing as a technique.

NURSING 1130
UNIT I
EXERCISE ON POSITIONS
Define the following positions and state what areas of the body can be assessed in this position.
Sitting
Supine
Dorsal recumbent
Sims
Prone
Lithotomy
Fowlers

UNIT I:
SUPPLEMENTAL READING
Chapman, K. (2009). Improving communication among nurses, patients and physicians. American Journal of
Nursing, 109(11), 21-25.
NLN Position Statement (May 9, 2008). Preparing the next generation of nurses to practice in a technology-
rich environment: an informatics agenda. Retrieved February 2009 from:
http//www.mlmn.org/aboutnln/Positionstatements/Informatics 052808

UNIT II: DATA GATHERING WITH THE INDIVIDUAL AND FAMILY
SECTION I: THE IN-DEPTH ASSESSMENT: FAMILY
At the end of this unit the learner will be prepared to: Reading Summary:
1. Identify the types of family structure:
1.1 Traditional/Nuclear
1.2 Blended
1.3 Extended
Berman & Snyder: Chap. 16, pp. 275-297 (Health Promotion), Chap 17, pp. 298-
314 (Health, Wellness, Illness), Chap. 18, pp. 316-334 (Culture), Chap. 24, pp. 434-
445 (Family Health), Chap. 20: pp. 354-371 (Development), Chap. 41, pp. 1058-
1076 (Spirituality), Chap 42, p. 1085 (Defense Mechanism), Chap. 23: p. 426 (Aging)
1.4 Single parent Participate in discussion.
1.5 Alternative
2. Identify techniques to be used when families are assessed:
2.1 Listening
2.2 Observing
2.3 Interviewing
3. Describe assessment of the family
3.1 Structure
- Type
- Size
- Ages of members
- Stage and tasks (Erikson)
- Roles and functions
 Work, employment
 Financial control
 Household
 Child-rearing
 Decision making
 Socialization
 Perceived roles
 Responsibilities accepted
- Physical health status
 Perception of health status of each member
 Preventive factors
 Routine health care practices
Choose a family in the community (not own immediate family) and complete an
assessment. See directions in front section of this LRP for Family Profile Portfolio
instructions.
- Social interactions
 Types
 With whom
- Lifestyle patterns:
 Family values
 Cultural/religious orientation
 Leisure time, recreation
 Education
 Transportation
NSG 1130/FALL 2012

 Income
- Coping resources
 Support to each other
 Outside support
 Methods used
 Insurance
 Caregivers (Children, Older Adults)
 Community resources
4. Describe assessment of the spiritual aspects
4.1 Characteristics of spirituality
- Relationships: self, nature, others, deity
- Spiritual distress
4.2 Interview
- Religious practices and rituals
- Relationship between religious beliefs and health
4.3 Observable signs of practice
Discuss spiritual assessment questions that can be used.
5. Describe how cultural, ethnic and social backgrounds function as
sources of patient, family and community values.
5.1 Culture and ethnicity definitions
5.2 Components of culture assessment
- Ethnohistory
- Biocultural history
- Social Organization
- Religious Beliefs
- Communication
- Time orientation
Refer to Guidelines for Communication with Diverse Cultures in LRP.
Identify personally held attitudes about caring for patients from different cultural,
ethnic and social backgrounds.
6. Describe assessment of coping, family or individual
6.1 Definition of Coping
− Types of coping strategies:
 Problem – focused
 Emotion - focused
Discuss how you have utilized problem-focused coping verses emotional-focused
coping strategies.
NSG 1130/FALL 2012

7. Concepts of illness
− Disease
− Acute illness
− Chronic illness
− Illness behaviors
− Impact of illness
 Individual
 Family
8. Discuss the assessment of the caregiver in the home.
8.1 Feelings:
− Guilt
− Inadequacy
− Resentment
− Anger
− Fear
− Satisfaction
Describe what it would be like to be a caregiver.
9. Use diagnostic reasoning to discuss the data gathered during the family
assessment to develop a family-centered care plan.
Participate in class discussion.
9.1 Questions related to preliminary data (Examples listed, not
inclusive)
− What is expected:
 in this family situation?
 in this culture?
 in this type home environment?
 because of this religion?
 in this age group?
 with this knowledge base?
9.2 Questions related to decision making
− What effect does lifestyle have?
− What effect does health status have?
− What deviates from expectations?
− Is more information needed?
− What is the health belief of patient and family?
9.3 Questions to gather supportive data
− Do I need to talk with other family members? or several at the
same time?
− Do I need a member of the clergy?
− Do I need an interpreter?
NSG 1130/FALL 2012

NSG 1130
GENERAL COMMUNICATION GUIDELINES FOR DIVERSE CULTURES
1. Speak slowly and clearly.
2. Use concrete language.
3. Make sentence structure simple.
4. Encourage person by smiling and by active listening.
5. Use cues such as pictures or gestures.
6. Avoid use of technical language.
7. Incorporate cultural language when possible.
8. Do not assume that because the patient smiles or nods that the communication is understood.
9. Allow enough time to interact.
10. Identify barriers to compliance such as social values, environment and language.
11. Repeat phrases, expand on basic themes.
12. Close with comments that show positive, appreciation of their participation.
13. If interpreter needed –meet with interpreter prior to patient interview.

UNIT II: DATA GATHERING WITH THE INDIVIDUAL AND FAMILY
SECTION II: THE IN-DEPTH ASSESSMENT: THE HOME
Reading Summary:
At the end of this unit the learner will be prepared to: Berman & Snyder: Review Chap. 24 (Family), Chap 7, pp. 116-129 (Community),
Chap. 32, pp. 716-729 (Safety)
1. Identify what is home to the patient
1.1 Traditional
1.2 Agency
1.3 Homeless Participate in lecture/discussion.
2. Discuss the home hazard appraisal
2.1 Walkways and stairways
2.2 Floors
2.3 Furniture
2.4 Bathroom
2.5 Kitchen
2.6 Bedrooms
2.7 Electrical
2.8 Fire protection
2.9 Toxic substance
2.10 Firearms, weapons
2.11 Telephone
3. Identify home hazards for specific age group
3.1 Infants, Toddlers, Pre-schooler
3.2 School -Age
3.3 Adolescents
3.4 Adults
3.5 Older adults
4. Discuss assessment of the environment of a homeless person, a person
living in a shelter
5. Discuss a community Participate in discussion.
5.1 Definitions
5.2 Subsystems of a community
− Environment
− Education
− Safety and transportation
− Politics and government
− Health and social services
− Communication
Identify aspects of Community Assessment.
Complete community windshield assessment assignment.

− Economics
− Recreation
− Resources
5.3 Diagnostic reasoning related to community
− What is the health status of the community?
 Its vulnerability?
− What is its health capability or ability to deal with health
problems?
− What are the ways in which the community is likely to work on
its health problems?
5.4 Indications of a healthy community
− Sense of being a community
− Concern about the future
− Recognizes groups within
− Prepared for crises
− Problem solves
− Open communication
− Settles disputes
− Group decision making
Make a list of community resources available in Dayton. Include resources for
health promotion.
Describe own house and family as a community

UNIT II: SECTION 1 AND 2
ASSESSMENT INDIVIDUAL, FAMILY, AND HOME
Define the following terminology:
Acute illness
Alternative family
Anger
Biocultural history
Blended family
Chronic illness
Compensation
Denial
Ethohistory
Extended family
Fear
Guilt
Homeless
Inadequacy
Life-style pattern
Nuclear family
Projection
Rationalization
Regression
Repression
Religious beliefs
Resentment
Single family
Social organization
Spiritual distress
Spirituality
Time orientation
Traditional family

UNIT II
Facente, A. (2010). Toward cultural competence. American Journal of Nursing, 110(12), 52-55.
Gray-Vickrey, P. (2010). Gathering “pearls” knowledge for assessing older adults. Nursing, 40(3), 34-42.
Hess, C.T. (2009). Assessing the total patient. Nursing, 38(11), 24.
Huber, L. (2009). Making community health care culturally correct. American Nurse Today,
4 (5), 13-15.
Lackey, S.A, (2009) Opening the door to spirituality sensitive nursing care. Nursing, 39(4), 46-46.
Levine, C. (2011). Supporting family caregivers: The hospital nurse’s assessment of family caregiver needs.
American Journal of Nursing, 111(10), 47-51.
Walton, M. (2011). Supporting family caregivers: Communicating with family caregivers. American Journal of
Nursing, 111(12), 47-53.

UNIT III: IN-DEPTH PHYSIOLOGICAL ASSESSMENT: EXCHANGING
Section 1: Circulation
At the end of this unit, the learner will be prepared to: Reading Summary:
Van Leeuwen & Poelhuis-Leth (V & P): Reference I-Touch for labs and
diagnostic tests which correlate to the learning outcomes.
1. Explain the physiological components of a cardiovascular assessment
1.1 Cardiac Output
- Stroke volume
- Heart rate
- Renal
2. Utilize physical assessment skills to complete a cardiovascular
assessment
2.1 Cardiac Output: Auscultation and Palpation
Berman & Snyder: Chap 23, pp. 418-421, Chap. 24, pp. 809-814 and 828-829
(Diagnostic Tests) Chap. 29, pp. 545-556 (Vital Signs, Pulse), pp. 560-567 (Vital
Signs, B/P), Chap. 30, pp. 626-636 (Cardiac/Vascular Assessment) Chap. 57,
pp. 1426-1442 (Circulation)
Complete study guide in LRP using the required videos in the Angel NSG
1130 site.
- Vital signs (Review) Participate in lecture.
Review the anatomy and physiology of the cardiovascular system.
- Heart sounds
− S1 - Valves involved
 Lub
− S2 - Valves involved
 Dub
− Anatomic landmarks
− Point of Maximum Intensity (PMI)
− Apical pulse/Heart rate
− Dysrhythmia
− Murmurs
- Abnormal heart sounds
− S3 - Ventricular gallop – Lub Dub Dee
− S4 - Atrial gallop – Dee Lub Dub
Review correct use of stethoscope.
Perform a cardiovascular assessment on a peer during college lab.
Review vital signs technique from nursing assistant course.
Practice vital signs in college lab.
Utilize heart sound simulator in skills lab.
2.2 Tissue Perfusion: Inspection and Palpation
- Peripheral
− Pulses
− Skin color
− Temperature of skin-chest vs. extremities
− Capillary refill
− Jugular vein distention
− Bruits
− Edema
 Definition
 Sites
 Grading
Demonstrate use of Doppler in skills lab.

− Hands/Feet assessment
 Homan’s sign
 Hair Growth
2.3 Fluid Balance: Inspection and palpation
- Mucous membranes
- Skin turgor
- Intake and output
3. Identify developmental changes (Moving) within the cardiovascular system
3.1 Changes with aging
− Decreased compliance of heart muscle & vascular system
− Increased rigidity/thickening of heart valves
− Dysrhythmias
− Thickening and decreased elasticity of vessel walls
− Decreased cardiac output
− Increased circulation time
− Diminished heart tones
− Hypertension
− Peripheral arteries become thicker/dilate less effectively
− Blood vessels become more tortuous
− Distal pulses lower extremities difficult palpate
- Decreased vascular compliance
- Decreased stroke volume
4. Utilize a focused interview with sensitivity and respect for human diversity
to identify experiential perspectives of a cardiovascular assessment.
4.1 Psychosocial (Knowing and Perceiving)
- Type A Personality
- Relaxation
- Stress
Identify your own experiential perspectives of your cardiovascular health.
4.2 Environmental (Valuing)
- Family history
- Culture
- Socioeconomic status
4.3 Self Care (Choosing and Moving)
- Diet
− Obesity
− Cholesterol
− Sodium intake
- Exercise
- Smoking

5. Identify diagnostic studies applicable for a cardiovascular assessment
5.1 Blood Studies: Definition and Normal Values
- Hematology - CBC (Complete Blood Count)
− RBC (Red Blood Count)
− Hemoglobin (Hgb)
− Hematocrit (Hct)
V&P
- Erythrocyte Sedimentation Rate (ESR) (Sed. Rate)
- White Blood Cells (WBCs)
V&P
V&P
5.2 Coagulation studies
- Platelet count
- Prothrombin time (PT)
- Partial Thromboplastin Time (PTT)
V&P
V&P
V&P
5.3 Chemistry studies
- Serum Electrolytes
 Potassium (K)
 Sodium (Na)
 Chloride (CL)
 Calcium (Ca)
V&P
V&P
V&P
V&P
5.4 Cholesterol
− High Density Lipid (HDL)
− Low Density Lipid (LDL)
− Triglycerides
V&P
V&P
5.5 Non-invasive studies – Definition and Normal Values
− X-Ray
 Chest (CXR)
− Electrocardiogram (ECG)
− Stress test
− Doppler
V&P
V&P
V&P
5.6 Invasive studies
− Angiography
 Arteriography
 Venography
 Cardiac catheterization
Lewis: pg. 706.
V&P
V&P
6. Use diagnostic reasoning to discuss the data gathered during the
cardiovascular assessment to develop a patient-centered care plan.
6.1 Questions related to cardiovascular assessment (not inclusive)

- Do patient’s findings correlate with a normal cardiovascular
assessment:
− If not, what caused the change?
° Age
° Other disease process
° Medications
- Are diagnostic studies normal or abnormal?
- What risk factors are contributing to the current cardiovascular
problems? Are they modifiable?
- Can family members or significant others offer information to
supplement cardiovascular assessment?
7. Identify nursing diagnoses commonly associated with the cardiovascular
assessment.
7.1 Responses
 Decreased cardiac output
 Acute pain
 Ineffective peripheral tissue perfusion
 Risk for decreased cardiac tissue perfusion
 Excess fluid volume
8. Identify evidence-based practice guidelines and standards that promote
cardiovascular health.
Assess your own participation in preventive cardiovascular health behaviors.
8.1 Health behaviors
 Diet
 Activity
 Smoking Cessation Program
 Stress Management
9. Recognize contributions of other individuals and groups in helping
patients achieve cardiovascular health care.
9.1 Health Care Team
 Physical Therapy-Cardiac Rehabilitation
 Dietician
9.2 Community Resources
 American Heart Association
 Smoking Cessation Programs
10. Identify the importance of cardiovascular assessment documentation
utilizing technology and information tools to achieve quality
improvement.
 Quality Improvement
 Patient outcomes
 Safety
 Coordination of care

UNIT III - SECTION 1
CIRCULATION
TERMINOLOGY
Define the following terms:
antipyretic
bruits
blood pressure
bradycardia
cardiomegaly
cardiac output
cyanosis
diastolic pressure
dysrhythmia
erythema
flushing
hypertension
hypotension
ischemia
jaundice
Korotkoff’s sounds
Murmur
obliterate
orthostatic hypotension
pallor
palpitations
perfusion
pulse
pulse deficit
pulse pressure
pyrexia
sphygmomanometer
stethoscope
stroke volume
syncope
systolic pressure
tachycardia
temperature
turgor
vital signs
NSG 1130/FALL 2011 37

LABEL:
1 – 8 -
2 – 9 -
3 – 10 -
4 – 11 -
5 – 12 -
6 – 13 -
7 -
35

HEART SOUNDS LOCATIONS
• Label the value name.
• Name the anatomic location of heart sound.
• Name the heart sound heard in each location (S1, S2).
36

NURSING 1130
STUDY GUIDE FOR CD ROM ON HEART SOUNDS (Stop at Splits)
(Physical Assessment – Heart & Lungs)
DIRECTIONS: Read the following questions before watching the required videos in the Angel NSG 1130 site.
Answer the questions in the space provided.
MATCHING
Match the identified sounds in Column I with the description/location in Column II.
Column I Column II
1. S1 heart sound _______ A. Tricuspid Valve - 5th
Intercostal Space ICS Left Sternal
Border (LSB)
2. S2 heart sound _______ B. Mitral Valve - 5th
ICS Midclavicular (MCL)
3. S3 heart sound _______C. Aortic Valve - 2nd
ICS Right Sternal Border (RSB)
4. S4 heart sound _______D. Pulmonary Valve - 2nd
ICS LSB
_______E. Ventricular gallop - heard at mitral area with bell of
stethoscope - sounds like Kentucky - (lub-dub-dee)
_______F. Atrial gallop - heard at aortic area with bell of
stethoscope - sounds like Tennessee - (dee-lub-dub)
_______G. Closure of semilunar valves
_______H. Closure of atrio-ventricular valves
QUESTIONS
1. What positions can be used to auscultate the heart sounds?
2. Identify the anatomic site (chest landmarks) where the following are located.
Apex of the heart
Base of the heart
3. When is the 3rd
heart sound considered normal?
4. When is the 4th
heart sound considered normal?
5. Identify where the following valves are located in the heart.
Mitral
Tricuspid
Aortic
Pulmonic
6. Which heart sound corresponds with the onset of systole?
7. Which heart sound corresponds with the onset of diastole?
8. Define systole:
Define diastole:
37

GUIDELINES FOR ASSESSING THE BLOOD PRESSURE WITH SELECTED REVIEW QUESTIONS.
(Berman & Snyder, pp. 562-567)
1. Select the best upper arm site for B/P assessment:
1.a Identify five reasons to avoid taking a B/P in a specific arm:
1.b What other site could be used if the BP cannot be taken in an upper arm?
1.c Name 2 positions the patient can assume for BP assessment.
2. Select the appropriate cuff size.
2.a What happens if a cuff is too small (narrow)?
What happens if the cuff is too large (wide)?
2.b How do you measure for correct cuff size?
2.c How should the arm be positioned?
2.d Should clothing on selected arm be removed?
3. What are the normal ranges for adult blood pressure (B/P)?
Systolic Diastolic
38

4. Palpate the brachial artery and make sure the markings on the cuff are correctly positioned or aligned.
4.a How far above the brachial artery is the cuff applied?
4.b Describe the location of the brachial artery.
5. Perform the palpatory blood pressure first.
5.a Wrap the cuff correctly on the upper arm. Place the aneroid gauge so that it can be visualized.
5.b Palpate the radial or brachial artery pulse.
5.c Inflate the cuff while continuing to palpate the pulse.
5.d Note the point of the gauge where the pulse disappears or is obliterated. This is an estimate of the
systolic pressure.
5.e Deflate the cuff, wait 30 seconds then inflate the cuff to 30 mm above the estimated systolic
pressure that was determined in #5d.
5.f Why do you perform the palpatory BP?
5.g How long do you wait before taking the BP using the stethoscope?
5.h How far do you inflate the cuff after the palpatory systolic reading is reached?
6. After waiting the appropriate time, relocate the brachial artery and with the stethoscope in place, rapidly
inflate cuff to the prescribed level above palpated pressure.
7. Slowly release the aneroid bulb pressure at a rate of 2-3 mm Hg/second and note when the first clear
sound is heard.
8. Continue to deflate the cuff until a muffling sound is heard which is the diastolic pressure.
9. Record the BP on a notepad until it can be documented on the patient’s chart.
39

UNIT III – SECTION I
CIRCULATION
SUPPLEMENTAL READING RESOURCES
Circulation
(2008). Heart Healthy Living. Nursing, 38(4), 43.
(2008). Cardiovascular Challenge. Nursing, 38(7), 58-59.
Cnizner, M.A. (2008). Cardiac auscultation: Rediscovering the lost art. Current Problems in Cardiology,
33(7), 326-408.
McCarron, K. (2008). The lipid lowdown. Nursing Made Incredibly Easy, 6(2), 56.
Miller, J. (2010). Deciphering clues in the CBC count. Nursing, 40(7), 52-55.
Portman, H. & Sheppard, S. (2011). Vital information about a vital sign: BP. Nursing, 41(2), 66.
Pullen, R. (2008). Preparing a patient for magnetic resonance imaging. Nursing, 38(10), 22.
Rushing, J. (2009). Assessing for dehydration. Nursing, 39(4), 14.
40

Section 2: Oxygenation
Van Leeuwen & Poelhuis-Leth (V&P) – Reference I-Touch labs and diagnostic
tests that correlate with learning outcomes.
1. Identify physiological components of the respiratory assessment
1.1 Gas exchange
− O2 saturation
− Respirations
− Mental Status
1.2 Airway Clearance
− Breath sounds
Berman & Snyder: Chap. 23, pp. 418 and 421, Chap. 29, pp. 555-560 (Vital signs
– Respiratory), pp. 567-570 (O2 Saturation), Chap. 30, pp. 618-626 (Resp.
Assessment), Chap. 34, pp. 812, 826-827, 832 (Diagnostic Tests), Chap. 50, pp.
1379-1390 (Oxygenation)
Complete Study guide in LRP using the required videos in the Angle NSG
1130 site.
2. Identify physical assessment skills to complete a respiratory assessment
2.1 Gas exchange: Inspection and auscultation
− Normal respirations
− Rate, rhythm, depth, ease
− Eupnea
− Dyspnea
− Orthopnea
− Apnea
Review the anatomy and physiology of the respiratory system.
Perform a respiratory assessment on a peer during college lab.
− Chest symmetry
− Normal breath sounds with anatomic sites
− Chest landmarks
− Bronchial
− Bronchovesicular
− Vesicular
Utilize breath sound simulator in skills lab.
− Adventitious Breath Sounds
− Rales (Crackles)
− Rhonchi (Gurgles)
− Wheezes
− Pleural Friction Rub
− Skin color
− Pallor
− Cyanosis
− Hypoxia
− Clubbing of fingers
− O2 Saturation
− Pulse oximetry
 Purpose
 Normal range
 Overview of procedure
Examine the pulse oximeter in college lab.
Measure your own oxygen saturation with the pulse oximeter.
− Mental Status
42

2.2 Airway clearance: Auscultation and Inspection
 Cough
 Sputum production (COCA)
 Breath sounds
 Respirations
3. Identify developmental changes (Moving) that occur in the respiratory
system
• Geriatric
− Decreased number of alveoli and pulmonary capillaries
Decreased diffusion
− Decreased lung elasticity
− Decreased vital capacity
− Decreased activity tolerance
− Decreased respiratory muscle mass/strength
− Decreased rib cage expansion due to skeletal changes
(calcification of costal cartilages, kyphosis, scoliosis, vertebral
changes)
− Decreased cough reflex
− Decreased inhalation and exhalation movements due to
weakened and atrophied thoracic muscles
− Increased residual volume
4. Utilize a focused interview with sensitivity and respect for human
diversity to identify experiential perspectives of a respiratory
assessment.
4.1 Psychosocial (Knowing and perceiving)
− Stress
− Anxiety
Identify your own experiential perspectives of your respiratory health.
− Home environment
 Pets
 Allergens
− Work environment
 Irritants
5. Identify diagnostic studies applicable to a respiratory assessment
5.1 Blood Studies: Definition and Normal Value
− Arterial Blood Gases (ABG’s)
 Ph
 HCO3
 PO2
 PCO2
− Hemoglobin and Hematocrit
V&P
43

5.2 Pulmonary function testing
5.2 Radiography
− Chest x-rays
5.3 Scans
− Lung Perfusion/Ventilation
− CT (Computerized Tomography-Thorax)
− MRI (Magnetic Resonance Imaging)
V&P
V&P
V&P
V&P
V&P
5.4 Endoscopy procedures
− Purpose – tissue examination
− Procedure
− Bronchoscopy
V&P
5.5 Bacteriology
− Culture and sensitivity
− Sputum specimen
V&P
respiratory assessment to develop a patient-centered plan of care.
6.1 Questions related to the respiratory assessment (not inclusive)
- Do the patient’s findings correlate with a normal respiratory
assessment?
- What risk factors are contributing to the current respiratory
problems?
− Smoker
− Asthma
− Environmental surroundings
7. Identify nursing diagnoses commonly associated with the respiratory
assessment
7.1 Responses
- Impaired Gas Exchange
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
respiratory heath.
Assess your own participation in preventive respiratory health behaviors.
8.1 Health Behaviors
44

- Activity
- Smoking cessation
- Vaccinations
- Environmental controls
- Pollutants
- Allergies
− Humidifiers
− Air filters
- Workplace safety
 Respirator
 Dust masks
patients achieve respiratory health goals.
- Respiratory Therapy
- Dietician
- American Lung Association
- Smoking Cessation Programs
10. Identify the importance of oxygenation assessment documentation
improvement.
 Safety
45

UNIT III: SECTION 2
OXYGENATION
TERMINOLOGY
adventitious breath sounds
alveoli
apnea
atelectasis
auscultation
bradypnea
Cheyne-Stokes respiration
crackles
diffusion
dyspnea
exhalation
eupnea
expiration
gurgles
hemoptysis
hyperpnea
hyperventilation
hypoventilation
hypoxia
hypoxemia
inspiration
Kussmaul’s respiration
nonproductive cough
orthopnea
percussion
pleural friction rub
productive cough
pulse oximetry
rales
respiration
rhonchi
tachypnea
ventilation
wheeze
46

Definition
Breath sounds are the sounds produced by the movement of air throughout the
respiratory tract. These sounds vary in their specific characteristics depending upon the
area of the thorax being auscultated and whether or not the underlying lung is diseased.
Breath Sounds Diagram
INSPIRATION - represented by up stroke
EXPIRATION - represented by down stroke
DURATION - represented by the length of stroke
AMPLITUDE - represented by the thickness of the stroke
PITCH - represented by the angle of the upstroke

III. Types of Breath Sounds
BRONCHIAL
Short inspiratory phase and louder expiratory phase.
Brief pause between inspiratory and expiratory phase.
High pitched sounds, loud, harsh, and tubular.
Anterior over the trachea.
Not normally heard over lung tissue.
BRONCHOVESICULAR
1. Heard normally over areas of the thorax where the major bronchi are close to the
chest wall:
a. either side of the sternum
b. between the scapula
2. Inspiration and expiration are equal in duration and intensity.
3. “Blowing” sounds created by air moving over larger airways.
VESICULAR
1. Heard over peripheral lung tissue – best heard at base of lungs.
2. Softest of breath sounds with a swishing, “gentle sighing” quality.
3. Long inspiratory phase and short expiratory phase.
4. Air moving through smaller airways (bronchioles and alveoli)

BREATH SOUNDS
NORMAL SOUNDS
1. Bronchial Pitch: High
Intensity: Loud, predominantly on expiration
Normal Findings: A sound like air blown through a hollow tube, heard over
suprasternal area and lower trachea mainstem bronchus.
Abnormal Findings: If heard over peripheral lung, may indicate atelectasis or
consolidation.
2. Bronchovesicular Pitch: Moderate
Intensity: Moderate
Normal Findings: A blowing sound heard over airways on either side
of sternum, at angle of Louis, and between scapulae.
Abnormal Findings: If heard over peripheral lung, may indicate consolidation.
3. Vesicular Pitch: High on inspiration, low on expiration
Intensity: Loud on inspiration, soft to absent on expiration
Normal Findings: Quiet, rustling sounds, heard over periphery
Abnormal Findings: If decreased over periphery, may indicate early pneumonia,
emphysema, pneumothorax, pleural effusion, or atelectasis
ADVENTITIOUS SOUNDS
c. Crackles (Rales)
Where to Auscultate: Over lung field and airways; heard commonly in bases of lower
lung lobes
Timing: More obvious during inspiration
Cause: Air passing through fluid or mucus in any air passage
Description: Light crackling, bubbling, high-pitched
c. Gurgles (Rhonchi)
Where to Auscultate: Over larger airways
Timing: More pronounced during expiration
Cause: Airways narrowed by bronchospasm or secretions
Description: Coarse rattling, gurgling, harsh, moaning or snoring quality
May be cleared by cough
c. Wheezes:
Where to Auscultate: Overall lung fields and airways
Timing: Inspiration or expiration
Cause: Air passing through narrowed airways
Description: Creaking, whistling, high-pitched, musical squeaks
c. Pleural Friction Rub:
Where to Auscultate: Anterior and lateral side of lung fields
Timing: Inspiration
Cause: Inflamed parietal and visceral pleural surfaces rubbing together
Description: Grating or squeaking sounds

This is a view of the front of the chest, or thorax.

This is a view of the chest or thorax, as seen from behind.

NURSING 1130
STUDY GUIDE FOR CD ROM ON BREATH SOUNDS
DIRECTIONS: Read the following questions before watching the required videos in the Angel NSG 1130
site. Answer the questions in the space provided.
MATCHING
Match the identified sounds in Column I with the description/location in Column II.
Column I Column II
1. Bronchial _______ A. Long inspiratory Phase, short
expiratory phase, rustling or swishing
quality
2. Bronchovesicular _______ B. Short inspiratory phase, louder
expiratory phase, brief pause between
inspiratory and expiratory phase
3. Vesicular _______C. High pitched sounds, loud, harsh,
tubular
_______D. Inspiration and expiration are equal in
duration and intensity
QUESTIONS
1. What positions will the patient be placed in to auscultate breath sounds?
2. Identify the anatomic site where the following are located.
a. Bronchial
b. Vesicular
3. What are friction rubs and when do they occur?
4. Identify the cause of the following abnormal breath sounds and the description of each sound.
Rales
Rhonchi
Wheezes
Friction Rub

NSG 1130
STUDY GUIDE FOR ASSESSING BREATH SOUNDS
Name
SITUATION: You are to assess Mrs. Bayton’s breath sounds.
1. The best position for Mrs. Bayton to effectively assess posterior breath sounds is:
a. sitting on bedside with legs dangling over the side.
b. sitting on bedside leaning over the bedside table.
c. prone.
d. supine propped with pillows.
2. An effective routine or pattern to follow in auscultating breath sounds is:
a. apex to base, comparing right side to left side.
b. base to apex, comparing right side to left side.
c. apex to base, right side of the chest first.
d. all of the anterior chest after the posterior chest.
3. During auscultation, you would ask Mrs. Bayton to:
a. breathe normally, mouth open.
b. breathe normally, mouth closed.
c. breathe deeply, mouth open.
d. breathe deeply, mouth closed.
4. The breath sounds with the longest inspiratory phase are:
a. bronchial.
b. bronchovesicular.
c. vesicular.
5. Bronchial breath sounds are usually:
a. breezy and soft-pitched.
b. loud, high pitched and hollow.
c. soft, swishy and breezy.
d. low pitched and crackly.
6. While auscultating Mrs. Bayton’s chest, you note soft, low-pitched breath sounds over most
of her lungs. These sounds are:
a. bronchial.
b. bronchovesicular.
c. vesicular.

Study Guide
Match the following words with the correct definitions
______ Kussmaul respirations a. Temporary absence of breathing
______ Orthopnea b. Bloody Sputum
______ Apnea c. Irregular rapid respirations followed by
periods of apnea and hyperventilation
______ Hypoxemia d. Unimpaired or normal respirations
______ Eupnea e. Deep gasping type of respirations
associated with acidotic conditions
______ Hemoptysis f. Decreased oxygen concentration of
arterial blood
______ Cheyne-Stokes respirations g. Ability to breath only in a sitting position

UNIT III: Section 2
OXYGENATION
Booker, R. (2008). Pulse oximetry. Nursing Standard, 22(30), 39-41.
Collecton, L. (2008). Beyond the stethoscope: Respiratory assessment of the older adult. Nursing, 40(7),
31-35.
Pruitt, B. (2009). Interpreting ABG’s: An inside look at your patient’s status. Nursing Made Incredibly Easy,
4(3), 12.
Pullen, R. (2010). Using pulse oximetry accurately. Nursing, 40(4), 63.
Sommers, m. (2011). Color Awareness: A must for patient assessment. American Nurse Today, 41(1).
www.american nursetoday.com
Stich, J. Cassella, D. (2009). Getting inspired about oxygen delivery devices. Nursing, 39 (9), 51-54.
Valdez-Lowe, C.L., Ghareeb, S. (2009). Pulse oximety in adults. American Journal of Nursing, 109 (6),
52-55.

UNIT III: Section 2
SUPPLEMENTAL MULTIMEDIA
VIDEOS
Access via Library Website – See directions in front of LRP
Title Length Date
Measuring Vital Signs, in New Nursing Assistant 27:26 min. 2009
Temperature, Pulse, and Respiration, in Measuring 20:02 min. 2011
Vital Signs 1 20:02 mins
Blood Pressure and Pain, in Measuring Vital Signs 2 17 min. 2011

Section 3: Neurological
1. Explain the physiological components of a neurological assessment
Berman & Snyder: Chap. 23, pp. 417-420, 425-426, Chap. 30, pp. 595-603
(Eyes), 603-608 (Ears), pp. 608-610 (Nose), pp. 614-618 (Neck), pp. 648-657
(neurological)., Chap. 39, pp. 1100-1019 (Sensory Perception)
1.1 Mental status
1.2 Level of consciousness
1.3 Motor/sensory function
Participate in lecture.
Review the anatomy and physiology of the neurological system.
2. Utilize physical assessment skills to complete a neurological assessment
2.1 Level of consciousness (LOC)
- Glasgow Coma Scale
- Alert and cooperation
- Lethargic
- Comatose - unresponsive
Perform a neurological assessment on a peer in college lab.
2.2 Language
− Aphasia
 Expressive/motor
 Receptive/sensory
2.3 Attention span
2.4 Orientation
− Time
− Place
− Person
− Situation
2.5 Memory
− Immediate recall
− Recent memory (short-term)
− Remote memory (long-term)
2.6 Cranial Nerves
- Functions
- Assessment

2.7 Sensory Function
− Touch
− Pain
− Temperature
2.8 Motor Function
− Coordination/Balance
− Grip
− Reflexes
2.9 Pupil Reactions- PERRLA/PERLA
− Size in mm
− Equal
− Round
− React to light
− React to accommodation
− Convergence
3. Identify developmental changes (Moving) that occur with the
neurological system
− Changes with aging
 Decreased blood supply to the brain
 Decreased number of neurons
 Decreased nerve conduction
 Coordination changes
 Decreased perception of deep pain
 Decreased perception of temperature
 Decreased neurotransmitters
 Diminished tendon reflex responses
 Decreased period of deep sleep
− Assessment of cognitive abilities
 Folstein – Mini mental assessment
View video: “Assessing the Elderly” – # 121.02 - located in the angel course
4. Utilize a focused interview to identify experiential perspectives of a
neurological assessment
4.1 Psychosocial (Knowing and perceiving)
− Stress
− Personality
− Culture
4.3 Self-care (Choosing and Moving)
− Lifestyle
− Medications
−

5. Identify diagnostic studies applicable for a neurological assessment
5.1 Noninvasive
− EEG (Electroencephalogram)
− Carotid ultrasound
− CT Brain
V&P
1.2 Invasive
− Carotid angiography
neurological assessment to plan patient care
6.1 Questions related to neurological assessment: (not inclusive):
− Do the patient’s findings correlate with a normal neurological
assessment?
 If not, what caused the change?
o Age
o Other disease process
o Medications
− Are diagnostic studies normal or abnormal?
− What risk factors are contributing to the current neurological
problems? Are they modifiable?
− Can family members or significant others offer information to
supplement neurological assessment?
7. Identify nursing diagnoses commonly associated with the neurological
assessment
7.1 Responses
− Risk for injury
− Risk for falls
− Risks for ineffective cerebral tissue perfusion
− Risk for peripheral neurovascular dysfunction
− Impaired swallowing
− Impaired physical mobility
− Impaired walking
− Bathing self care deficient
− Eating self care deficient
− Impaired memory
− Impaired verbal communication

neurologic health goals.
Review safety issues from LPN courses.
− Healthy diet
− No smoking
− Regular exercise
− No alcohol consumption
− Helmet use
− Seat belt use
− No substance abuse
− Safe participation in physical and recreational activities
− Hypertension control
− Diabetes control
Assess your own participation in preventive neurological health behaviors.
patients achieve respiratory health goals.
− Physical therapy
− Speech therapy
− Occupational therapy
− Dietician
− Neuro nurse specialist
− American Lung Association
− Smoking Cessation Programs
10. Identify the importance of oxygenation assessment documentation
improvement.
10.1 Quality Improvement
− Patient outcomes
− Safety
− Coordination of care

UNIT III – SECTION 3
NEUROLOGICAL
TERMINOLOGY
accommodation
alert
aphasia
attention span
comatose
convergence
extraocular movements (EOM)
Glasgow Coma scale
lethargic
level of consciousness (LOC)
memory
orientation
PERRLA /PERLA
pupil reactions
pupil size
reflex

COMPONENTS OF THE FOLSTEIN-MINI MENTAL STATE EXAMINATION
1. Orientation to time---year, season, date, day, month.
2. Orientation to place---state, county, city, hospital, floor.
3. Registration---give three words to remember, have repeat.
4. Subtraction serial 7s counting backwards from 100 or spelling world backwards.
5. Recall---ask to repeat the three words.
2. Language
Naming---name a watch, pencil.
Repetition---ask to repeat--No ifs, ands or buts.
Command---give piece of paper, ask to fold and put on floor.
Read---give card with “close your eyes” and ask to read and do it.
Write---ask to write a complete sentence on a piece of paper.
Copy---ask to copy a design--polygon.
Scoring--Out of possible 30.

Examples of questions to ask when screening a patient's thought processes. Make sure you know the
answer before starting:
What is your name? Orientation to person
What is your mother's name? Orientation to other people
What is today's date? Orientation to time
What year is it? Orientation to time
Where are you now? Orientation to place
How old are you? Memory
Where were you born? Remote memory
What did you have for breakfast? Recent memory
Why are you here? Recent memory
Who is the U.S. president? General knowledge
Can you count backward from 20 to 1? Attention span and calculation skills
Can you repeat the numbers 2, 8, 11, 14, 20? Attention span and calculation skills

UNIT III – SECTION 3
NEUROLOGICAL
SUPPLEMENAL READING RESOURCES
(2010). Assessing visual acuity. Nursing, 40(8), 65.
Anness, E. (2009). Evaluating the neurologic status of unconscious patients. American Nurse Today,
4(4), 8-10.
Huntley, A. (2008). Documenting level of consciousness. Nursing, 38(7), 8.
Otrt, L. (2008). Assessing blood flow with CT angiography. Nursing, 38(1), 26.
Palmieri, R. (2009). Wrapping your head around cranial nerves. Nursing, 39(9), 24-31.
Pullen, R. (2008). Preparing a patient for magnetic resonance imaging. Nursing, 38(10), 22.
Vacca, V. (2010). How to perform a 60 second neurologic exam. Nursing, 40(6), 58-59.

Unit III: IN-DEPTH PHYSIOLOGICAL ASSESSMENT: EXCHANGING
Section 4: Nutrition
1. Explain the physiological components of a nutritional assessment
1.1 Intake
− Type of diet
− Food pyramid
Berman & Snyder: Chap. 23, pp. 419 & 421, Chap. 30, pp. 611-614 (Mouth),
Chap. 34, pp. 812-818, 829, 831, 833 (Diagnostic Testing), Chap. 47, pp. 1250-
1281 (Nutrition)
1.2 Digestion
1.3 Dietary history
Review the anatomy and physiology of the gastrointestinal system.
2. Utilize physical assessment skills to complete a nutritional assessment
2.1 Intake
− Dysphagia
− Condition of oral mucosa
− Teeth
Discuss nutritional assessment.
2.2 Digestion
− Loss of appetite (anorexia)
− Nausea
− Vomiting
− Food allergies
− Diarrhea/constipation
Complete nutrition assessment on peer in college lab.
Review: Bowel Sounds.
2.3 Evidence of nutritional health
− IBW
− BMI
− Hair pattern
− Skin
 Surgical wounds
− Anthropometric studies
 Triceps skin fold
 Mid-arm circumference
− Dietary data
 Food diary
 24 hour recall

3. Identify developmental changes (Moving) that occur with nutrition
3.1 Geriatric
− Decreased digestive enzymes
− Decreased peristalsis
− Decreased saliva
− Decreased gastric mucosa
− Malabsorption of Ca, Fe, Vit B12
− Decreased saliva and number of taste buds
− Decreased number of absorption cells
− Decreased hepatic blood flow
− Increased amount body fat
Decreased metabolic rate
4. Utilize a focused interview with sensitivity and respect for human
diversity to identify experiential perspectives of a nutritional assessment.
Identify your own experiential perspectives of your nutritional health.
− Emotional eating
− Stress
− Customs
− Finances
− Store location
− Storage of food
4.3 Self care (Choosing and Moving)
− Diet
− Food pyramid
− Special intake needs
− Caffeine intake
− Alcohol usage
5. Identify diagnostic studies applicable to a nutritional assessment
5.1 Hematology: Definition and Normal Values
− Hemoglobin
− Hematocrit
V&P
5.2 Chemistry: Definition and Normal Values
− Albumin
− BUN (Blood Urea Nitrogen)
− Creatinine
− Electrolytes - Calcium, Na, K., Cl.
− Blood Glucose (FBS)
− Hgb A1C
V&P
V&P
V&P
Refer to pages listed under Circulatory section 1-Unit 3.
V&P

5.3 Invasive exams
− Barium Swallow
− Upper GI series
− E.G.D. (Esophagogastroduodenoscopy)
− Capsule Endoscopy
V&P
V&P
V&P
V&P
6. Utilize diagnostic reasoning to discuss the data gathered during the
nutritional assessment to develop a patient-centered plan of care.
6.1 Questions related to nutritional assessment (not inclusive)
− What associated disease processes could be altering adequate
intake?
− Does the client have difficulty preparing meals?
− What physical limitations might the patient have that limit
adequate nutritional intake?
− What medications might alter taste which can lead to altered
intake?
Do patient’s findings correlate with a normal nutritional assessment?
7. Identify nursing diagnoses commonly associated with a nutritional
assessment
7.1 Responses
− Imbalanced Nutrition
− Less than body requirements
− More than body requirements
− Impaired oral mucous membranes
− Impaired swallowing
− Nausea
− Impaired dentition
− Feeding self-care deficit
nutritional health goals.
Assess your own participation in preventive nutritional health behaviors.
− Special dietary requirements
− Healthy Diet
− Weight control
− Exercise
Record dietary intake for one day.
patients achieve nutritional health goals.
- Dietician
- Occupational therapy

- Speech Therapy
- Social worker
- United States Dept. of Agriculture (www.mypyramid.gov)
- Dietary and dental health guidelines for American Healthy
People 2010
- American Dietetic Association
- American Obesity Association
10. Identify the importance of nutritional assessment documentation utilizing
technology and information tools to achieve quality improvement.
 Safety

UNIT III: SECTION 4
NUTRITION
TERMINOLOGY
anorexia
anorexia nervosa
anthropometric
basal metabolism rate
buccal cavity
bulimia nervosa
caries
cholesterol
digestion
dysphagia
heartburn
ideal body weight
lipid
minerals
nutrient
triglycerides
vitamins

UNIT III: SECTION 4
NUTRITION
Nutrition
Grames, l., Sparemulli, M. (2008). Assessing a patient for dysphagia. Nursing, 38(8), 15.
(2008). Hard to Swallow: Understanding dysphagia. Nursing , 38(3), 44-45.
Schawartz, A., Powell, S. (2009). Brush up on oral assessment. Nursing, 39(3), 31-32.
(2009). The root cause of hair loss. Nursing, 39(11), 49.

UNIT III: IN-DEPTH PHYSICIOLOGICAL ASSESSMENT: EXCHANGING
Section 5: Bowel Elimination
1. Identify physiological components of the bowel elimination assessment
1.1 Peristalsis
1.2 Waste Elimination
Berman & Snyder: Chap. 23, pp. 419 & 421, Chap. 30, pp. 639-645, 663, 666
(Abdomen), Chap. 34, pp. 818-820, 828 (Diagnostic Testing), Chap. 49, pp. 1344-
1358 (Bowel Elimination)
2. Identify physical assessment skills to complete a bowel elimination
assessment
Review the anatomy and physiology of the gastrointestinal system.
2.1 Peristalsis: Auscultation, Inspection, and Palpation
− Abdomen
 Contour
 Symmetry
Perform an abdominal assessment on a peer in college lab.
o Girth
 Firmness
 Bowel sounds
o Hypoactive
o Hyperactive
o Absent
 Stoma
Practice auscultation of bowel sounds
2.2 Waste Elimination
− Stool
 Color
 Consistency
 Odor
 Amount
 Elimination Pattern
2.3 Alterations in Pattern
− Diarrhea
− Constipation
− Impaction
− Incontinence
Sample documentation of COCA.

3. Identify developmental (Moving) changes that occur within the bowel.
3.1 Geriatric
- Decreased peristalsis
- Decreased gastric secretions
− Decreased muscle tone of intestines and abdominal muscle
− Decreased motility and sphincter tone
− Increased fatty tissue in the trunk
4. Utilize a focused interview to identify experiential perspectives of a
bowel elimination assessment
− Stress level
− Laxative use
Identify your own experiential perspectives of your bowel elimination health.
5. Identify diagnostic studies applicable for a bowel elimination
assessment
5.1 Laboratory Studies
− Stool cultures
 Procedure for collection
− Stool for C. Difficile
− Occult blood (Hemoccult) (Guaiac)
V&P
V&P
5.2 Noninvasive
− Abdominal x-ray
− CT scan
− Barium enema
5.3 Invasive
− Colonoscopy
− Sigmoidoscopy
V&P
V&P
6. Use diagnostic reasoning to discuss the data gathered during the bowel
assessment to plan patient care.
6.1 Questions related to the bowel elimination assessment. (not
inclusive)
- Do patient’s findings correlate with a normal bowel
assessment?
- Have there been any changes in elimination habits in recent
past?
 Color
 Consistency
- Have there been any changes in activity or diet in recent past?

- Has the client utilized measures to correct the problems with
elimination?
- Has the client traveled abroad in the last few weeks?
7. Identify common nursing diagnoses associated with the elimination
assessment
7.1 Responses
- Bowel incontinence
- Constipation
- Diarrhea
Identify your own participation in bowel elimination health promotion.
8. Identify participation in health promotion
8.1 Health Behaviors
- Diet
 Fiber
 Low fat
- Stress management
- Fluid intake
patients achieve bowel elimination health goals.
- Dietician
- Enterostomal therapy nurse
- International Ostomy Association
- American Cancer Society
10. Identify the importance of bowel elimination assessment documentation
improvement.
10.1 Quality improvement
- Patient outcomes
- Safety
- Coordination of care

BOWELSOUNDS
BBOWELOWEL SSOUNDSOUNDS AREARE CAUSEDCAUSED BYBY AIRAIR ANDAND LIQUIDSLIQUIDS MOVINGMOVING THROUGHTHROUGH THETHE GASTROINTESTINALGASTROINTESTINAL TRACTTRACT..
Procedure
1. Place the patient in Supine position with knees flexed.
2. Warm the diaphragm in your palm.
3. Place it on the beginning quadrant. (The abdomen is divided mentally into four quadrants, you may
start in the RLQ and proceed counter clockwise. See drawing. Or begin in any quadrant and listen
to all four)
4. Listen for 5 minutes, in each quadrant before concluding absent sounds.
5. Document the presence or absence of sounds.
Normal bowel sounds are high pitched gurgling noises that occur approximately every 5 to 20 seconds. The
frequency of sounds is related to presence of food in the GI tract or to the state of digestion.
Terms
Hyperactive bowel sounds --- Loud, gurgling rushed sounds such as more than 35 sounds occurring per
minute.
Borborygmi --- noisy loud “growling” sounds.
Hypoactive bowel sounds --- Soft, low, widely separated sounds such as less than 5 sounds occurring per
minute.
Absent sounds --- when sounds are not heard for 5 minutes of auscultating in each quadrant. Report this
immediately as it may be a complication such as intestinal obstruction, peritonitis or paralytic ileus,

UNIT III: SECTION 5
BOWEL ELIMINATION
TERMINOLOGY
borborygmi
bowel movement
colon
constipation
diarrhea
fecal impaction
feces
flatulence
flatus
girth
Hemoccult (Occult blood, Guaiac)
hemorrhoids
hyperactive bowel sounds
hypoactive bowel sounds
incontinence (bowel)
laxative
ostomy
peristalsis
stool

UNIT III: SECTION 5
BOWEL ELIMINATION
Elimination - Bowel
Holcomb, S. (2009). What’s causing your patient’s abdominal pain? Nursing, 39(4), 57-58.
O’Laughlin, M. (2009). Making sense of abdominal assessment. Nursing Made Incredibly Easy, 7(5), 15-19.
Pullen, R. (2009). Colonoscopy. Nursing, 39(10), 40.
Wisniewski, A. (2010). Acute Abdomen: What a pain. Shaking down the suspects. Nursing Made Incredibly
Easy, 8(1), 42-52.

Section 6: Urinary Elimination
1. Explain the physiological components of a urinary elimination assessment
1.1 Formation of urine – Kidneys
Berman & Snyder: Chap. 23, p. 419 & 421-422, Chap. 30, pp. 639-645 , 663-
666 (Abdomen), Chap. 34, pp. 820-826, 828 (Diagnostic Testing), Chap. 48, pp.
1304-1317 (Urinary Assessment)
1.2 Excretion of urine – Bladder
- Usual pattern Review the anatomy and physiology of the urinary system.
2. Utilize a physical assessment to complete a urinary elimination
assessment
2.1 Kidney: Inspection and Palpation
- Abdomen
- Costovertebral angles
2.2 Urine: Inspection
- Color
- Odor
- Consistency
- Amount
- Frequency
- Fluid intake
- Sodium intake
- Intake and output
Sample documentation of COCA.
Complete urinary assessment on peer in college lab.
2.3 Altered urinary production
− Anuria
− Dysuria
− Frequency
− Hematuria
− Hesitancy
− Incontinence
− Nocturia
− Oliguria
− Polyuria
− Pyuria
− Retention
− Residual
− Urgency
Reference: P & P: Table 45-1, p. 1138.

2.4 Bladder
− Palpation procedure
− Incontinence types
 Functional
 Reflex
 Stress
 Urge
 Mixed
Discuss and define types of incontinence.
3. Identify developmental changes (Moving) that occur within the urinary
system.
Geriatric
− Decreased nephrons
− Decreased blood supply to kidneys
− Decreased bladder tone and contractability
− Decreased ability to concentrate urine
− Urinary urgency and frequency
− Decreased bladder capacity
− Enlarged prostate in males
− Decreased sphincter tone in females
4. Utilize a focused interview with sensitivity and respect for human diversity to
identify experiential perspectives of a urinary elimination assessment.
4.1 Psychosocial ( Knowing and Perceiving)
- Stress
- Self- esteem disturbance
- Body image
- Unfamiliar surroundings
- Toxic chemicals
4.3 Self- care (Choosing and Moving)
− Hygiene
− Alcohol consumption
− Cigarette smoking
5. Identify diagnostic studies applicable for a urinary elimination assessment
5.1 Blood studies
- BUN
- Creatinine
V&P
V&P
5.2 Chemistry-urine

- Urine specimen collection
 Clean voided
 Clean catch – midstream
 Timed
- Urinalysis
 Ph of urine
 Specific gravity
 Protein, ketones, glucose
Discuss collection of urine specimens.
V&P
5.3 Microbiology
- Culture and sensitivity V&P
5.4 Noninvasive
- KUB
- CT scan
V&P
V&P
5.5 Invasive
- Cystoscopy
- Intravenous pyelogram (IVP)
V&P
V&P
6. Use diagnostic reasoning to discuss the data gathered during the urinary
elimination assessment to develop a patient-centered care plan.
6.1 Questions related to assessment data (not inclusive)
- Do patient’s findings correlate with a normal urinary assessment?
- How often does the patient urinate during the day? Does the
patient awaken at night?
- Has the patient noticed any changes in usual voiding pattern?
- Does the patient have any history of urinary elimination
problems?
- Does patient have artificial orifices to aid urinary elimination?
7. Identify nursing diagnoses commonly associated with the urinary
elimination assessment
7.1 Responses
- Impaired urinary elimination
- Overflow urinary incontinence
- Stress urinary incontinence
- Urge urinary incontinence
- Functional urinary incontinence
- Reflex urinary incontinence
- Urinary retention

urinary elimination health goals
Assess your own participation preventive urinary elimination health behaviors.
- Fluid intake
- Voiding on a regular basis
- Limiting caffeine intake
- Maintain active lifestyle
- Hypertension control
- Diabetes control
- Proper wiping of perineal area
9. Recognize contributions of other individuals and groups in helping patients
achieve urinary elimination health goals.
- Enterostomal therapy nurse
- American Urological Association
- National Kidney Foundation
- United Ostomy Association of America
10. Identify the importance of urinary elimination assessment documentation
utilizing technology and information tools to achieve quality improvement.
 Safety

ASSESSING FOR BLADDER DISTENTION
If your patient’s urine output is insufficient, your patient may be retaining
urine.
ANESTHESIA, SURGERY, PREGNANCY, OR AN OBSTRUCTION IN THE
URINARY TRACT CAN CAUSE YOUR patient's bladder to retain urine and
become distended. Ask your patient when they last voided to determine whether
their bladder may be full. Assess them in a comfortable, private setting.
Ask your patient to lie on their back. Standing at their side, place the extended
fingers of your dominant hand at their umbilicus and the fingers of your other hand
over them. Palpate deeply with your fingertips, moving toward their symphysis pubis
until you feel the smooth, rounded bladder.
Another way to assess for distension is to percuss your patient's bladder, beginning
over their symphysis pubis and working toward their umbilicus. A urine-filled bladder
produces a dull sound: a change to tympany indicates the bladder's border.
Document your findings as: Bladder border ___ cm below the umbilicus. An empty
bladder rests behind the symphysis pubis and should be documented as: Bladder
not palpable.
If your patient can't void and their bladder is distended, notify the physician. A patient
with a distended bladder who can't urinate must be catheterized to prevent
complications. Unrelieved urine retention can cause pain, dyspnea, hypotension,
hypertension, diaphoresis, or restlessness.

UNIT III: SECTON 6
URINARY ELIMINATION
TERMINOLOGY
anuria
catheterization
costovertebral angle
cystoscopy
dysuria
enuresis
flank
frequency
incontinence
glycosuria
hematuria
hesitancy
micturition
nocturia
oliguria
polyuria
proteinuria
pyuria
residual urine
retention

Section 7: Reproductive System
1. Explain the physiological components of reproduction system.
Reading Summary:
Van Leeuwen & Poelhuis-Leth (V&P) - Reference I-Touch labs and
diagnostic tests that correlate with learning outcomes.
1.1 Breasts/Axillae
1.2 Female Genitals
1.3 Male Genitals
1.4 Inguinal Are
Berman & Snyder: Chap. 30, pp. 635, 638, (Breast), 658-660 (Female
Genitals), 660-663 (Male Genitals), Chap. 40, pp. 1036-1057
(Sexuality), p. 422 (Aging)
2. Utilize physical assessment to complete a reproductive system assessment Participate in class discussion.
2.1 Breasts/Axillae: Inspect and Palpation
− Size
− Symmetry
− Contour or shape
− Skin
 Discoloration
 Hyperpigmentation
 Retraction or dimpling
 Swelling or edema
 Lesion
− Masses
− Areola
 Size
 Shape
 Symmetry
 Color
 Masses
 Lesions
− Nipples
 Size
 Shape
 Position
 Color
 Discharge
 Lesions
− Axillary, Subclavicular and supraclavicular, lymph nodes for masses
2.2 Female genital area: Inspection
− Public hair
 Amount
 Distribution
Review the anatomy and physiology of the reproductive system for both
female and male.
Discuss variations in examination techniques appropriate for clients of
different ages and sex.
Practice self breast exam on demonstration model in college lab.
escribe suggested sequencing to conduct a reproductive system
physical exam.

− Public skin, labia, clitoris, urethral, and vaginal orifice
 Parasites
 Inflammation
 Swelling
 Lesions
2.3 Male genital area: Inspection
− Pubic hair
 Amount
 Distribution
− Penile shaft and glans
 Lesions
 Nodules
 Swelling
 Inflammation
 Circumcised
− Scrotum
 Appearance
 Size
 Symmetry
 Masses
2.4 Inguinal area: inspect and palpate
− Female
 Palpate inguinal nodes
 Enlargement
 Tenderness
− Male
 Bulges
 Swelling
3. Identify developmental changing that occurs within the reproductive system.
3.1 Geriatric
− Breast change
 Pendulous
 Flaccid
 Atrophy of glandular tissue
 Increase in amount of fat
 Easier to detect lesions with decrease in connective tissue
− Female genitals
 Atrophied and flatter labia


 Atrophy and fragile vulva
 Vaginal dryer, more alkaline
 Cervix and uterus decrease size
 Fallopian tubes and ovaries atrophy
 Ovulation and estrogen production ceases
 Uterine prolapsed
 Decrease libido
− Male genitals
 Decrease size of penis
 Decrease size and firmness of scrotum
 Decreased testosterone
 Difficulty obtaining and maintaining erection
 Decrease amount and viscosity of seminal fluid
 Urinary frequency, nocturia, dribbling, and difficulty starting a stream
related to enlarged prostate
 Decrease libido
4.0 Utilize a focused interview with sensitivity and respect for human diversity to
identify experiential perspectives of a reproductive assessment
− Stress
− Self- esteem disturbance
− Body image
− Modesty
− Unfamiliar surroundings
− Toxic chemicals
4.3 Self- care (Choosing and Moving)
− Hygiene
− Alcohol consumption
− Cigarette smoking
− Self breast and testicular exams
− Use of protective barriers
Identify your own experiential perspectives of your reproductive health.
Discuss the gender and cultural issues related to reproductive exam by
opposite sex examiner.
5. Identify diagnostic studies applicable for a urinary elimination assessment
1.1 Blood studies
− Prostate specific antigen (PSA)
− hCG (Human Chorionic Gonadotropin) pregnancy test
− Prolactin
− Testosterone

− Progesterone
− Estradiol
− Follicle-stimulating hormone (FSH)
− VDRL (Venereal disease research laboratory
− RPR (Rysid plasma reagin) syphilis
5.2 Urine studies
− HCG
− Testosterone
− FSH
− Urinalysis
5.3 Microbiology
− Wet mounts
− Cultures
− Gram stain
5.4 Cytologic studies
− Pap test
5.5 Genetic testing
− BRCA1
− BRCA2
5.6 Noninvasive radiologic studies
− Mammography
− Abdominal/transvaginal ultrasound
− CT
− MRI
5.7 Invasive Diagnostic Procedures
− Breast biopsy
− Hysteroscopy
− Colposcopy
− Conization
− Dilation and curettage (D & C)
− Laparoscopy
Discuss collection of urine and culture specimens.
Discuss legal and ethical issues related to genetic testing.
6. Use diagnostic reasoning to discuss the data gathered during the reproductive
system assessment to develop a patient-centered care plan.
6.1 Questions related to assessment data (no inclusive)
− Do patient’s findings correlate with a normal reproductive assessment?
− Have there been any changes such as breast pain, tenderness, lumps,
nipple discharge, lumps, vaginal discharge, scrotal enlargement, or penile
discharge?

− Has there been any changes with urinary and bowel function?
− Is there any family history of breast, prostrate, or testicular cancer?
− Do you or have you used oral contraceptives or taken estrogen
replacement therapy?
− What was age of onset of menstruation and last menstrual period?
− What is regularity of cycle, duration, amount of daily flow, painful?
− Number of pregnancies and live births?
− Any history of sexually transmitted diseases?
− Are you currently sexually active?
− Are you sexually active with one or more partners?
− Do you use protective mechanisms?
7. Identify nursing diagnoses commonly associated with the reproductive assessment
7.1 Responses
− Stress urinary incontinence
− Urinary retention
− Risk for infection
− Ineffective self health maintenance
− Deficient knowledge (conception, STDs, contraception, normal sexual
changes over the lifespan)
− Sexual dysfunction
− Disturbed body image
− Have there been any changes such as breast pain, tenderness, lumps,
nipple discharge, lumps, vaginal discharge, scrotal enlargement, or penile
discharge?
reproductive health goals
− Primary prevention
 Breast self exams (female and male) (BSE)
 Testicular self exams (TSE)
 Limiting alcohol
 Smoking cessation
 Use of protective barriers (condoms and dental dams)
− Secondary prevention
 Pap smear
 Mammogram
 Prostate-specific antigen (PSA) test
 STD & HIV Testing
Identify possible etiologies for the various nursing diagnoses listed to
the left.
Identify your own participation in primary and secondary prevention
reproductive health promotion.

−
9. Recognize contributions of other individuals and groups in helping patients achieve
reproductive health goals.
− Oncology nurse specialist
− Centers for Disease Control and Prevention STD/HIV/AIDS (www.cdc.gov)
− American Cancer Society
− National Women’s Health Information Center
− National Prostate Cancer Coalition
10. Identify the importance of reproductive assessment documentation utilizing
technology in information tools to achieve quality improvement.
− Quality Improvement
 Safety

UNIT III: Section 7
Reproductive System
Supplemental Reading Resources
Marchese, K. (2009). Improving evidence-based practice : use of the POP-Q system for the assessment
of pelvic organ prolapsed. Urologic Nursing, 29(4), pp. 216-224.
Mclennon, L., VanSell, S., O’Quin, L., Kindred, C., & Raymond, N. (2009). Awareness of breast
cancer in men. RN, 72(8), 16-21.
Wallace, M. (2008). Assessment of Sexual Health in Older Adults. American Journal of Nursing, 108(7),
pp. 52-60.

Section 8: Physical Integrity/Physical Regulation
1. Explain the physiological components of a physical integrity assessment
(Protection)
Reading Summary:
Van Leeuwen & Poelhuis-Leth (V&P) - Reference I-Touch labs and
diagnostic tests that correlate with learning outcomes.
1.1 Tissue Integrity
- Skin
- Subcutaneous tissue
2. Utilize physical assessment to complete a physical integrity assessment
2.1 Assessment of Skin/Tissue Integrity: Inspection and Palpation
- Intactness
− Primary Skin Lesions
Berman & Snyder: Chap. 23, p. 147, 148,149, (Aging-Skin), p. 419,
Chap. 29, pp. 535-545 (Vital signs – Temp.), Chap. 30, pp. 585-594
(Skin), Chap. 31, pp. 676-677, pp. 682-685 (Immunity), (Chap. 36, pp.
99-935 (Ulcer/Wounds).
− Wound types
− Secondary Skin Lesions
 Intentional, Unintentional
 Closed
° Contusion
 Open
° Incision, abrasion, puncture, laceration
- Cleanliness
- Color
- Turgor
- Odor
- Temperature
- Secretions
- Sensation
2.2 Skin integrity risks
- Pressure
- Immobility
- Edema
- Confusion
- Diminished sensation
 Heat & Cold
- Incontinence
- Inadequate nutrition
- Braden Scale
2.3 4 stages of pressure ulcers
2.4 Inflammation
- Redness
- Warmth
- Swelling
- Pain
Review the anatomy and physiology of the integumentary system.
Review skin integrity content from LPN course.
Perform a physical integrity and regulation assessment on a peer during
college lab.
Discuss states of pressure ulcers

2.5 Infection
- Drainage
- Odor
2.6 Allergies
3. Identify developmental changes that occur with physical integrity and regulation
- Geriatrics
- Decreased thermoregulatory control
- Inadequate diet
- Decreased salivary gland activity
- Decreased immune responses
- SKIN
 Decreased skin elasticity
 Decrease in sweat and sebaceous activity
 Progressive atrophy of sebaceous glands
 Keratosis
 Lentigo Senilus (benign hyperpigmentation or brown spots)
 Skin tags
 Skin Tears
 Thinning epithelium (increased visibility of blood vessels)
 Decreased subcutaneous fat causing loss of elasticity ( skin wrinkles, skin
turgor decreases)
 Reduced blood flow to skin and increased fragility of capillaries(paler color,
red blotches)
- HAIR
 Graying
 Thinning
 Reduction in hair shaft diameter
 Scanty leg hair
 Eyebrow, ear and nasal hair coarser and longer
 Coarse facial hair in women
4. Identify diagnostic studies applicable to a physical regulation assessment
4.1 Blood studies: WBC with differential
− Monocyte
− Neutrophils
− Basophils
− Eosinophils
− Lymphocytes
− ESR (Sed Rate)
V&P
4.2 Culture/Sensitivity
− Wound
− Urine
V&P
− Sputum
− Blood Identify your own experiential perspectives to sleep and rest.

5. Utilize a focused interview to identify experiential perspective of a physical integrity
and regulation assessment.
5.1 Psychosocial (Knowing and Perceiving) Identify your own experiential perspectives of physical integrity and
- Self image
- Stress
regulation.
- Cultural heritage
- Occupation
5.3 Self care (Choosing)
− Hygiene
− Sun exposure
− Chemical exposure
− Immunizations
6. Use diagnostic reasoning to discuss the data gathered during the physical
regulation and rest/sleep assessment to develop a patient centered care plan.
6.1 Questions related to physical integrity assessment data (not inclusive)
- What are the client’s hygiene habits?
- Has the client noted any unusual or new skin lesions in recent weeks?
- Does the client develop rashes?
- After taking medications?
- Wearing certain clothes/jewelry?
- Does the client sunburn easily?
- Has the client noted any drainage from skin lesions? Are these lesions
slow to heal?
- Does the client participate in safety programs?
6.2 Questions related to physical regulation data (not inclusive)
- Has patient’s stress level increased in the recent past?
- Has the patient been exposed to any person with known infection?
- Does the patient have a diagnosed disease, the treatment of which alters
the normal immune response? If so, describe the disease treatment.
- Are all diagnostic studies normal or abnormal?
- Describe the patient’s personal hygiene practices.
7. Identify nursing diagnosis commonly associated with physical integrity and
regulation.

7.1 Physical Integrity Responses
- Impaired tissue integrity
- Impaired skin integrity
- Impaired oral mucous membranes
- Latex allergy response
- Risk for infection
7.2 Physical Regulation Responses
- Risk for infection
- Ineffective thermoregulation
- Hypothermia
- Hyperthermia
- Risk for Imbalanced Body Temperature
8. Identify evidence based practice guidelines and standards that promote physical
integrity and regulation health goals
Assess your own participation in preventive physical integrity and
regulation health behaviors.
- Handwashing
- Healthy diet
- Activity
- No smoking
- Avoid chemical exposure
- Sunscreen protection
- Rest and sleep
- Self skin examination
- Immunizations
- Safe sex practices
9. Recognize contributions of other individuals and groups in helping patients achieve
physical integrity and regulation health goals
- Enterostomal Wound Therapy nurse
- Infection Control nurse
- Dietician
- American Academy of Dermatology
- Dermatology Foundation
- American Cancer Society
- American Academy of Wound Management
- Center for Disease control (CDC)
- Infectious Disease Society of America

10. Identify the importance of physical regulation and rest/sleep assessment
documentation utilizing technology and information tools to achieve quality
improvement.
− Quality Improvement
 Safety

ASSESSMENT DATA FOR COMMON AGE-RELATED CHANGES
1. SENSORY 2. CARDIOVASCULAR SYSTEM
Vision:
• Decreased size of pupils and speed in adjusting
to light changes
• Increased visual threshold (more light needed to
stimulate visual receptors)
• Decreased visual acuity
• Lens more rigid (decreased accommodation to
near and far vision; presbyopia)
• “Yellow filter effect” of lens distorts color
perception
• Decreased peripheral vision
• Arcus senilus (gray-white color around
cornea)
• Increased fatty tissue in heart
• Decreased compliance of heart muscle
• Increased rigidity and thickening of heart
valves
• Thickening and decreased elasticity of
vessel walls
• Decreased vascular compliance
• Decreased stroke volume
• Decreased cardiac output (50 percent by
80 years)
• Increased circulation time (15 seconds in
young adult; 27 sec. in 70 year)
Hearing:
• Presbycusis (decreased perception of high
tones)
3.RESPIRATORY SYSTEM
• Decreased rib cage expansion due to
skeletal changes (calcification of costal
• Increased accumulation of ear wax
• Deterioration of hair cells (auditory receptors) in
cochlea
• Decreased number of functioning neurons
• Ossicles degenerate and stiffen
• Decreased blood supply to cochlea
cartilages, kyphosis, scoliosis, vertebral
changes)
• Decreased inhalation and exhalation
movements due to weakened and
atrophied thoracic muscles
• Decreased elasticity of lungs
• Increased residual volume
Taste and Smell • Decreased vital capacity
• Decrease in taste buds (loss of 64 percent by 75
years)
• Higher taste threshold in functioning taste buds
• Decreased number of olfactory neurons
• Olfactory acuity decreased to 80 percent by 65
years
• Decreased diffusion
• Decreased number of alveoli and
pulmonary capillaries

Vestibular and Kinesthetic Senses
• Decrease in receptors for balance and
equilibrium in semicircular canals
• Decrease in receptors for joint movement and
body position in muscles and tendons
• Higher threshold for vestibular and kinesthetic
stimulation
4. GASTROINTESTINAL SYSTEM
• Decreased saliva and number of taste
buds
• Decreased secretion of digestive juices
• Decreased motility and sphincter tone
• Decreased number of absorption cells
• Decreased hepatic blood flow
• Increased amount body fat
• Decreased muscle tone of intestines and
abdominal muscles
• Degeneration of gastric mucosa
decreased metabolic rate
• Malabsorption of calcium, iron, Vitamin
B12
5. URINARY SYSTEM 9. MUSCULOSKELETAL SYSTEM
• Decreased number of nephrons
• Decreased blood supply to kidney
• Decreased ability to concentrate urine
• Decreased secretion of ADH
• Increased plasma urea and uric acid
• Decreased neuromuscular stimulation of
bladder
• Decreased bladder capacity
• Decrease in bone mass
• Thinning of intervertebral discs
• Calcification within cartilage and ligament
• Decreased elasticity of tendons and muscles
• Decrease in muscle mass, tone, and strength
• Ankylosis of ligaments and joints
• Loss of stature and change in bodily
configuration (head and neck held forward,
knees flexed)
• Progressive changes in gait
6. REPRODUCTION SYSTEM 10. INTEGUMENTARY
• Gradual decline in gonadal secretion
• Gradual atrophy of ovarian, uterine, and vaginal
tissues
• Decreased vaginal lubrication
• More alkaline vaginal secretions
• Muscle and glandular tone diminished skin is
less elastic, resulting in loss of firmness of
breast tissue
• Smaller testes
• Enlarged prostate
• Decrease in volume and viscosity of seminal
fluid
• Reduction in force of ejaculation
• Longer time needed to achieve erection
Hair:
• Graying
• Thinning
• Reduction in hair shaft diameter
• Scanty leg hair
• Eyebrow, ear, and nasal hair coarser and
longer
• Course facial hair in women
Skin:
• Thinning epithelium (increased visibility of
blood vessels
• Progressive atrophy of sebaceous glands
• Lentigo senilus (benign hyperpigmentation
7.NEUROLOGICAL SYSTEM or brown spots on dorsum of hands)
• Decrease in weight of brain • Decreased subcutaneous fat causing loss

• Decrease in blood supply to brain
• Loss of neurons
• Increased size of ventricles
• Decreased neurotransmitters
• Decreased nerve conduction
• Diminished tendon reflex responses
• Impaired thermoregulatory reflexes
• Decreased period of deep sleep
of elasticity (skin wrinkles, turgor
decreased)
• Reduced blood flow to skin and increased
fragility of capillaries (paler color, red
blotches)
• Senile keratosis
8.ENDOCRINE SYSTEM
• Decreased tissue response to hormones
• Decreased responsive
• Decreased secretion of aldosterone by
adrenals resulting in decreased sodium
reabsorption
• Decreased insulin synthesis
• Decreased secretion of thyroxin

UNIT III: SECTION 8
PHYSICAL INTEGRITY & REGULATION
TERMINOLOGY
Physical Regulation Physical Integrity
antibody abrasion
antigen alopecia
hyperthermia ashen
hypothermia cerumen
immunity contusion
inflammation dermis
macrophage diaphoresis
perspiration ecchymosis
phagocyte epidermis
saliva exudates
thermoregulation gingivitis
halitosis
hematoma
hirsutism
incision
integumentary system
keratosis
laceration
lentigo senilus
necrosis
petechiae
pressure ulcer (decubitus ulcer)
puncture
sebum

UNIT III: SECTION 8
PHYSICAL INTEGRITY & REGULATION
(2009). Assessing skin color changes. Nursing, 39(4), 49-50.
(2009). Wound wise: How to assess pressure ulcers. NURSING MADE INCREDIBLY EASY, 7(6), 20-
25.
Blaney, W. (2010). Taking steps to prevent pressure ulcers. Nursing, 40(3), 45-47.
Hess, C. (2009). Performing a skin assessment. Nursing, 40(7), 66.
Hess, C.T. (2009). Taking steps to prevent pressure ulcers. Nursing, 39(1), 61.
Hathaway, L. (2009). A wrinkle in time: Assessing the skin of older adults. Nursing Made
Incredibly Easy, 7(4), 9-12.
Knoblauch,M. (2010). Protect yourself against bloodborne pathogens. NURSING MADE
INCREDIBLY EASY, 8(1), 30-40.
Krapfl, G., & Does, G. (2008). Does regular repositioning prevent pressure ulcers? Journal of
Wound, Ostomy, Continence Nursing, 35(6), 571-577.
Paciella, M.E. (2009). “Bundle” up to prevent pressure ulcers. American Nurse Today, 4(4), 42-
45.
Pagana, K. (2009). What does the absolute neutrophil count tell you? American Nurse Today,
4(2), 12-13.
Thompson, P., Hanson, D., Anderson, J., & Hunter, S. (2008). Assessing skin rashes.
Nursing, 38(4), 59.

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