Health Promotion and Maintenance

Master health promotion and maintenance concepts with free flashcards and spaced repetition practice. This lesson covers developmental stages across the lifespan, immunization schedules, physical assessment techniques, prenatal through postpartum care, disease prevention strategies, and health screening guidelines—essential knowledge for the NCLEX-RN exam and professional nursing practice.

Welcome to Health Promotion and Maintenance 🏥

Health Promotion and Maintenance represents one of the four major client needs categories on the NCLEX-RN examination, typically comprising 6-12% of test questions. This domain focuses on the nurse's role in preventing illness, promoting wellness, and helping clients achieve optimal health throughout the lifespan. Unlike acute care scenarios, these questions emphasize anticipatory guidance, health education, developmental milestones, and preventive strategies.

As a nurse, you'll spend significant time teaching clients about healthy lifestyle choices, conducting health screenings, administering immunizations, and supporting families through developmental transitions. This lesson builds on your foundation in safe care environments by focusing on proactive rather than reactive interventions.

Core Concepts in Health Promotion 🌱

Understanding Health Promotion vs. Disease Prevention

Health promotion involves activities that enhance well-being and maximize health potential, while disease prevention specifically targets reducing the risk of developing illness. Though related, they represent different approaches:

Health Promotion	Disease Prevention
🎯 Positive wellness focus	🛡️ Risk reduction focus
Exercise programs for fitness	Exercise to prevent heart disease
Nutrition education for optimal health	Low-sodium diet to prevent hypertension
Stress management for well-being	Stress reduction to prevent ulcers
Benefits ALL individuals	Targets at-risk populations

Three Levels of Prevention 🔺

Understanding prevention levels is crucial for NCLEX success:

💡 NCLEX Tip: Questions often ask you to identify which prevention level applies to a scenario. Remember: Primary = Prevention, Secondary = Screening, Tertiary = Treatment/Rehabilitation.

Developmental Stages Across the Lifespan 👶➡️👴

Erik Erikson's psychosocial developmental theory provides the framework nurses use to understand age-appropriate behaviors and challenges. Each stage involves a crisis that must be resolved for healthy development:

ERIKSON'S PSYCHOSOCIAL STAGES

👶 Infancy (0-1 year)
   Trust vs. Mistrust
   Key: Consistent, responsive care
   ↓
🧒 Toddler (1-3 years)
   Autonomy vs. Shame/Doubt
   Key: Encouraging independence
   ↓
🎨 Preschool (3-6 years)
   Initiative vs. Guilt
   Key: Supporting exploration
   ↓
📚 School Age (6-12 years)
   Industry vs. Inferiority
   Key: Academic & social success
   ↓
🎭 Adolescence (12-18 years)
   Identity vs. Role Confusion
   Key: Self-discovery & peer relationships
   ↓
💼 Young Adult (18-40 years)
   Intimacy vs. Isolation
   Key: Forming committed relationships
   ↓
👨‍👩‍👧 Middle Adult (40-65 years)
   Generativity vs. Stagnation
   Key: Contributing to society/family
   ↓
🌅 Older Adult (65+ years)
   Integrity vs. Despair
   Key: Life review & acceptance

Physical developmental milestones are equally important. Here are critical age-specific expectations:

Age	Gross Motor	Fine Motor	Social/Cognitive
2 months	Lifts head when prone	Follows objects to midline	Social smile
4 months	Rolls front to back	Reaches for objects	Laughs aloud
6 months	Sits without support	Transfers objects hand-to-hand	Stranger anxiety begins
9 months	Crawls, pulls to stand	Pincer grasp	Plays peek-a-boo
12 months	Walks independently	Feeds self finger foods	Says 1-2 words
18 months	Runs, climbs stairs	Stacks 3-4 blocks	Uses 10-20 words
2 years	Jumps, kicks ball	Turns pages, removes clothing	2-word phrases
3 years	Rides tricycle, stands on one foot	Copies circle, uses utensils	Knows full name, age

⚠️ Red Flags for Developmental Delay: No social smile by 3 months, not sitting by 9 months, not walking by 18 months, no words by 18 months, or loss of previously acquired skills at ANY age.

Immunization Schedules 💉

Immunizations are a cornerstone of primary prevention. The CDC publishes recommended schedules, but NCLEX focuses on key principles:

Childhood Immunization Highlights:

• Birth: Hepatitis B (first dose)
• 2 months: DTaP, IPV, Hib, PCV13, RV (rotavirus)
• 6 months: Influenza (annually thereafter)
• 12-15 months: MMR, Varicella, Hepatitis A
• 4-6 years: DTaP, IPV, MMR, Varicella boosters
• 11-12 years: Tdap, HPV, MenACWY

Adult Immunizations:

• Tdap: Once, then Td booster every 10 years
• Influenza: Annually for everyone ≥6 months
• Pneumococcal (PPSV23/PCV13): ≥65 years or high-risk
• Shingles (RZV): ≥50 years (2 doses)
• HPV: Through age 26 (catch-up through 45)

💡 Mnemonic for MMR/Varicella timing: "Measles, Mumps, Rubella, Varicella at 1, More at 4" (12 months and 4-6 years)

Contraindications to Immunizations:

• Live vaccines (MMR, varicella, intranasal flu, rotavirus): Contraindicated in pregnancy, severe immunocompromise
• Egg allergy: Most vaccines safe; severe allergy requires observation with flu vaccine
• Previous severe reaction: Contraindication to that specific vaccine
• Moderate/severe acute illness: Delay vaccination (mild illness is NOT a contraindication)

⚠️ Common Mistake: Many students think mild cold or low-grade fever contraindicates vaccination—it does NOT. Only moderate-to-severe illness requires postponement.

Techniques of Physical Assessment 🔍

Health promotion includes regular health screenings using systematic physical assessment. The order varies by body system:

Health Screening Guidelines (Adults):

Screening	Population	Frequency
Blood pressure	All adults ≥18	Every 2 years if normal; annually if elevated
Cholesterol	Men ≥35, Women ≥45	Every 5 years
Diabetes (HbA1c/FBG)	Adults ≥35 or with risk factors	Every 3 years
Colorectal cancer	Adults 45-75 years	Colonoscopy every 10 years (or other methods)
Mammogram	Women 40-75 years	Every 1-2 years
Pap smear	Women 21-65 years	Every 3 years (or every 5 years with HPV test)
Osteoporosis (DEXA)	Women ≥65, Men ≥70	Based on risk factors

🧠 Memory Device - Cancer Screenings: "CBMP at different ages"

• Colorectal: 45
• Breast (mammogram): 40
• Mammogram continues to 75
• Pap: 21-65

Prenatal, Intrapartum, and Postpartum Care 🤰

Prenatal Care Essentials:

Pregnancy is divided into three trimesters, each with specific assessments and teaching needs:

PRENATAL CARE TIMELINE

First Trimester (Weeks 1-13)
│ ✓ Confirm pregnancy
│ ✓ Prenatal vitamins (folic acid 400-800 mcg)
│ ✓ Initial labs (CBC, blood type, STI screening)
│ ✓ Dating ultrasound
│ ✓ Genetic screening offered (10-13 weeks)
↓
Second Trimester (Weeks 14-27)
│ ✓ Anatomy ultrasound (18-22 weeks)
│ ✓ Quad screen (15-20 weeks)
│ ✓ Glucose challenge test (24-28 weeks)
│ ✓ Fetal movement monitoring begins
↓
Third Trimester (Weeks 28-40)
│ ✓ Group B Strep screening (35-37 weeks)
│ ✓ Fetal monitoring increases
│ ✓ Weekly visits after 36 weeks
│ ✓ Birth plan discussion
↓
👶 BIRTH

Critical Prenatal Teaching:

• Nutrition: Increase caloric intake by 300 kcal/day; adequate protein, iron, calcium
• Weight gain: 25-35 lbs for normal BMI (less if overweight, more if underweight)
• Danger signs: Vaginal bleeding, severe headache, visual changes, decreased fetal movement, fluid leakage, contractions before term
• Avoid: Alcohol, tobacco, raw fish/meat, soft cheeses, cat litter, hot tubs

💡 NCLEX Pearl: Questions about prenatal teaching often focus on danger signs that require immediate reporting. Memorize these!

Intrapartum (Labor and Delivery) Stages:

Stage	Phase	Cervical Dilation	Duration (Primipara)	Characteristics
Stage 1: Cervical Dilation	Latent	0-3 cm	8-20 hours	Mild, irregular contractions
	Active	4-7 cm	3-6 hours	Regular, painful contractions
	Transition	8-10 cm	30-90 minutes	Intense contractions, irritability
Stage 2: Pushing	—	10 cm	30 min-3 hours	Urge to push, crowning
Stage 3: Placental Delivery	—	After birth	5-30 minutes	Placenta expulsion
Stage 4: Recovery	—	After placenta	1-4 hours	Stabilization, bonding

Postpartum Care Priorities:

Use "BUBBLE-HE" to remember postpartum assessment:

• Breasts: Engorgement, lactation support
• Uterus: Fundal height, firmness (should be firm at umbilicus immediately postpartum)
• Bladder: Voiding adequacy (distension prevents uterine contraction)
• Bowel: Return of function
• Lochia: Color, amount, odor (rubra→serosa→alba progression)
• Episiotomy/incision: REEDA (Redness, Edema, Ecchymosis, Drainage, Approximation)
• Homan's sign/DVT risk: Leg pain, swelling
• Emotions: Postpartum blues vs. depression screening

⚠️ Postpartum Hemorrhage Warning Signs: Boggy uterus, lochia saturation >1 pad/hour, large clots, tachycardia, hypotension. This is a medical emergency requiring immediate intervention!

Newborn Care and Assessment 👶

Immediate Newborn Assessment - APGAR Score:

Performed at 1 and 5 minutes after birth (and every 5 minutes if score <7):

Sign	0 Points	1 Point	2 Points
Appearance (color)	Blue/pale all over	Pink body, blue extremities	Pink all over
Pulse (heart rate)	Absent	<100 bpm	>100 bpm
Grimace (reflex)	No response	Grimace/weak cry	Cry/cough/sneeze
Activity (muscle tone)	Limp	Some flexion	Active movement
Respiration	Absent	Weak/irregular	Strong cry

Score interpretation: 7-10 = Normal, 4-6 = Moderately depressed (needs stimulation/oxygen), 0-3 = Severely depressed (needs resuscitation)

Newborn Vital Signs (Normal Ranges):

• Heart rate: 120-160 bpm (100 sleeping, up to 180 crying)
• Respiratory rate: 30-60 breaths/min
• Temperature: 97.7-99.5°F (36.5-37.5°C) axillary
• Blood pressure: 60-80/40-50 mmHg

Normal Newborn Characteristics:

• Weight: 2500-4000 g (5.5-8.8 lbs); 10% loss in first week is normal
• Length: 45-55 cm (18-22 inches)
• Head circumference: 33-35 cm (larger than chest initially)
• Acrocyanosis: Blue hands/feet (normal first 24 hours)
• Milia: White pinpoint spots on nose (blocked sebaceous glands)
• Erythema toxicum: Pink rash with white/yellow center ("newborn rash," appears day 2-3)
• Vernix caseosa: Cheesy white coating (protective)
• Lanugo: Fine body hair (more in preterm infants)

Critical Newborn Reflexes:

Reflex	How to Elicit	Normal Response	Disappears By
Moro (startle)	Sudden head drop or loud noise	Arms extend then flex, may cry	3-6 months
Rooting	Stroke cheek	Turns toward stimulus, opens mouth	3-4 months
Sucking	Place object in mouth	Strong sucking motion	4-6 months
Palmar grasp	Place finger in palm	Fingers curl to grasp	3-4 months
Plantar grasp	Touch sole of foot	Toes curl	8-12 months
Babinski	Stroke lateral sole upward	Toes fan out and up	12 months
Tonic neck (fencing)	Turn head to side	Same-side arm/leg extend	3-4 months

⚠️ Abnormal Findings: Absence of reflexes, asymmetric responses, or persistence beyond expected age can indicate neurological problems.

Lifestyle Choices and High-Risk Behaviors 🚭

Substance Use Screening and Counseling:

The CAGE questionnaire screens for alcohol use disorder:

• C: Have you felt you should Cut down?
• A: Have people Annoyed you by criticizing your drinking?
• G: Have you felt Guilty about drinking?
• E: Have you had an Eye-opener (morning drink)?

≥2 "yes" responses suggest problem drinking requiring intervention.

Tobacco Cessation - The 5 A's:

1. Ask: Screen all patients for tobacco use
2. Advise: Urge all tobacco users to quit
3. Assess: Determine willingness to quit
4. Assist: Provide resources (medications, counseling)
5. Arrange: Schedule follow-up

High-Risk Sexual Behaviors:

• Multiple partners, unprotected sex
• Prevention education: Condom use, STI testing, pre-exposure prophylaxis (PrEP) for HIV
• Contraception counseling: Options, effectiveness rates, proper use

Adolescent Risk Assessment:

Use HEEADSSS for comprehensive adolescent screening:

• Home environment
• Education/employment
• Eating/exercise
• Activities/peers
• Drugs/alcohol
• Sexuality
• Suicide/depression
• Safety (violence, abuse)

💡 Confidentiality Note: Adolescents are more likely to disclose risky behaviors if assured of confidentiality (with exceptions for safety concerns).

Aging Process and Older Adult Care 🌅

Normal Age-Related Changes:

System	Changes	Nursing Implications
Cardiovascular	↓ Cardiac output, ↑ BP, arterial stiffening	Monitor for orthostatic hypotension, heart failure
Respiratory	↓ Lung elasticity, ↓ cough reflex	Increased pneumonia risk, encourage deep breathing
Musculoskeletal	↓ Bone density, ↓ muscle mass	Fall prevention, weight-bearing exercise
Sensory	↓ Vision/hearing, ↓ taste/smell	Safety modifications, nutritional support
Integumentary	Thinner skin, ↓ turgor, ↓ subcutaneous fat	Pressure injury prevention, temperature regulation
Renal	↓ GFR, ↓ bladder capacity	Medication dosing adjustments, incontinence management
Neurological	↓ Reaction time, ↓ short-term memory	Allow more time for responses (dementia is NOT normal)

⚠️ Critical Distinction: While mild memory changes are normal with aging, dementia, depression, and incontinence are NOT normal aging processes and require evaluation and treatment.

Fall Prevention Strategies:

• Intrinsic factors: Address vision, medications causing dizziness, muscle weakness
• Extrinsic factors: Remove throw rugs, improve lighting, install grab bars
• Assistive devices: Properly fitted walkers, canes
• Exercise programs: Balance and strength training

Polypharmacy Concerns:

• Older adults often take ≥5 medications
• Beers Criteria: Lists potentially inappropriate medications for older adults
• High-risk: Anticholinergics, benzodiazepines, NSAIDs (long-term)
• Encourage medication reconciliation at every visit

Example Scenarios 📖

Example 1: Well-Child Visit - 6-Month Developmental Assessment

Scenario: Parents bring their 6-month-old infant for a routine well-child visit. They express concern that their baby "isn't doing as much" as their friend's baby of the same age.

Assessment Approach:

1. Review expected 6-month milestones:

   • Sits without support ✓
   • Transfers objects hand-to-hand ✓
   • Rolls both directions ✓
   • Responds to name ✓
   • Babbles ✓

2. Perform developmental screening: Use standardized tool (e.g., Ages & Stages Questionnaire)

3. Provide anticipatory guidance:

   • Each child develops at own pace within normal ranges
   • Avoid comparing to other children
   • Focus on progression, not perfection
   • Next milestones: Crawling (8-10 months), pulling to stand (9-12 months)

4. Safety teaching:

   • Childproof home (covers on outlets, safety gates)
   • Never leave unattended on elevated surfaces
   • Introduce solid foods (start with iron-fortified cereals)
   • Continue rear-facing car seat

5. Immunizations due: Review schedule, administer if appropriate, provide education about expected reactions

Teaching Point: Developmental surveillance is continuous; one-time assessments can miss delays. Encourage parents to report concerns between visits.

Example 2: First Trimester Prenatal Teaching

Scenario: A 28-year-old woman in her first pregnancy presents at 8 weeks gestation for initial prenatal visit.

Priority Assessments and Teaching:

1. Confirm pregnancy and dating: LMP, positive pregnancy test, potential ultrasound

2. Baseline labs: CBC (check for anemia), blood type/Rh (risk of incompatibility), rubella immunity, STI screening, urinalysis

3. Medication review: Discontinue teratogens, start prenatal vitamin with folic acid

4. Nutritional counseling:

   • Small, frequent meals for nausea
   • Avoid raw/undercooked foods, unpasteurized products, high-mercury fish
   • Adequate hydration
   • Caloric increase not needed in first trimester

5. Common discomforts and management:

   • Nausea/vomiting: Crackers before rising, vitamin B6, avoid triggers
   • Fatigue: Rest when possible, normal in first trimester
   • Breast tenderness: Supportive bra

6. Danger signs to report immediately:

   • Vaginal bleeding or cramping
   • Severe vomiting (hyperemesis)
   • Fever >100.4°F
   • Burning with urination

7. Lifestyle modifications:

   • NO alcohol, tobacco, recreational drugs
   • Limit caffeine (<200 mg/day)
   • Avoid hot tubs/saunas
   • Continue exercise (moderate intensity)

Follow-up Plan: Return in 4 weeks; schedule anatomy ultrasound for 18-22 weeks; genetic counseling if indicated

Example 3: Adult Health Promotion - 50-Year-Old Health Screening

Scenario: A 50-year-old male presents for routine physical examination. He has no current health complaints but hasn't seen a provider in 5 years. Family history includes father with MI at age 62, mother with Type 2 diabetes.

Health Promotion Priorities:

1. Vital signs and anthropometrics:

   • BP: 138/86 mmHg → Elevated; recheck or confirm with home monitoring
   • BMI: 29 (overweight)
   • Waist circumference: 42 inches (increased cardiovascular risk)

2. Recommended screenings at age 50:

   • Lipid panel: Due to family history and age
   • Fasting glucose or HbA1c: Diabetes screening (family history)
   • Colorectal cancer screening: Begin at 45-50 (colonoscopy, FIT, or other methods)
   • Hepatitis C: One-time screening for adults born 1945-1965
   • Abdominal aortic aneurysm: If male smoker ages 65-75 (plan for future)

3. Immunization update:

   • Tdap if not received in adulthood
   • Annual influenza vaccine
   • Zoster (shingles) vaccine at age 50
   • Pneumococcal at age 65

4. Health behavior counseling:

   • Diet: Mediterranean or DASH diet for CV health
   • Exercise: 150 min/week moderate aerobic + strength training
   • Weight loss: Even 5-10% reduces disease risk
   • Smoking cessation: If applicable (assess with 5 A's)
   • Alcohol: Limit to ≤2 drinks/day for men

5. Risk reduction strategies (given family history):

   • Primary prevention for cardiovascular disease: Discuss aspirin therapy if benefit outweighs bleeding risk
   • Diabetes prevention: Weight loss, exercise, consider metformin if prediabetic

Follow-Up: Return in 1-2 weeks to confirm BP readings; review lab results; establish ongoing primary care relationship

Example 4: Postpartum Home Visit - Day 3

Scenario: Nurse conducts home visit to assess mother and newborn on postpartum day 3. Mother reports feeling overwhelmed and tearful.

Comprehensive Assessment:

1. Maternal Assessment (BUBBLE-HE):

   • Breasts: Engorged, reports painful latch; provide breastfeeding support
   • Uterus: Firm at umbilicus (normal)
   • Bladder: Voiding without difficulty
   • Bowel: No BM since delivery (provide stool softener education)
   • Lochia: Moderate rubra (red), no foul odor (normal)
   • Episiotomy: REEDA assessment shows slight edema, no redness (normal healing)
   • Homan's sign: Negative (no DVT)
   • Emotions: Tearful, overwhelmed, but bonding with baby

2. Postpartum Blues vs. Depression Screening:

   • Postpartum blues (50-80% of mothers): Peaks day 3-5, resolves in 2 weeks; characterized by mood swings, crying, anxiety
   • Postpartum depression (10-20%): Persistent sadness, inability to care for self/baby, thoughts of harm
   • This mother's symptoms consistent with blues; provide support and education, screen again in 2 weeks

3. Newborn Assessment:

   • Weight: 3100g (birth weight 3400g → 9% loss, within normal limits)
   • Feeding: 8-12 times/24 hours, good latch after assistance
   • Output: 6 wet diapers, 3 stools/day (adequate)
   • Umbilical cord: Dry, no drainage
   • Jaundice: Slight yellow tint to skin (physiologic jaundice common day 2-4)

4. Education and Support:

   • Breastfeeding: Correct positioning, ensure infant's mouth covers areola, nurse on demand
   • Emotional support: Normalize blues, encourage rest, accept help
   • Warning signs: Fever, heavy bleeding, severe depression, suicidal thoughts → call immediately
   • Newborn jaundice: Monitor; if worsens or baby lethargic, seek evaluation
   • Safe sleep: Back to sleep, firm surface, no loose bedding

5. Resources: Provide lactation consultant referral, local support groups, postpartum depression hotline number

Follow-Up: Phone call in 2 days; return visit at 2 weeks for postpartum check

Common Mistakes to Avoid ⚠️

Mistake 1: Confusing Normal Variants with Pathology in Newborns

Problem: Students often panic over normal newborn findings like acrocyanosis, milia, or erythema toxicum. Solution: Memorize normal newborn characteristics. Remember: Blue hands/feet day 1 = OK; Central cyanosis = EMERGENCY. White spots on nose = benign milia; pustular rash with erythema = infection requiring evaluation.

Mistake 2: Missing Developmental Red Flags

Problem: Assuming all children develop at different paces and failing to recognize true delays. Solution: Know absolute milestones that warrant referral: No social smile by 3 months, not sitting by 9 months, no words by 18 months, or any loss of skills. "Wait and see" can delay critical early intervention.

Mistake 3: Applying Adult Immunization Rules to Children

Problem: Incorrectly spacing vaccines or missing catch-up schedules. Solution: Use CDC's catch-up immunization scheduler tool. Remember: Minimum intervals matter! Live vaccines can be given same day or ≥28 days apart (not in between).

Mistake 4: Overlooking Secondary Prevention Opportunities

Problem: Focusing only on treating illness rather than screening asymptomatic patients. Solution: Know age-based and risk-based screening guidelines. A healthy-appearing 50-year-old still needs colorectal cancer screening. A 65-year-old woman needs bone density testing even without symptoms.

Mistake 5: Normalizing Pathology in Older Adults

Problem: Attributing symptoms to "just getting old" when they represent disease. Solution: Remember: Dementia, depression, and incontinence are NEVER normal aging. Decreased hearing/vision, slower reflexes, and mild forgetfulness are normal; significant functional decline is not.

Mistake 6: Inadequate Prenatal Danger Sign Education

Problem: Patients don't know which symptoms require immediate attention. Solution: At every prenatal visit, review danger signs: vaginal bleeding, severe headache/visual changes, sudden edema, decreased fetal movement, rupture of membranes, regular contractions before term. Give written materials.

Mistake 7: Confusing Prevention Levels

Problem: Misidentifying interventions as primary when they're secondary or tertiary. Solution: Use this rule: Primary = No disease yet (vaccines, education), Secondary = Detecting early disease (screenings), Tertiary = Managing diagnosed disease (cardiac rehab). If disease is present, it's tertiary!

Key Takeaways 🎯

Further Study 📚

1. CDC Immunization Schedules: https://www.cdc.gov/vaccines/schedules/index.html - Current childhood, adolescent, and adult vaccination recommendations with catch-up schedules

2. US Preventive Services Task Force (USPSTF): https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics - Evidence-based screening recommendations by age and risk factors

3. CDC Developmental Milestones: https://www.cdc.gov/ncbddd/actearly/milestones/index.html - Age-specific checklists with developmental screening tools for parents and providers

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Congratulations! You've completed a comprehensive review of Health Promotion and Maintenance. This content forms the foundation for 6-12% of NCLEX-RN questions. Focus on prevention levels, developmental milestones, prenatal/postpartum danger signs, and age-appropriate screenings. Practice applying these concepts to clinical scenarios, as NCLEX tests application rather than memorization. Use the free flashcards embedded throughout this lesson to reinforce key concepts with spaced repetition. Next, you'll build on this foundation by exploring psychosocial integrity and physiological adaptation!